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Archives of cardiovascular diseases
Volume 103, n° 8-9
pages 460-468 (août 2010)
Doi : 10.1016/j.acvd.2010.09.002
Received : 21 June 2010 ;  accepted : 6 September 2010
Characteristics and management of acute ST-segment elevation myocardial infarctions occurring in ski resorts in the French Alps: Impact of an acute coronary care network
Caractéristiques et prise en charge des infarctus du myocarde avec sus-décalage du segment ST dans les stations de ski alpines : rôle d’un réseau des urgences coronaires
 

Mathieu Chacornac a, Gilles Baronne-Rochette a, Marie-Hélène Schmidt b, Dominique Savary c, Daniel Habold d, Hélène Bouvaist a, Stéphanie Marliere a, Loic Belle e, Jacques Machecourt a, Gérald Vanzetto a,

on behalf of the REseau des URgences CORonariennes (RESURCOR)

a Department of Cardiology, University Hospital, 38043 Grenoble cedex 09, France 
b Service d’aide médicale urgente, University Hospital, 38043 Grenoble cedex 09, France 
c Service d’aide médicale urgente, Annecy Hospital, 74374 Pringy cedex, France 
d Service d’aide médicale urgente, Chambery Hospital, 73011 Chambery cedex, France 
e Department of Cardiology, Annecy Hospital, 74374 Pringy cedex, France 

Corresponding author. Cardiologie et urgences cardiologiques, CHU de Grenoble, BP 217, 38043 Grenoble cedex 09, France. Fax: +33 4 76 76 58 26.
Summary
Background

Compliance with guidelines for the management of ST-segment elevation myocardial infarction (STEMI) may be difficult in hard-to-access areas.

Aims

To analyse the characteristics, management and outcome of STEMIs occurring at altitude in the French Alps and managed by mobile medical emergency units.

Methods

From January 2006 to December 2008, from the prospective RESURCOR registry, 114 patients with a STEMI of less than 12hours’ duration, occurring in a ski resort or at high altitude and managed by the RESURCOR care system, were identified. Baseline characteristics, treatments and in-hospital outcomes were analysed.

Results

Ninety-three per cent of patients were men; the mean age was 57years. STEMIs occurred during or less than 1hour after physical activity in 76.3% of cases (mainly during or after alpine/cross-country skiing). Killip class greater or equal to 2 and cardiac arrest were observed in 35% and 7.9% of cases, respectively. Fifty-two (45.6%) patients underwent thrombolysis and 62 (54.4%) had percutaneous coronary intervention (PCI). Median delays were: first call to treatment, 82min (17–230min); symptoms to treatment, 165min (52–770min). All delays were significantly longer for PCI than for thrombolysis. First call to treatment delay was less than 120min in 98.1% of patients who underwent thrombolysis and in 51.6% who had PCI (P <0.0001). In-hospital survival was 96.5%.

Conclusion

Altitude STEMIs happen mainly during sporting activities. Clinical presentation is often severe, but an emergency coronary care network allows rapid reperfusion. These findings emphasize the need for an efficient network for STEMI management in geographically difficult-to-access areas.

The full text of this article is available in PDF format.
Résumé
Contexte

Les recommandations de prise en charge de l’infarctus avec sus-décalage de ST (STEMI) peuvent être difficiles à appliquer dans les zones isolées.

Objectifs

Analyser les caractéristiques et la gestion des STEMI pris en charge par les SAMU dans les Alpes françaises.

Méthodes

Sur trois ans (2006–2008), à partir du registre prospectif RESURCOR, 114 patients avec STEMI moins de 12heures survenant dans une station de ski ou en altitude ont été identifiés. Les caractéristiques, traitements mis en œuvre et pronostic de ces patients ont été analysés.

