Influence of Geographical Location on Access to Reperfusion Therapies and Mortality of Patients with STEMI in Sergipe: VICTIM Register

Oliveira, Jeferson Cunha; Ferreira, Guilherme José dos Santos; Oliveira, Jussiely Cunha; Lima, Ticiane Clair Remacre Munareto; Barreto, Ikaro Daniel de Carvalho; Oliveira, Laís Costa Souza; Arcelino, Larissa Andreline Maia; Sousa, Antônio Carlos; Barreto-Filho, José Augusto Soares

doi:10.36660/abc.20200015

Abstract

Background

The concentration of high-complexity services in Aracaju, Sergipe can impose certain disparity in the quality of care for the patients with ST-segment elevation acute myocardial infarction (STEMI) (STEMI) who receive care from Brazil’s Unified Health System (SUS, acronym in Portuguese) and whose symptoms started in other health regions of the state.

Objective

To evaluate disparities in access to reperfusion therapies and 30-day mortality, among patients with STEMI, who were users of SUS, in each of the 7 health regions of Sergipe.

Methods

A total of 844 patients with STEMI in the period from 2014 to 2018, assisted by the only hospital with the capacity to offer primary percutaneous coronary intervention (PPCI) to SUS users in the state of Sergipe, were evaluated. The patients were divided into 7 groups according to the location at the onset of symptoms, following the existing division of health regions in the state. For comparison between groups, a significant difference was considered when p < 0.05.

Results

Of the total of 844 patients suffering from STEMI who were transferred to the hospital with PPCI that serves SUS patients, 386 patients (45.8%) underwent primary angioplasty. The mean rate of fibrinolytic use was 2.6%, with no differences between the regions. The mean total time of arrival to the hospital with PPCI was 21 hours and 55 minutes, with a median of 10 hours and 22 minutes (6 hours and 30 minutes to 22 hours and 52 minutes). Total 30-day mortality was 12.8%, but without differences between the regions, even when adjusted for age and sex.

Conclusions

This study reveals that fibrinolytics are underused throughout the state and that there is a significant delay in access to the hospital with PPCI, in all health regions of Sergipe.

Cardiovascular Diseases; Myocardial Infarction; Myocardial Reperfusion; Mortality; Epidemiology; Cross-Sectional Studies

Resumo

Fundamento

A concentração de serviços de alta complexidade em Aracaju/SE pode proporcionar disparidade na qualidade assistencial para os pacientes do SUS com infarto agudo do miocárdio com supradesnivelamento do segmento ST (IAMcSST) cujos sintomas se iniciaram em outras regiões de saúde do estado.

Objetivo

Avaliar disparidades no acesso às terapias de reperfusão e mortalidade em 30 dias, entre pacientes com IAMcSST, usuários do SUS, em cada uma das 7 regiões de saúde em Sergipe.

Métodos

Foram avaliados 844 pacientes com IAMcSST no período de 2014 a 2018 atendidos pelo único hospital com capacidade de ofertar intervenção coronariana percutânea (ICP) primária para usuários do SUS no estado de Sergipe. Os pacientes foram divididos em 7 grupos de acordo com o local de início dos sintomas e obedecendo a divisão já existente das regiões de saúde do Estado. Para comparação entre grupos, foi considerada diferença significativa quando p < 0,05.

Resultados

Do total de 844 pacientes vítimas de IAMcSST e transferidos ao hospital com ICP que atende pacientes do SUS, 386 pacientes (45,8%) realizaram angioplastia primária. A taxa média do uso de fibrinolítico foi de 2,6%, não havendo diferenças entre as regiões. O tempo médio total de chegada ao hospital com ICP foi de 21h55’ com mediana de 10h22’ (6h30’ – 22h52’). A mortalidade total em 30 dias foi 12,8%, mas sem diferenças entre as regiões, mesmo quando ajustada para idade e sexo.

