ORIGINAL ARTICLE

Heraldo D’Imperio^MTSAC, Adrián Charask^MTSAC, Yanina Castillo Costa^MTSAC, Gerardo Zapata, Mauro Quiroga, Alejandro Meiriño, Stella Macín, Juan Gagliardi^MTSAC

Address for reprints: Heraldo D’Imperio E-mail: heraldodimperio@gmail.com

Rev Argent Cardiol 2023;91:415-422. http://dx.doi.org/10.7775/rac.v91.i6.20712

Financing: None
This work received the Dr. Raúl Borracci Award at the 49th Argentine Congress of Cardiology.

ABSTRACT

Background: The continuous Argentine ST-segment Elevation Acute Myocardial Infarction (ARGEN-IAM-ST) registry presents its third general report.
Objectives: The aim of this study was to evaluate the main ST-segment elevation myocardial infarction (STEMI) markers of care and its complications in the continuous ARGEN-IAM-ST registry, and assess the outcome of reperfusion therapy and mortality in the last 8 years.
Methods: This was a national, prospective, multicenter study, including STEMI patients with up to 36-hour evolution.
Results: A total of 6765 patients, mean age 61±12 years, 65 % male , were included in the study. A significant burden of cardiovascular risk factors was observed: 58 % of patients had hypertension, 23 % diabetes, 42 % dyslipidemia, 37 % were active smokers, and 17 % had a family history of cardiovascular disease. In 13.5 % of cases, patients had prior history of coronary heart disease. On admission, 49 % presented with anterior AMI and 23 % with heart failure. Median (interquartile range, IQR) pain-consultation time was 120 minutes (IQR 60-285), door-to-needle time 50 minutes (IQR 25-110) and door-to-balloon time 100 minutes (IQR 58-190)
Overall in-hospital mortality was 8.8 %. An exploratory and descriptive analysis was performed to assess the variation in reperfusion and mortality over 8 years, showing no marked changes in mortality despite high reperfusion rates.
Conclusion: In the last 8 years, the mortality recorded in the ARGEN-IAM-ST registry has remained at high values despite the high reperfusion rates reported.

Key words: Myocardial infarction - ST-segment elevation myocardial infarction - Epidemiology - Balloon angioplasty - Reperfusion

RESUMEN

Introducción: Se presenta el tercer reporte general del registro continuo de infarto ARGEN- IAM-ST.
Objetivos: Evaluar los principales marcadores de atención y las complicaciones del infarto agudo de miocardio (IAM) con elevación del segmento ST en el registro continuo de infarto ARGEN-IAM-ST. Conocer la evolución de la terapia de reperfusión y la mortalidad en los últimos 8 años.
Material y métodos: Estudio prospectivo multicéntrico, con alcance nacional. Se incluyeron pacientes con IAM con elevación del segmento ST de hasta 36 horas de evolución.
Resultados: Se incluyeron 6765 pacientes, con una edad media de 61 ± 12 años, 65 % de género masculino. Se observó una importante carga de factores de riesgo cardiovascular: hipertensión arterial 58 %, diabetes 23 %, dislipidemia 42 %, tabaquismo activo 37 % y antecedentes familiares de enfermedad cardiovascular 17 %. El 13,5 % presentó antecedente de enfermedad coronaria; al ingreso un 49 % presentó IAM de cara anterior y el 23 % falla cardíaca. La mediana de tiempo de dolor a la consulta fue de 120 minutos (rango intercuartílico, RIC, 60-285), el tiempo puerta-aguja fue de 50 minutos (RIC 25-110) y el tiempo puerta balón fue de 100 minutos (RIC 58-190).
La mortalidad general intrahospitalaria fue del 8,8 %. Se realizó un análisis exploratorio y descriptivo para observar la variación de la reperfusión y mortalidad durante 8 años donde no se muestran cambios acentuados en la mortalidad a pesar de las altas tasas de reperfusión.
Conclusión: En los últimos 8 años la mortalidad registrada en el registro ARGEN IAM-ST se ha mantenido en valores elevados a pesar de las altas tasas de reporte de reperfusión.