Résultats

Quatre-vingt-treize pour cent des patients étaient des hommes, d’âge moyen 57 ans ; 76,3 % des STEMI sont survenus au cours ou dans l’heure suivant un exercice physique intense, essentiellement du ski. Une insuffisance cardiaque Killip supérieure ou égale à 2 et un arrêt cardiaque sont survenus dans 35,0 % et 7,9 % des cas, respectivement. Cinquante-deux patients (45,6 %) on bénéficié d’une thrombolyse et 62 (54,4 %) d’une angioplastie première (AP). Les délais médian étaient : premier appel-traitement : 82minutes [17–230] et symptômes-traitement : 165minutes [52–770]. Ces délais étaient plus longs pour les d’AP que les thrombolyses. Le délai premier appel-traitement était moins de 120minutes dans 98,1 % des thrombolyses et 51,6 % des AP (p <0,0001). La survie hospitalière était de 96,5 %.

Conclusion

Les infarctus d’altitude surviennent majoritairement au cours d’une activité sportive. La présentation clinique initiale est souvent sévère, mais un réseau de soins adapté permet une reperfusion rapide. Ces résultats soulignent la nécessité d’un réseau efficace de prise en charge des STEMI dans les zones d’accessibilité difficile.

The full text of this article is available in PDF format.

Keywords : Acute myocardial infarction, Altitude, Thrombolysis, Percutaneous coronary intervention, Emergency care network

Mots clés : Infarctus du myocarde, Altitude, Thrombolyse, Angioplastie primaire, Réseau de soins

Abbreviations : ECG, ICCU, PCI, RESURCOR, SMUR, STEMI, TIMI


Background

Reperfusion strategies, and the prehospital and in-hospital management of ST-segment elevation myocardial infarction (STEMI), are well codified by the guidelines of the European Society of Cardiology, especially with regard to the respective use of thrombolysis and percutaneous coronary intervention (PCI) [1]. These recommendations state that PCI is the preferred reperfusion therapy in patients presenting within 12hours after onset of symptoms, when performed by experienced teams within 2hours after first medical contact (or within 90minutes for an early presenter with a large infarct and low bleeding risk) [1]. Conversely, fibrinolytic therapy should be performed–in the absence of contraindications–if PCI cannot be performed within the recommended time. These standards of care often need to be adapted locally, however, because of geographical specificities, especially the availability of centres that are able to perform 24-hour PCI.

The French Alps–also called “the Alpine Arch”–comprise three French departments (Isère, Savoie and Haute-Savoie) covering an area of 14,800km2 that is mainly mountainous and has 2.3 million inhabitants. The departments include more than 100 ski resorts, with a huge population increase during the ski season and access difficulties due to geographical and meteorological conditions. Furthermore, STEMIs that occur during sport activities in these resorts often happen in perilous, hard-to-access areas.

The REseau des URgences CORonariennes (RESURCOR, i.e. emergency coronary care network) is a network that combines the 13 services mobile d’urgence et réanimation (SMURs, i.e. mobile medical emergency units), the seven Intensive Coronary Care Units (ICCUs) and the four interventional cardiology laboratories of the Alpine Arch, and aims to optimize prehospital and in-hospital management of acute coronary syndrome in the region [2, 3, 4, 5]. A uniform management algorithm is applied across the entire network to provide every patient with the optimal time to reperfusion, according to evidence-based medicine and adapted from the updated guidelines from the European Society of Cardiology (Figure 1).



Figure 1


Figure 1. 

Management algorithm for patients presenting with acute ST-segment elevation myocardial infarction less than 12hours from onset of symptoms.

Zoom

Accordingly, the aims of our study were: to describe the baseline characteristics and clinical presentation of STEMIs occurring at high altitude in the French Alps; to investigate the prehospital management and reperfusion strategies in this setting, with a particular focus on time delays; and to analyse in-hospital outcome.

Methods
Study population

From January 2006 to December 2008, 1856 patients presenting with an acute STEMI managed by a SMUR were included prospectively in the RESURCOR registry; after exclusion of 1657 patients with a STEMI that occurred at an altitude less than 1000m, 71 patients in whom the diagnosis of STEMI was not confirmed and 14 patients who presented 12hours after the onset of symptoms, 114 patients were identified as presenting with a STEMI of less than 12hours’ duration that occurred at altitude; this group formed our study population.

STEMI was defined classically by the presence of compatible symptoms, associated with electrocardiogram (ECG) changes on at least two contiguous leads, with persistent ST-segment elevation or left bundle-branch block and/or significant elevation of serum markers of myocardial necrosis (creatine kinase-MB or troponin) [6].