Conclusões

Este estudo revela que os fibrinolíticos são subutilizados em todo o estado e que existe um atraso significativo no acesso ao hospital com ICP, em todas as regiões de saúde de Sergipe.

Doenças Cardiovasculares; Infarto do Miocárdio; Reperfusão Miocárdica; Mortalidade; Epidemiologia; Estudos de Corte Transversal

Introduction

Cardiovascular diseases (CVDs) represent the main cause of death in Brazil and worldwide. Within this group, ST-segment elevation acute myocardial infarction (STEMI) is responsible for the highest mortality in the ischemic heart disease class, due to its severity in clinical prognosis. ¹1. Farshid A , Allada C , Chandrasekhar J , Marley P , McGill D , O’Connor S , et al .. Shorter ischaemic time and improved survival with pre-hospital STEMI diagnosis and direct transfer for primary PCI . Heart Lung Circ . 2015 ; 24 ( 3 ): 234 - 40 .

In this context, early access and immediate coronary reperfusion is the main objective in the treatment of STEMI, because they reduce adverse outcomes and mortality. ²2. França AVC . Atenção Hospitalar no Estado de Sergipe: Saberes e tecnologias para implantação de uma política . In: França AVC . Atenção Hospitalar no Estado de Sergipe . Sergipe: Sergipe : Fundação Estadual de Saúde ; 2021 .p. 1 - 188 , ³3. Gale CP , Cattle BA , Woolston A , Baxter PD , West TH , Simms AD , et al . Resolving inequalities in care? Reduced mortality in the elderly after acute coronary syndromes. The Myocardial Ischaemia National Audit Project 2003–2010 . Eur Heart J . 2011 ; 33 ( 5 ): 630 - 9 . Among the reperfusion therapies, primary percutaneous coronary intervention (PPCI) and the use of fibrinolytics are the main therapeutic strategies. However, PPCI is considered the gold standard in treatment, if performed within fewer than 12 hours after the onset of symptoms, and it has been shown to be superior to fibrinolytics in reducing mortality, reinfarction and stroke. ⁴4. Gershlick AH , Banning AP , Myat A , Verheugt WA , Gersh BJ . Reperfusion therapy for STEMI: is there still a role for thrombolysis in the era of primary percutaneous coronary intervention? . Lancet . 2013 ; 382 ( 9892 ): 624 - 32 .

A previous study developed by Oliveira et al. ⁵5. Oliveira JC , Santos MA , Oliveira JC , Oliveira LC , Barreto ID , Lima TC , et al . Disparities in Access and Mortality of Patients With ST-Segment elevation Myocardial Infarction Using the Brazilian Public Healthcare System: VICTIM Register . J Am HeartAssoc . 2019 ; 8 ( 20 ): e013057 . showed that, in Sergipe, the time from the onset of symptoms to arrival at the hospital with PPCI (24.4 h ± 36.5 h) is twice as long as recommended in patients using Brazil’s Unified Health System (SUS, acronym in Portuguese). While the rates of fibrinolytic use are low in both public and private services, they are even lower in SUS patients, and 30-day mortality was also higher in the SUS (11.9%) when compared to patients in the private service (5.9%). These data can be even worse when comparing the health regions of Sergipe. ⁵5. Oliveira JC , Santos MA , Oliveira JC , Oliveira LC , Barreto ID , Lima TC , et al . Disparities in Access and Mortality of Patients With ST-Segment elevation Myocardial Infarction Using the Brazilian Public Healthcare System: VICTIM Register . J Am HeartAssoc . 2019 ; 8 ( 20 ): e013057 .

In addition, based on the SUS organizational principles, the state is divided into 7 health regions; however, despite the division, all the hospitals with a hemodynamics service are located in a single health region. Moreover, to make matters worse, only one of these hospitals is a cardiology reference for SUS users, and it is not open-doors.