Palabras clave: Infarto de miocardio - Infarto de miocardio con elevación del ST -Epidemiología - Angioplastia coronaria con balón – Reperfusión

Received: 11/06/2023
Accepted: 11/17/2023

INTRODUCTION

Acute myocardial infarction (AMI) is the main cause of death in Argentina, as well as the main reason of clinical cardiovascular disease. Due to the burden it implies for the healthcare system, it is necessary to know the most important indicators of care, as well as the results and complications. (1) The continuous ST-segment elevation acute myocardial infarction (ARGEN-IAM-ST) registry led by the Argentine Society of Cardiology (SAC) and the Argentine Federation of Cardiology (FAC) allows an approach to the reality of care and has generated previous reports alerting on the results together with opportunities for improvement that could impact on usual clinical practice. Moreover, it is well-known that registries of common diseases are very useful tools to control the implementation of policies as the conformation of care networks, promote awareness of early consultation, incorporate new technologies, etc. (2)
In the case of the ARGEN-IAM-ST registry, active since 2015, the participation of centers from different provinces allows knowing the evolution of AMI care throughout time, not only in different regions, but also in different health systems of Argentina. Our objectives were to evaluate the main AMI markers of care and complications in the continuous ARGENIAM- ST registry and assess the reperfusion outcome and mortality in the last 8 years.

METHODS

The ARGEN-IAM-ST registry is a national, prospective, multicenter study carried out in collaboration between SAC and FAC, which is active since the end of 2014, and whose protocol has been previously published. (3) The target population were all patients suffering an AMI with ST-segment elevation within 36 hours from the event. Following the end of the first phase in December 2015, all the participating centers were invited to continue with the registry.
The most relevant data collected were coronary risk factors, history of comorbidities, clinical presentation, treatment used (antiplatelet agents, reperfusion, adjuvant therapy) and in-hospital clinical outcome. Data related to delay to achieve effective treatment were one of the mainstays for the registry report. The following times and delays were considered:

1. Pain-consultation time: time elapsed between the onset of symptoms suggestive of coronary artery ischemia and the first medical contact.
2. Time to reperfusion: time elapsed between arrival to a medical center and onset of reperfusion treatment:
   a. In case of fibrinolytics:
   – Time window: time interval in minutes from symptom onset to start of infusion.
   – Door-to-needle time: time interval in minutes since arrival at the institution and start of infusion.
   b. In case of angioplasty:
   – Time window: time interval in minutes from symptom onset to balloon inflation.
   – Door-to-balloon time: time interval in minutes from arrival at the institution to balloon inflation.

Data collection was performed in the REDCap platform.

Ethical considerations

The ARGEN-IAM-ST registry protocol was approved by the ethics committee of the Argentine Society of Cardiology.

Statistical analysis

Qualitative variables are presented as frequencies and percentages with their confidence intervals, and quantitative variables are described using mean and standard deviation (SD) or median and interquartile range (IQR), according to their distribution.
Discrete variables were analyzed with contingency tables and continuous variables using Student’s t test or the Kruskall Wallis test for unpaired data, or the analysis of variance (ANOVA), as appropriate. Significance was considered for p < 0.05. The R statistical package was used to perform the analysis.
The protocol was registered in ClinicalTrials.gov under the NCT2458885 number.

RESULTS

A total of 6765 patients were analyzed, with mean age 61±12 years and 65% male. A significant burden of cardiovascular risk factors was observed: 58% of patients had hypertension, 23% diabetes, 42% dyslipidemia, 37% were active smokers, and 17% had a family history of cardiovascular disease. In 13.5% of cases, patients had prior history of coronary heart disease. On admission, 49% presented with anterior AMI and 77% had Killip and Kimball (KK) A classification (Table 1). Recorded consultation and care times were longer than clinical recommendations, impacting on total ischemic time. Pain-consultation time was 120 minutes (IQR 60-285), door-to-needle time 50 minutes (IQR 25-110) and door-to-balloon time 100 minutes (58-190) (Table 2). Among the main causes of delay physicians reported patient delay in performing the consultation in 61% of cases, followed by ambulance-related delays in 35% and emergency room care in 25% of cases (Table 2 of Supplementary material).
Overall reperfusion rate was 89% and reperfusion strategies used were fibrinolytics in 16.6% and percutaneous coronary intervention (PCI) in 79,3% (89 % primary PCI) (Table 3). The chief cause for non-reperfusion was late presentation of the infarction in 3.5% of cases, according to the survey carried out in the registry (see Table 3 of the Supplementary material). In the case of in-hospital evolution, 12% heart failure (in patients admitted in KK A) and 9.8% atrial fibrillation were the most frequent complications, and 3.5% major bleeding was among other less frequent complications. Overall mortality was 8.8%, and the rest of in-hospital AMI complications are shown in Table 4. An exploratory and descriptive analysis was made to analyze the variation of reperfusion and mortality from 2015 to 2022 (complete annual periods were considered at the time of the report) showing no marked percent changes in mortality despite higher reperfusion rates (Figure 1), with the lowest mortality value recorded in the 2022 period (6%) and the maximum (9.3%) in 2017.