Data collection

Data available from the prospective RESURCOR registry were: age, sex, clinical presentation, Killip class, initial ECG data, site of medical team intervention, hour of onset of symptoms, hour of first medical call, hour of arrival of mobile medical emergency unit, hour of treatment (thrombolysis or PCI), prehospital treatment administered, initial thrombolysis in myocardial infarction (TIMI) flow, final TIMI flow and time to TIMI 3 flow in patients with immediate coronary angiography. Prehospital outcomes were obtained from the SMUR computerized database, and in-hospital outcomes from computerized medical files from the ICCU, the interventional cardiology laboratories, and the echography and biology laboratories (i.e. coronary angiography results, PCI data, left ventricular ejection fraction, associated treatments, serum markers and clinical events).

Data analysis

Continuous variables are presented as means±standard deviations or median values and interquartile ranges. Categorical variables are presented as absolute and relative frequency distributions. Comparisons between groups were performed using Student’s t test (or a Mann-Whitney non-parametric test in cases of non-normal distribution) for continuous variables, and a Chi-squared test or Fisher’s exact test for discrete variables. For all tests, P <0.05 was considered as statistically significant.

Results
Baseline characteristics and clinical presentation

Of the 114 patients included, 93.0% were men and the mean age was 57years. Most patients had two or more cardiovascular risk factors, 10.5% had diabetes, and 14.0% had previously documented coronary artery disease. Seventy (61.4%) patients were tourists, while 44 (38.5%) were local residents. There were no significant differences between patients treated by thrombolytic therapy and those who underwent PCI. Detailed baseline characteristics of the study population are summarized in Table 1.

Most STEMIs occurred in the winter trimester (Figure 2), during or within 1hour of heavy physical activity in 76.3% of the patients, mainly during or after alpine or cross-country skiing (Table 2). STEMIs were revealed by a typical chest pain in 84.2% of patients, while 7.9% of patients experienced a cardiac arrest as the first manifestation.



Figure 2


Figure 2. 

Frequency distribution of ST-segment elevation myocardial infarction occurring at altitude, according to seasons.

Zoom

The first medical contact occurred in the ski area in 40.3% of the cases and at the place of residence in 23.7%, while 36.0% of the patients presented by themselves at the local general practitioner’s office. Overall, 80.7% of patients were transferred by helicopter to the ICCU or interventional cardiology laboratory (Table 2).

Reperfusion strategies and associated treatments

Fifty-two (45.6%) patients underwent prehospital thrombolysis as a reperfusion therapy, while 62 (54.4%) underwent PCI. All patients had a coronary angiography, except two who died during the prehospital period (both were thrombolyzed patients; one died at the intervention site and one during road transfer to the PCI centre). Of the 50 patients with initial thrombolytic therapy who arrived in hospital alive, coronary angiography was done immediately in 41 cases (82.0%)–as part of a rescue procedure because of persistent chest pain and ST-segment elevation (n =16, 32.0%) or for assessment of reperfusion quality because of equivocal reperfusion criteria (n =25, 50.0%)–and was elective in nine (18.0%) cases. Initial TIMI flow 0 was observed more frequently in the PCI group than in the prehospital thrombolysis group (61.3 vs 32.7%, P =0.003). Conversely, initial TIMI flow 3 was observed in 44.2% of thrombolyzed patients versus only 21.0% of PCI patients (P =0.008). Only two patients had no angiographically visible coronary artery disease.

PCIs (immediate, rescue or delayed) were performed in 86.0% of patients, less frequently in those who received initial thrombolysis than in patients who had primary PCI although with no difference in procedures between the two groups (except for the use of instrumental thrombectomy, which was used more frequently in the PCI group). Of the 41 PCIs performed in the thrombolysis group, 29 (70.7%) were rescue PCIs in patients with initial TIMI flow less than 3, six (14.6%) were immediate in patients with initial TIMI 3 flow, and six (14.6%) were delayed more than 24hours in patients with initial TIMI 3 flow. A high rate of final TIMI 3 flow was observed whatever the reperfusion strategy (Table 3).