In this context, this study aims to assess the possible differences regarding access to reperfusion therapies and mortality in patients with STEMI who are treated exclusively by the SUS, between the different health regions of Sergipe.

Material and methods

This is a cross-sectional study with a quantitative approach, conducted with data obtained between December 2014 and March 2018, using the database of the VICTIM Register (Via Crucis for the Treatment of Myocardial Infarction). This study was approved by the Ethics and Research Committee of the Federal University of Sergipe, under opinion number 483,749. The data were collected at the only hospital in the state where primary PPCI is made available by the SUS. This hospital, in turn, does not have an open-door system, that is, patients must be referred from other health services with confirmed diagnosis of STEMI.

Collection was carried out by the researchers using their own research instrument, the case report form (CRF), composed of sociodemographic variables, clinical conditions at hospitalization, data referring to the time and path traveled from the onset of symptoms to the care provided in a specialized hospital, angiography procedure, and evolution of the patients during hospitalization after the acute myocardial infarction. The information was collected through interviews with patients or companions and data from medical records.

Patients of both sexes, over 18 years old, with onset of symptoms within the territory of Sergipe, and with diagnosis of STEMI confirmed by the electrocardiogram, according to the defining criteria proposed by the V Guidelines of the Brazilian Society of Cardiology ⁶6. Piegas LS , Timerman A , Feitosa GS , Nicolau JC , Mattos LA , Andrade MD , et al . V Diretriz da Sociedade Brasileira de Cardiologia sobre Tratamento do Infarto Agudo do Miocárdio com Supradesnível do Segmento ST . Arq Bras Cardiol . 2015 ; 105 ( 2 ): 1 - 105 . were included, provided that they received care exclusively from the SUS and signed the Free and Informed Consent Form.

The following exclusion criteria were applied: died before the interview; refused to participate in the research; presented onset of symptoms outside the territory of Sergipe; received care in a private network; did not characterize the Via Crucis, that is, those patients who did not travel the path from the onset of the symptoms to the arrival at the hospital with the capacity to perform PPCI because they had already presented STEMI within the hospital; those whose acute STEMI event was characterized as reinfarction (occurring within 28 days of the incident infarction); had a change in diagnosis during hospitalization; and assisted by agreement in a philanthropic hospital.

Once the study inclusion criteria were met, the patients were allocated consecutively. For analysis, patients with STEMI were divided into 7 groups, from the health region where onset of symptoms occurred, namely: 1. Aracaju, 2. Itabaiana, 3. Estância, 4. Lagarto, 5. Nossa Senhora do Socorro (Socorro), 6. Nossa Senhora da Glória (Glória), and 7. Propriá. These health regions were defined according to Deliberation No. 065/2012, of April 18 ^th , 2012, which ratifies the division of the state territory of Sergipe into 7 health regions, determining the municipalities that make up each region ( Figure 1 ). Based on the last census conducted by the Brazilian Institute of Geography and Statistics, the state of Sergipe and its 75 municipalities have an estimated population of just over 2 million inhabitants, ⁷7. InstitutoBrasileiro de Geografia e Estatística.(IBGE) . Estimativa populacional 2018 . Disponível em: < https://www.ibge.gov.br/estatísticas-ovoportal/sociais/populacao/9103-estimativas-de-populacao.html?=&t=downloads> . Acesso em: 06 de fevereiro de 2018 .
https://www.ibge.gov.br/estatísticas-ovo... who are divided, in the perspective of the SUS, into these 7 health regions. ²2. França AVC . Atenção Hospitalar no Estado de Sergipe: Saberes e tecnologias para implantação de uma política . In: França AVC . Atenção Hospitalar no Estado de Sergipe . Sergipe: Sergipe : Fundação Estadual de Saúde ; 2021 .p. 1 - 188

Figure 1
– Map of Sergipe and its health regions. Source: state health secretariat (2016)