Table. 1 Baseline characteristics.

* Number of patients from which the data was obtained
** It expresses the proportion of patients in each category
CI: Confidence interval; COPD: Chronic obstructive pulmonary disease; SD: Standard deviation

Table 2. Consultation and reperfusion times (in minutes).

IQR: Interquartile range

DISCUSSION

This report presents the third general data update of the ARGEN-IAM-ST registry, which allows monitoring the most important parameters involved in the care and outcome of patients treated for infarction in centers of different provinces in Argentina. (3, 4) Despite the core of participating centers has decreased, the registry continues with the incorporation of an annual volume of patients that allows a real-life critical view (see Table 1 of the Supplementary material)
On a first approach, no significant changes in treatment times and overall in-hospital mortality is observed compared with previous registry publications, which continue to be high. In addition, an extensive total ischemic time is recorded, especially in reperfusion times, which are longer than clinical practice guideline recommendations. (5-8) Regardless the heterogeneity of each period, due to the very dissimilar number of participating institutions, as well as their different complexity, which hinder an accurate statistical assessment as a comparative tool, the value of in-hospital overall mortality remains constant in the last 8 years and in percentages that can be improved beyond the comparative instruments.
This promotes the development of effective strategies to reverse this situation, reminding us of successful experiences in Argentina of infarction networks which have been shown to reduce times and improve the mortality rate, in addition to being a reasonable application tool in common clinical practice. (9-12) This type of strategy becomes appropriate considering that physicians reported ambulance and emergency room delays as a second and third factor that impact on total ischemic time, a relevant wellknown factor of infarction mortality (13) Moreover, the centers’ heterogeneous complexity also affects results such as in-hospital mortality, indicating that network care could improve the use of resources according to the severity of the clinical condition. (14)
To conclude, it is necessary to highlight that local experiences in infarction care networks have been able to reproduce international results, a great stimulus and incentive for their implementation due to their reproducibility and low cost. (15, 16)
Regarding in-hospital mortality, not only high values are observed compared with other registries, but no improvements are perceived throughout 8 years, which raises special concern if we consider the evolution of this marker in other registries over the course of 10 years. An example is the ARIAM registry from Andalucia, which recorded patients with ST-segment elevation and non-ST-segment elevation AMI, and reported 9.2% ST-segment elevation AMI in-hospital mortality in 2011, that decreased to 6.1% in 2021. (17, 18)
In another international registry, including European countries, among them Italy, Spain, Denmark, Portugal, Sweden and Hungary, average raw ST-segment elevation AMI in-hospital mortality was 6.8%, and did not exceed 4.4% in 2021. (19, 20)
Another behavior observed in the registry deserving attention is the high reperfusion rate in contrast with elevated mortality. A possible interpretation is the high total ischemic time evidenced in this registry and its known close relationship with adverse events, which as reported in previous registries, negatively impacts on survival. (4, 13) Finally, although the registry has methodological weaknesses, it is still the only independent instrument open to the scientific community which allows discussing the reality of AMI in Argentina. It should therefore be strengthened to obtain information that will improve the quality of care.

Table. 3 Reperfusion therapy.

* Number of patients from which the data was obtained
** It includes primary coronary angioplasty, rescue coronary angioplasty and pharmacoinvasive therapy
*** It expresses the proportion of patients in each category
CI: Confidence interval

Table. 4 Events during hospitalization.

CI: confidence interval
* Number of patients from which the data was obtained

Fig. 1 Time variation of reperfusion therapy and mortality in the ARGEN-IAM-ST registry

Limitations

The ARGEN-IAM-ST registry is voluntary, without economic stimulus and without case audit in each institution. The contribution of participating investigators and institutions is essential for its support. This registry model can be subject to reporting bias and does not have a sampling strategy.

CONCLUSION

In the last 8 years, mortality recorded in the ARGENIAM- ST registry has remained elevated despite the high reperfusion rates reported. The ARGEN-IAM-ST registry shows that notwithstanding the availability of data to monitor the principal markers of AMI care, there have been no advances in strong indicators such as mortality, which is a call for attention indicating that political resolve is required to reverse these undesirable results in Argentina.