Associated treatments were similar in both groups, except for prehospital heparin, prehospital clopidogrel, and glycoprotein IIb/IIIa inhibitors, which were used more frequently in patients with primary PCI (Table 3).

Time delays

Median time delays in the whole population were: symptoms to first call, 67min (5–650min, interquartile range 35–165); first call to treatment, 82min (17–230min, interquartile range 55–122); and symptoms to treatment, 165min (52–770min, interquartile range 110–280). All time delays were significantly longer in patients treated with PCI than in those who underwent prehospital thrombolysis: symptoms to first call, +44min (P =0.02); first call to treatment, +62min (p <0.001); and symptoms to treatment, +128min (P <0.001) (Figure 3). Delay between first call/medical contact and treatment was less than 120min in all patients except one (98.1%) in the prehospital thrombolysis group, and in 32/62 (51.6%) in the PCI group (P <0.0001) (Figure 4). Total ischaemic time (i.e. symptoms to treatment delay) was below the ideal recommended 180-minute threshold in 43/52 (82.7%) and 23/62 (37.1%) patients in the prehospital thrombolysis and PCI groups, respectively (P <0.0001) (Figure 5).



Figure 3


Figure 3. 

Median time delays between symptoms to first call or medical contact, first call to treatment and symptoms to treatment in the PCI group (black bars) and the thrombolysis group (white bars). Values in parenthesis are interquartile ranges.

Zoom



Figure 4


Figure 4. 

Cumulative first call to treatment time delays in the thrombolysis group (white squares) and the PCI group (black squares). The dotted line represents the recommended maximum delay between first medical contact and treatment of 120min.

Zoom



Figure 5


Figure 5. 

Cumulative “total ischaemic time” (i.e. symptoms to treatment time delay) in the thrombolysis group (white squares) and the PCI group (black squares). The dotted line represents the ideal recommended maximum ischaemic time of 180min.

Zoom

Outcome

Overall, in-hospital survival was 96.5%: two patients died during the prehospital transfer from refractory cardiac arrest and two during the in-hospital period from refractory cardiogenic shock with multiorgan failure, despite extracorporeal life support. The rate of in-hospital major adverse cardiovascular events (i.e. cardiac death+recurrent non-fatal myocardial infarction+stroke) was 7.0%, with a trend toward a higher rate in the thrombolysis group than in the PCI group (11.5 vs 3.2%, respectively; P =0.08). Maximum Killip class was greater or equal to 2 in 35.1% of patients overall, and was significantly higher in the PCI group than in the thrombolysis group (43.5 vs 25.0%, respectively; P <0.05). One-fifth of patients experienced at least one major or minor adverse event, without any difference according to initial reperfusion therapy (Table 4).

Discussion

The main findings of our study are that: altitude STEMIs in the French Alps occur mainly in relatively young men with two or more cardiovascular risk factors and significant coronary artery disease on angiography, and occur during or after exercise in 76% of cases; a coronary emergency care network enables reasonable reperfusion therapy delays despite extreme geographical conditions; and the short-term prognosis for individuals with STEMI occurring in this setting is good, with an in-hospital death rate of 3.5%.

The altitude limit of 1000m was chosen in our study as it corresponds to the threshold above which almost all the ski resorts in the French Alps are sited; no mobile emergency teams are based permanently above this altitude, leading to relative geographical isolation. In these conditions, our study population is younger than that usually reported for STEMI patients. In the FAST-MI registry (a nationwide registry in France that included 223 centres and enrolled 1714 patients with acute coronary syndrome over a 1-month period at the end of 2005) [7, 8], the average age of STEMI patients was 61years (i.e. 4years older than in our present study). Similarly, 38% of the STEMI patients in the MONICA registry [9] were aged more than 65years versus only 24.5% in our population. Moreover, the prevalences of hypertension, diabetes mellitus and obesity were also lower in our series than in FAST-MI patients: 30 versus 44%, 11 versus 19% and 11 versus 21%, respectively.