Statistical analysis

The categorical variables were described using absolute and relative frequency. The associations were tested using the chi-square test with Monte-Carlo simulations. The multiple comparisons for the proportions were tested using the Z test with Bonferroni correction. The continuous variables were described as median and interquartile range due to their non-adherence to the normal distribution assessed by the Shapiro-Wilk test. The differences in the measures of central tendency were tested using the Kruskal-Wallis test. The multiple comparisons for the measures of central tendency were tested by the Kruskal-Wallis test with Bonferroni correction. The gross and adjusted odds ratios were estimated for overall 30-day mortality through logistic regression. The significance level adopted was 5%, and the software used was R Core Team 2019.

Results

Sociodemographic Profile

A total of 844 patients were analyzed, 294 (34.8%) of whom were from the Aracaju health region, 102 (12.1%) from the Itabaiana region, 119 (14.1%) from the Estancia region, 122 (14.5%) from the Lagarto region, 119 (14.1%) from the Socorro region, 41 (4.85%) from the Glória region, and 47 (5.6%) from the Propriá region.

The total median age was 61 years old; among the regions, Estância had a significantly higher median age and the Glória region had the lowest. In all regions, there was prevalence of male patients and non-white ethnicity (70%), with a difference between the Socorro region when compared to Lagarto or Glória (p = 0.02) ( Table 1 ).

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Table 1
– Sociodemographic characteristics of patients with STEMI by health region*

Clinical features

Among the risk factors, diabetes mellitus was the only one that presented significant variability, ranging from 17.1% in Glória to 42.6% in Propriá (p = 0.026). The other risk factors showed similar prevalence values between the groups ( Table 2 ).

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Table 2
– Clinical characteristics of the patients with STEMI by health regions*

Regarding the values of systemic blood pressure upon admission to the hospital with PPCI ( Table 2 ), systolic blood pressure had a total median of 140 mmHg, presenting the highest value in the Aracaju region and the lowest in Nossa Senhora da Glória, with differences when compared to each other (p = 0.016). Diastolic blood pressure, on the other hand, reached a total median of 83 mmHg, with the highest median in Aracaju, Nossa Senhora do Socorro, and Itabaiana, and the lowest median in Nossa Senhora da Glória, Estância, Lagarto, and Propriá (p = 0.007).

The Lagarto region showed the highest rate of patients considered to be at high risk of mortality by the GRACE score (64.4%) ( Table 2 ), while Aracaju had the lowest (41.9%), and it possible to observe a difference when comparing the Aracaju and Nossa Senhora da Glória regions in relation to Lagarto (p = 0.001). Of the total number of patients, 85.3% had Killip I, and 62.5% of the STEMI were of the anterior wall; this behavior pattern was repeated across the regions.

Coronary reperfusion

The total primary PPCI rate was 45.8%, with the Aracaju region having the highest (51.9%) and Glória the lowest (17.1%), with a difference when compared to Aracaju or Itabaiana (p = 0.03). Of the total, 25.1% of the study patients did not undergo PPCI, and the total rate of fibrinolytic use was 2.6% ( Table 3 ).

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Table 3
– Procedures performed on patients with STEMI by health regions*

The mean time between the onset of symptoms and arrival at the hospital with PPCI was 21 hours and 55 minutes with a median of 10 hours and 22 minutes (6 hours and 30 minutes to 22 hours and 52 minutes), with Glória showing the longest delay, and Aracaju the shortest. A statistical difference was recorded when the Glória and Socorro regions were compared in relation to Aracaju (p = 0.001). Of the periods that make up this entire time interval, the time elapsed between arrival at a hospital without PPCI and arrival at a hospital with PPCI was the most impactful, recording a median time of 7 hours and 37 minutes. In this regard, the region with the longest delay was Glória, and the one with the lowest was Aracaju; it was possible to observe differences when comparing the Lagarto and Glória regions with Aracaju ( Table 4 ).

