uloga registra u praćenju kvalitete · widimsky p, groch l, zelizko m, et al. multicenter...
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Uloga registra u praćenju kvalitete
Doc.dr.sc. Zdravko BabićRadna skupina za akutni koronarni sindrom
Hrvatsko kardiološko društvo
2. Nacionalna konferencija
Kvaliteta i sigurnost u zdravstvu
Zagreb, 03. Prosinac 2015.
HRVATSKO KARDIOLOŠKO DRUŠTVO
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AKUTNI INFARKT MIOKARDA
REZULTATI
NAJNOVIJA DOSTIGNUĆA
HRVATSKA MREŽA pPCI
BUDUĆI PLANOVI
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AKUTNI INFARKT MIOKARDA
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Ateroskleroza i njene kliničke manifestacije
Klinički nijemaAngina
Bolovi u nogama
Infarkt miokarda
Moždani udar
Kritička ishemija nogu
Iznenadna srčana smrt
Nestabilna angina pektoris
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Akutni koronarni sindrom AKS
Bez ST elevacije Sa ST elevacijom STEMI
NSTEMI
Nestabilna angina Infarkt miokarda
bez Q-zupca
Infarkt miokarda s Q-zupcem
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Akutni infarkt miokarda (AIM) -nekroza miokarda prouzročena naglim smanjenjem ili potpunim prekidom koronarnog protoka, -najčešća komplikacija aterosklerotske bolesti srca
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MEDIKAMENTOZNA TERAPIJA
Analgetici (nitrati, opioidni analgetici),
Antiagregacijska th. (ASK, ADP blokatori, Gp IIb/IIIa inhibitori),
Antiishemijski lijekovi (beta blokatori, nitrati, ca antagonist),
Antikoagulansi (UFH, LMWH, fondaparinux, bivalirudin)
REPERFUZIJSKA TERAPIJA (u STEMI)
Fibrinolitička terapija -spašava 30 života na 1000 liječenih STEMI u prvih 6-12 sati, -problemi: TIMI 3 protok u 50-60% bolesnika, 5-15% rana reokluzija i re-IM, 4-13% velikih necerebralnih i 1-2% intrakranijalnih krvarenja, smrtnost oko 15% -kontraindikacije - u 15-20% bolesnika
Primarna PCI (engl. percutanepous coronary intervention) Mehaničko otvaranje okludirane ili stenozirane koronarne arterije metodama intervencijske kardiologije -PCI u STEMI -superiorna metoda u odnosu na trombolizu, -smanjena smrtnost (2-5%)-smanjena učestalost reinfarkta (90-95% TIMI 3), moždanog udara, popuštanja srca i angine pektoris
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HRVATSKA MREŽA pPCI
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STANJE ZNANJA RANIH 2000-tih
- primarna PCI u visokovolumnim centrima je superiorna metoda liječenja akutnog STEMI,
- relativno mali broj visokovolumnih PCI centara i u najrazvijenijim zemljama svijeta, - transport u takve centre radi primarne PCI duljine i do 150 km siguran je i uglavnom ima bolje rezultate od fibrinolize i ostale medikamentozne terapije
Widimsky P, Groch L, Zelizko M, et al. Multicenter randomized trial comparing transport to primary angioplasty vs. immediate thrombolysis vs combined strategy for
patients with acute myocardial infarction presenting to a community hospital without a catheterization laboratory. The PRAGUE Study. Eur Heart J
2000;21:823-31.
Widimsky P, Budesinsky D, Vorac D et al. Long distance transport for primary angioplasty vs. immediate thrombolysis in acute myocardial infarction. Final results of
the randomized national multicentre trial-PRAGUE-2. Eur Heart J 2003;24:94-104.
Andersen HR, Nielsen TT, Rasmussen K, Thuesen L, Kelbaek H, Thayssen P, Abildgaard U, Pedersen F, Madsen JK, Grande P, Villadsen AB, Krusell LR, Haghfelt
T, Lomholt P, Husted SE, Vigholt E, Kjaergard HK, Mortensen LS, for the DANAMI-2 Investigators. A comparison of coronary angioplasty with fibrinolytic
therapy in acute myocardial infarction. N Engl J Med. 2003;349:733-742.
Silber S, Albertsson P, Aviles FF, Camici PG, Colombo A, Hamm C, Jorgensen E, Marco J, Nordrehaug JE, Ruzyllo W, Urban P, Stone GW, Wijns W. Guidelines for
Percutaneous Coronary Intervention. The Task Force for Percutaneous Coronary Interventions of the European Society of Cardiology. Eur Heart J 2005;
26: 804-47.
Altman EM, Hand M, Armstrong PW et al. 2007 focused update of the ACC/AHA 2004 guidelines for the management of patients with ST-elevation myocardial
infarction; a report of the ACC/AHA Task force on practice guidelines. Circulation 2007;
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STEMI
Urgentna PCI (< 2 sata)
Rana invazivna strategija (< 24 sata)
PCI unutar 72 sata
NSTEMI
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- 2004. organizacijske predradnje,- 2005. Nacionalni program intervencijske kardiologije Ministarstva zdravstva- osnovni cilj: jednaka razina liječenja AIM u svim dijelovima Republike Hrvatske
Principi
Princip postepene implementacije (step-by-step princip): 1.upoznavanje vlasti s problemom, medijska kampanja;2.proširenje primarne PCI na 150 km oko Zagreba i Rijeke (prva godina, pilot-faza);3.proširenje Hrvatske mreže pPCI na cijelu državu (druga godina) 4.implementacija u zdravstveni sustav Republike Hrvatske.