Conflicts of interest

None declared. (See authors' conflict of interests forms on the web).

https://creativecommons.org/licenses/by-nc-sa/4.0/

©Revista Argentina de Cardiología

REFERENCES

1. Amini M, Zayeri F, Salehi M. Trend analysis of cardiovascular disease mortality, incidence, and mortality-to-incidence ratio: results from global burden of disease study 2017. BMC Public Health 2021;21:401. https://doi.org/10.1186/s12889-021-10429-0


2. Sørensen ST, Kristensen FP, Troelsen FS, Schmidt M, Sørensen HT. Health registries as research tools: a review of methodological key issues. Dan Med J 2023;70:A12220796.


3. Gagliardi J, Charask A, Perna E, D´Imperio H, Bono J, Castillo Costa Y, et al. Encuesta nacional de infarto agudo de miocardio con elevación del ST en la República Argentina (ARGEN-IAM-ST). Rev Argent Cardiol 2016;84:548-57. https://doi.org/10.7775/rac.es.v84.i6.9508


4. D’Imperio H, Gagliardi J, Charask A, Zoni R, Quiroga W, Castillo Costa Y, et al. Infarto agudo de miocardio con elevación del segmento ST en la Argentina. Datos del registro continuo ARGEN-IAM-ST. Rev Argent Cardiol 2020:88:297-397. https://doi.org/10.7775/rac.es.v88.i4.18658


5. Tajer C, Charask A, Castillo Costa Y, Antonietti L, Geronazzo R. Consenso de infarto agudo de miocardio con elevación del segmento ST. Consenso de la Sociedad Argentina de Cardiología. Rev Argent Cardiol 2015;83(4).


6. Lawton JS, Tamis-Holland JE, Bangalore S, Bates ER, Beckie TM, Bischoff JM, et al. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization. J Am Coll Cardiol 2022;79:e21-129. https://doi.org/10.1016/j.jacc.2021.09.006


7. Neumann FJ, Sousa-Uva M, Ahlsson A, Alfonso F, Banning AP, Benedetto U, et al. 2018 ESC/EACTS Guidelines on myocardial revascularization. Eur Heart J 2019;40:87-165. https://doi.org/10.1093/ eurheartj/ehy394


8. Wong GC, Welsford M, Ainsworth C, Abuzeid W, Fordyce CB, Greene J, et al. 2019 Canadian Cardiovascular Society/Canadian Association of Interventional Cardiology Guidelines on the Acute Management of ST-Elevation Myocardial Infarction: Focused Update on Regionalization and Reperfusion. Can J Cardiol 2019;35:107-32. https://doi.org/10.1016/j.cjca.2018.11.031


9. Saleeb S, Newburger J, Geva T, Baird C, Gauvreau K, Padera R, et al. Accelerated degeneration of a bovine pericardial bioprosthetic aortic valve in children and young adults. Circulation 2014;130:51–60. https://doi.org/10.1161/CIRCULATIONAHA.114.009835


10. Kohan MR, Messler V, Buffa H, Fernández R, Fernández Estaiye LM, Pachado JG, et al. Tiempos de reperfusión de un programa guiado por telemedicina para la atención del infarto agudo de miocardio con elevación del ST en la Provincia de La Pampa. Rev Argent Cardiol 2022;90:280-6. https://doi.org/10.7775/rac.es.v90.i4.20536


11. Candiello A, Alexander T, Delport R, Toth GT, Ong P, Snyders A, et al. How to set up regional STEMI networks: a "Stent - Save a life!" initiative. EuroIntervention. 2022;17:1313-7. https://doi.org/10.4244/EIJ-D-21-00694


12. French WJ, Gunderson M, Travis D, Bieniarz M, Zegre-Hemsey J, Goyal A, et al. Emergency Interhospital Transfer of Patients With ST-Segment–Elevation Myocardial Infarction: Call 9-1-1—The American Heart Association Mission: Lifeline Program. JAHA. 2022;11:e026700. https://doi.org/10.1161/JAHA.122.026700


13. Charask A, Gagliardi J, Tajer C, Castillo Costa Y, D´Imperio H, Marturano MP, et al. Mortalidad por infarto agudo de miocardio en el registro continuo ARGEN-IAM-ST. Su relación con las diferentes terapias de reperfusión. Rev Argent Cardiol. 2021;89:323-31. https://doi.org/10.7775/rac.es.v89.i4.20412