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Table 4
– Time and geographical course between onset of symptoms and arrival at the hospital with PPCI by health region*

Regarding the number of institutions visited before the hospital with PPCI, the vast majority of the patients (81.2%) went through at least one institution before the hospital with PPCI. Nearly 2.4% of the patients went to at least three institutions before the hospital with PPCI, while only 1.7% had direct access to this hospital ( Table 4 ).

Mortality

When assessing 30-day mortality ( Table 5 ), it was observed that the Estância region had the highest rate (18.6%), and Nossa Senhora da Glória had the lowest (7.5%) (p = 0.03). When adjusted for age and sex, adopting the Aracaju region as a control group, no statistical differences were observed.

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Table 5
– Odds ratio for 30-day mortality in patients with STEMI by health regions, adjusted for age and sex

Discussion

Three main findings expressively marked the results of this study. The first points to major delays in the arrival of patients with STEMI at the hospital with PPCI, regardless of the onset of symptoms. The second testifies to disparities in the use of reperfusion therapies between patients in the different health regions. The third shows the regional influence on mortality. These findings demonstrate that there is an urgent need to improve quality of care for patients with STEMI throughout the state of Sergipe.

Despite greater knowledge about the therapeutic goals in the management of STEMI, the reproducibility of these targets is still a difficult task, especially in the field of public health in Brazil. ⁸8. Carvalho G , Rassi S , Guerios N , Curado FA , Bastos AT . Striving to meet targets for ideal treatment of acute myocardial infarction in Brazil: Data from the Midwest region . J Interv Cardiol . 2018 ; 31 ( 4 ): 450 - 4 . , ⁹9. Piegas LS e Haddad N . Intervenção coronariana percutânea no Brasil: resultados do Sistema Único de Saúde . Arq Bras Cardiol . 2011 ; 96 ( 4 ): 317 - 24 . Patients with onset of STEMI in the state of Sergipe have a 30-day mortality rate far from what is considered desirable. A report by the European Society of Cardiology, including several countries, showed in-hospital mortality ranging from 3.1% to 6.1%. ¹⁰10. Kristensen SD , Laut KG , Fajadet J , Kaifoszova Z , Kala P , Mario C , et al . Reperfusion therapy for ST elevation acute myocardial infarction 2010/2011: current status in 37 ESC countries . Eur Heart J . 2014 ; 35 ( 29 ): 1957 - 70 . A French trial, carried out between 1995 and 2010, found a reduction in 30-day mortality from 13.7% to 4.4%. This decrease is due to multiple factors within care for patients with STEMI, such as the increase in the number of mobile intensive care units, an increase in the number of public information campaigns on the symptoms related to the disease, and lesser delays in both arrival at a qualified hospital and in the decision to seek help. ¹¹11. Puymirat E , Simon T , Steg PG , Schiele F , Gueret P , Blanchard D , et al . Association of changes in clinical characteristics and management with improvement in survival among patients with ST-elevation myocardial infarction . JAMA . 2012 ; 308 ( 10 ): 998 - 1006 .

Concomitantly, both regions with the worst rates presented the highest mean age groups. Despite the reduction in mortality due to acute coronary syndromes at all ages, it is known that older patients have worse prognosis compared to younger ones, due both to the fact that they have a higher number of comorbidities and to the lesser use of reperfusion and medication therapies. ³3. Gale CP , Cattle BA , Woolston A , Baxter PD , West TH , Simms AD , et al . Resolving inequalities in care? Reduced mortality in the elderly after acute coronary syndromes. The Myocardial Ischaemia National Audit Project 2003–2010 . Eur Heart J . 2011 ; 33 ( 5 ): 630 - 9 . , ¹²12. Halon DA , Adawi S , Dobrecky-Mery I , Lewis BS . Importance of increasing age on the presentation and outcome of acute coronary syndromes in elderly patients . J Am Coll Cardiol . 2004 ; 43 ( 3 ): 346 - 52 . , ¹³13. Tran CT , Laupacis A , Mamdani MM , Tu JV . Effect of age on the use of evidence-based therapies for acute myocardial infarction . Am Heart J . 2004 ; 148 ( 5 ): 834 - 41 .