Ravnomjerna distribucija PCI centara u sve dijelove Hrvatske (daljnji razvoj PCI centara u Zagrebu i ostalim dijelovima Hrvatske).
Kontinuirana obostrana komunikacija (sastanci, edukacijski tečajevi, evaluacija)
Hrvatska mreža primarne PCI
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2000-2004.
2000-2004.
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2005.2005.
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2006.2006.
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2009.-
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2010.
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2014.-
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REZULTATI
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-retrospektivni diskontinuirani multicentrični registar (2005.-2014.)-istraživani vremenski periodi: -1.9.2005.-31.8.2007. (prva faza), 1.1.2008.-31.12.2009. (druga
faza), 1.11.2010.-1.11.2011 (treća faza), 1.1.2012.-31.12.2013. (četvrta faza)-11 PCI centara iz svih dijelova Republike Hrvatske: -KBC Sestre milosrdnice, KBC Zagreb, KB
Dubrava, KBC Rijeka, KBC Split, KKVB Magdalena, KB Sveti duh, KBC Osijek, OB Zadar, OB Sl. Brod, KB Merkur
BOLESNICI I METODE
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-bolesnici: -10151 akutni STEMI bolesnik liječen pPCI; 1161 u prvoj fazi, 2543 u drugoj fazi, 1946 u trećoj fazi, 4501 u četvrtoj fazi istraživanja
-bolesnici su direktno zaprimani u PCI centar ili transportirani kolima HMP iz okolnih bolnica
BOLESNICI I METODE
Prosječna duljina transporta (2005.-2007.)
Hrvatska mreža pPCI DANAMI PRAGUE-2
72 km 3-150 km 5-120 km
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2005-07 2008-09 2010-11 2012-13
581
1272
1946
2251
STEMI/godina
Rezultati Hrvatske mreže pPCISTEMI/godina
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2005-07 2008-09 2010-11 2012-13
60 61 6163
27 26
3129
4345
49
44
Dob Ženski spol Prednja stjenka
Rezultati Hrvatske mreže pPCIRizični profil
%
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2005-07 2008-09 2010-11 2012-13
0,7
1,6
1,1
1
0,4 0,4
0,5
0,4
LM By-pass
Rezultati Hrvatske mreže pPCIRizični profil
%
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2005-07 2008-09 2010-11 2012-13
6,7
7,9 7,8
5,4
Kardiogeni šok
%
Rezultati Hrvatske mreže pPCIRizični profil
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STEMI bolesnici 2005-07 2008-09 2010-11 2012-13
Dob (god.) 60 61 62 63
Spol(M/Ž) (%) 73.3/26.7 74.0/26.0 69.0/31.0 70.6/29.4
Stjenka miokarda(% ant./inf.) 42.6/57.4 44.9/55.1 48.9/51.1 43.7/66.3
Kardiogeni šok (%) 6.7 7.9 7.8 5.4
Postproceduralni TIMI 3 protok (%) 87.1 81.8 88.9 87.0
Mortalitet (unutarbolnički) (%) 4.4 4.4 5.9 4.8
Rezultati Hrvatske mreže pPCI
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0
100
200
300
400
500
600
700
Ukupno
Bolnički izvori
Izvori Hrv. Mreže pPCI
DES
* 1000 kuna
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Bruto nacionalni dohodak po glavi stanovnika
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Bruto nacionalni dohodak po glavi stanovnika 2006.-2014.
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Croatian pPCI Network – single pPCI (24/7)
centre / 476 735 inhibitans
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455
520551
0
100
200
300
400
500
600
2011 2012 2013
Rezultati Hrvatske mreže pPCIBr. pPCI/milijun stanovnika/god.
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44
45
46
47
48
49
50
51
52
53
54
Kardiovaskularni mortalitet u Hrvatskoj
2005 2009 2013 2014
Rezultati
Kardiovaskularni mortalitet u Hrvatskoj
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2005. god. 53%
2009.god.50%
Cardiovascular mortality in Croatia
Druge bolesti
Druge KV bolesti
Maligne bolesti
Koronarna bolest srca
Maligne bolesti
Koronarna bolest srca
Druge bolesti
Druge KV bolestiCVI
CVI
Kardiovaskularni mortalitet (2005. i 2009.)
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NAJNOVIJA DOSTIGNUĆA
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Najnovija dostignuća u Hrvatskoj mreži pPCI(2015. god.)
stvaranje kontinuiranog prospektivnog registra za infarkt
miokarda, invazivne i intervencijske kardiologije u
suradnji s Agencijom za kvalitetu i akreditaciju u zdravstvu i
socijalnoj skrbi po ugledu na sl. europske registre
(MINAP, SWEDEHEART)
porast penetracije DES (~40% na nacionalnoj razini)
šestmjesečno oslobađanje od nadoplate tikagrelora
nakon STEMI
medijska kampanja i edukacija populacije
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BUDUĆI PLANOVI
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Budući planovi Hrvatske mreže pPCI
povećanje financijskih sredstava za liječenje AIM
povećanje broja PCI u akutnom/subakutnom NSTEMI
jednogodišnje oslobađanje od nadoplate tikagrelora i
prasugrela nakon STEMI i NSTEMI
početak kontinuiranog prospektivnog registra
kontinuirana edukacaija svih sudionika u Hrvatskoj mreži
pPCI, medijska kampanja i edukacija populacije
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HVALA NA PAŽNJI!