IJCS | Volume 31, Nº5, September / October 2018

524 Hoepfner et al. Myocardial infarction in Joinville Int J Cardiovasc Sci. 2018;31(5)520-526 Original Article of the health service can call the emergency medical service, and those deemed in need of an ambulance are transported to the catheterization laboratory. The study was designed to evaluate the effect of several variables on late mortality. Patients were allocated into two groups, one transported directly to the percutaneous coronary intervention center and the other group transported to local hospitals first and then transferred to the treatment center. The time from pain onset to initiation of reperfusion therapy was calculated and categorized in patient delay, transportation delay, door- to-balloon time, system delay and total delay in both groups, in addition to hospital delay and prehospital system delay (time between transportation and arrival at the percutaneous coronary intervention center in one of the groups. After exclusion of patients that did not receive reperfusion, patients with a treatment delay longer than 12 hours, and patients with missing data, a total of 6,209 patients were followed-up. Door to balloon time was 39 (24-70) minutes in the group directly transported to treatment center and 29 (21-72) minutes in the other group. The study showed that in the group transferred from other hospitals, treatment delay was significantly longer (240 minutes vs. 170 minutes) than in the group directly transported for treatment. Mean follow-up period was 3.4 (1.8-5.2) years, with mortality of 15.4% in patients with system delays < 60 minutes, 23.3% in those with delays of 61-120 minutes, 28.1% in those with delays of 121-180 minutes, and 30.8% in those with delays of 180-360 minutes. Multivariate analysis showed that both prehospital delay and door- to-balloon time were associated with mortality, and efforts should be made to reduce them. Barreto et al., 28 also demonstrated that transportation delay from other centers to the catheterization laboratory was a predictor of adverse events. Bagai et al., 22,23 compared patients evaluated in the emergency department and those transported directly to the catheterization laboratory. The authors reported that a median time of 30 minutes was spent in the emergency department, with potential decrease. The authors confirmed the beneficial effects of ambulance services and direct transportation of patients to the catheterization laboratory on the door-to-balloon time. However, the authors highlighted that the service is used infrequently and no differences in in-hospital mortality was observed between the groups. Jollis et al., 21 published the first results of the STEMI Systems Accelerator project, a large national effort to adequate regional STEMI care to national guidelines in the USA. The program was developed in 2012 and included emergency medical services and hospitals, regional and central coordinators, training of leaders, physicians and paramedics, ambulance and emergency staff, development of protocols, establishment of common criteria for STEMI diagnosis and treatment, and data storage in a national registry and timely feedback. Analysis of the program during the first two years revealed that the call for medical emergency by the citizens causes a decrease in the pain-to-first medical contact time and in door-to-balloon time, incrementing the percentage of patients who receives primary percutaneous coronary interventionwithin 90minutes of paramedic arrival. Shorter delays in emergency services resulted in a reduction in in-hospital mortality. In our study, prehospital delay was estimated using partial data, and seemed to be greater than 240 minutes in almost all patients. Also, the DAT was elevated, suggesting many possibilities for improvement. In view of the studies cited in this study, we can say that difficulties in the treatment of STEMI are present (and similar) in many countries, and the strongest difference is in the efforts for their improvement. I n B r a z i l , s ome i n t e r ven t i on s have be en published. 29-32 Escosteguy et al., 29 published the results of a multidisciplinary program for implementation of clinical guidelines on AMI in a public emergency unit in Rio de Janeiro. Caluza et al., 30 described the implementation steps and the first results of an AMI treatment system in Sao Paulo. The program standardized the processes of clinical diagnosis of STEMI, immediate ECG using tele-ECG, therapy decision (PTA or thrombolysis) and availability of care in the referral hospital. Andrade et al., 31 described an integrated system for cardiovascular emergency services in Marilia, Brazil, with direct transportation of patients to the catheterization laboratory. The authors reported high symptom-to-balloon time in patients transferred from other units (5.0 ± 2.2 hours) and in those directly admitted to the hospital (3.3 ± 2.2 hours). Marcolino et al., 32 reported the results of an integrated system for AMI approach ( Linha de Cuidado do Infarto Agudo do Miocárdio ) implemented in the city of Belo Horizonte, Brazil, between 2010 and 2011, which included training and motivation programs of the emergency service staff, interaction between the units and accessibility to the catheterization laboratory.