Occurrence of STEMI in this young population with relatively fewer cardiovascular risks may be explained by the particular pathophysiology of acute myocardial infarction in this setting. Indeed, strenuous and unusual levels of physical activity (present in 76% of our patients), low temperature, dehydration and depletion of carbohydrates are known to increase adrenergic activity [10, 11, 12] and to lead to platelet activation [13, 14]. Therefore, the conjunction of abrupt changes in heart rate and blood pressure with subsequent haemodynamic stress, increased oxygen demand and increased thrombogenicity, may favour vulnerable atherosclerotic plaque disruption and thrombus formation, leading subsequently to an acute coronary syndrome [15]. Furthermore, the association of low temperature with hyperventilation has been demonstrated to potentiate the occurrence of coronary spasm–another mechanism that may contribute to an increase in local arterial stress and plaque ruptures in this particular setting [16].

Initial presentation of STEMI was, however, more severe than reported in the FAST-MI registry, with patients presenting more frequently with Killip class greater or equal to 2 and in cardiac arrest due to ventricular fibrillation (respectively, 35% and 8% vs 15% and 3% in the FAST-MI registry [8]). We may hypothesize that relative hypoxaemia secondary to high altitude may also increase myocardial ischaemia and susceptibility to arrhythmias [17].

Fourteen per cent of our study patients had known coronary artery disease. This result is consistent with that of Faulhaber et al. [17]; in their series of 1431 hikers and 1043 skiers in the Austrian Alps, 12.7% (11.0–14.4%) of hikers and 11.2% (9.3–13.1%) of skiers had at least one type of cardiovascular disease. The authors assumed accordingly that four to five million hikers and skiers with known cardiovascular diseases are active in the Alps annually. Our results are also concordant with data published by Burtscher and Ponchia, reporting that the risk of fatal cardiovascular events during mountain sports activities was highest for men older than 35years and increased with age, and that by comparison, male skiers older than 34years who experienced sudden cardiac death during mountain activity were much more likely to have a history of prior myocardial infarction (41% vs 1.5%), hypertension (50% vs 17%) or known CAD without prior myocardial infarction (9% vs 3%), and were less likely to be engaged in regular strenuous exercise (4% vs 15%) than controls [11, 18].

In terms of public health systems, these findings emphasize the need for an efficient emergency coronary care network in ski resorts. Our data show that such a network allows high rates of and short delays in reperfusion therapy in this setting. Indeed, 54% of patients could benefit from PCI–a similar rate to that reported in the FAST-MI registry (55%). Similarly, the median first call to treatment delay in our study was similar to that observed in the FAST-MI registry in the thrombolysis group (55 vs 57min, respectively), and was even 1hour shorter in the PCI group (117 vs 170min, respectively). Of note, 98% of the patients who underwent prehospital thrombolysis in our study had a first call to treatment delay of less than 2hours. Conversely, only 52% of patients in the PCI group underwent reperfusion therapy beyond this 2-hour threshold. Indeed, the first call to treatment delay was 1hour longer in the PCI group than in the prehospital thrombolysis group, which is consistent with previous randomized studies comparing these two strategies [19]. Finally, the median symptom to treatment delay of 245min in the PCI group may reflect good compliance with ESC guidelines, the risk–benefit ratio of thrombolysis being unfavourable in “late presenters” [19, 20] and PCI being the preferred treatment in this setting.

Despite the perilous situation in which STEMI occurred in our series, in-hospital outcome was favourable, with major adverse events being as infrequent as in the FAST-MI study and death rates of 3.5% versus 4.7%, respectively. Even if these differences may be explained in part by the lower risk profile of our patients (younger age and fewer risk factors), it could have been offset by the more severe initial clinical presentation. We can therefore hypothesize that these relatively good results may reflect–at least partially–the efficiency of the RESURCOR network.

Conclusion

Altitude STEMI, happening mainly during sporting activities, occurs in relatively young patients with few cardiovascular risk factors. Nevertheless, initial clinical presentation is often severe, with frequent haemodynamic instability and a high prevalence of cardiac arrests. The Alpine Arch emergency coronary care network, combining mountain rescue team, medical mobile unit able to perform prehospital thrombolysis and hospitals with on-site PCI, allows rapid reperfusion therapy in most cases. These findings emphasize the need for an efficient network for acute STEMI management, especially in geographically difficult-to-access areas.

Conflict of interest statement

None.

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