14. Bertomeu V, Cequier Á, Bernal JL, Alfonso F, Anguita MP, Muñiz J, y cols. Mortalidad intrahospitalaria por infarto agudo de miocardio. Relevancia del tipo de hospital y la atención dispensada. Estudio RECALCAR. Rev Esp Cardiol 2013;66:935–42. https://doi.org/10.1016/j.recesp.2013.06.008


15. Aldama G, López M, Santás M, Flores X, Piñon P, Salgado J, y cols. Miocardio con elevación del segmento ST. Estudio IPHENAMIC. Rev Esp Cardiol. 2020;73:632-42. https://doi.org/10.1016/j.recesp.2019.09.013


16. Hernández González MA, Navarrete Becerra KJ, Amador-Licona N, Borrayo Sánchez G, Bernal Ruiz EA, Solorio Meza SE. Impacto de la asistencia en red para infarto agudo al miocardio en la región del Bajío, México. NS. 2020;12. https://doi.org/10.21640/ns.v12i24.2122


17. Latour Pérez J, Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias. ARIAM, análisis del corte 2011. [Madrid] Sociedad Española de Medicina Intensiva, 2012. https://semicyuc.org/wp-content/uploads/2018/12/2011_ariam.pdf


18. Rodríguez Esteban M de los Á, Llanos JC, Farrais Villalba M, et al. INFORME ARIAM 2021.


19. Kristensen SD, Laut KG, Fajadet J, et al. Reperfusion therapy for ST elevation acute myocardial infarction 2010/2011: current status in 37 ESC countries. Eur Heart J 2014;35:1957–70. https://doi.org/10.1093/eurheartj/eht529


20. Zeymer U, Ludman P, Danchin N, Kala P, Laroche C, Sadeghi M, et al. Reperfusion therapies and in-hospital outcomes for STelevation myocardial infarction in Europe: the ACVC-EAPCI EORP STEMI Registry of the European Society of Cardiology. Eur Heart J 2021;42:4536-49. https://doi.org/10.1093/eurheartj/ehab342

SUPPLEMENTARY MATERIAL

Acute myocardial infarction. Third ARGEN-IAM-ST registry report and 8-year mortality behavior

Table. 1 Participating centers, patients included, reperfusion therapy and in-hospital mortality, discriminated by year.

Table. 2 Causes of delay (more than one option could be chosen)

Table. 3 Main causes for non-reperfusion

APPENDIX

Acknowledgements to the participating centers and investigators in this phase of the continuous ARGE-IAM-ST registry.

• Centro Modelo de Cardiología – Tucumán: Dra. Lorena López
• Clínica Bazterrica – CABA: Dr. Adrián Charask
• Clínica Santa Isabel – CABA: Dr. Víctor Mauro
• Hospital de Clínicas José de San Martín – CABA: Dr. Víctor López
• Hospital Central de Mendoza – Mendoza: Dr. Leonardo Ripa, Dr. Javier Ortego
• Hospital Córdoba – Córdoba: Dr. Mauro Quiroga
• Hospital Dr. Teodoro Álvarez – CABA: Dr. Marcos Tomasella
• Hospital El Cruce “Nestor Kirchner” – Provincia de Buenos Aires: Dr. Mariano Adamowski
• Hospital General de Agudos Dr. Cosme Argerich – CABA: Dra. Jeanette Lacusant
• Hospital Teodoro J. Schestakow – Mendoza: Dr. Leonardo Schiavone
• Instituto de Cardiología Dr. Luis González Sabathié – Santa Fé: Dr. Lautaro Jiménez
• Instituto Cardiovascular de Rosario – Santa Fé: Dr. Alejandro Meiriño, Dr. Fernando Bagnera.
• Instituto de Cardiología JF Cabral – Corrientes: Dra. Stella Macín, Dra. Mariela Onocko.
• Sanatorio Adventista del Plata – Entre Ríos: Dr. Ramiro Ayala
• Sanatorio Allende – Córdoba: Dra. Yésica Bofer, Dra. Valentina Belluzo
• Sanatorio Guemes – CABA: Dr. Joaquin Perea
• Sanatorio Los Lapachos – Jujuy: Augusto Barboza
• Sanatorio Modelo de Caseros – Provincia de Buenos Aires: Dr. Eugenio Korolov
• Sanatorio Modelo de Quilmes – Provincia de Buenos Aires: Dr. Adrián Hrabar
• Sanatorio Pasteur – Catamarca: Dra. María Pía Marturano
• Sanatorio Sagrado Corazón – CABA: Dr. Diego Costa