Before arriving at the hospital with the capacity to perform PPCI, some patients had to go through at least one health unit lacking this service until they were transferred to the specialized hospital. These data were also analyzed in this study and the result obtained was that most of the patients went to a hospital before arriving at the hospital with the capacity to perform PPCI, a fact that was already expected, since the only public hospital with capacity for performing PPCI does not offer open-door service. Some patients who have direct access to the hospital with PPCI were regulated and referred by the Mobile Emergency Care Service.

The period between the onset of symptoms and access to a hemodynamics service plays a decisive role in the patients’ prognosis. ¹⁴14. Blankenship JC , Skelding KA , Scott TD , Berger PB , Parise H , Brodie BR , et al . Predictors of reperfusion delay in patients with acute myocardial infarction undergoing primary percutaneous coronary intervention from the HORIZONS-AMI trial . Am J Cardiol . 2010 ; 106 ( 11 ): 1527 - 33 . In Sergipe, in this period the mean time spent was 21 hours and 55 minutes with a median of 10 hours and 22 minutes (6 hours and 30 minutes to 22 hours and 52 minutes), bordering twice the 12-hour window established by the national and international guidelines. Evaluating from a regional perspective, this mean interval reached values of 26 hours and 24 minutes and 26 hours and 10 minutes in the Socorro and Glória regions, respectively, and they were shorter in Estância, with 16 hours and 22 minutes. However, despite this discrepancy, it was only possible to observe statistical differences when comparing Socorro and Glória to Aracaju. It is worth highlighting that the municipality farthest from the capital is nearly 3 hours away.

In the state of Sergipe, the time interval experienced by patients with STEMI from the onset of symptoms to access to a qualified hospital suffers a huge impact from the hospital interim period, constituting approximately 87% of the entire process. From this perspective, these results do not correspond to the geographic reality of Sergipe, which is considered the smallest state in Brazil, where it takes around 4 hours to go from one end of the state to the other by car. In addition to that, the Socorro region, despite its relative proximity to the Aracaju region compared to the others, paradoxically presents the largest of these delays, with 23 hours and 15 minutes.

Several elements can be linked to the prolongation of this interval, ranging from delays in disease diagnosis to inefficiency in the transportation means between the assisting institutions. ¹1. Farshid A , Allada C , Chandrasekhar J , Marley P , McGill D , O’Connor S , et al .. Shorter ischaemic time and improved survival with pre-hospital STEMI diagnosis and direct transfer for primary PCI . Heart Lung Circ . 2015 ; 24 ( 3 ): 234 - 40 . , ¹⁵15. Postma S , Dambrink JH , Boer MJ , Gosselink AT , Ottervanger JP , Koopmans PC , et al . The influence of residential distance on time to treatment in ST-elevation myocardial infarction patients . Neth Heart J . 2014 ; 22 ( 11 ): 513 - 19 . A piece of data that deserves to be highlighted is the impossibility of referring patients directly to the qualified hospital. In Sergipe, the only hospital capable of offering definitive treatment to SUS patients with STEMI only receives patients through referrals made by another institution, as long as they are already diagnosed.

A study carried out in the state of North Carolina, in the period between 2008 and 2010, evaluated 1,288 patients diagnosed with STEMI, dividing them into two groups, those who were transferred directly to hospitals with PPCI regardless of the distance and those who were transported to the nearest hospital without PPCI. In this comparison, 46.5% of the patients directly transferred to a center with a hemodynamics service arrived within 90 minutes after the first medical contact, while, in the other group, only 21.5% of the patients arrived at a hemodynamics center within 120 minutes after the first medical contact. ¹⁶16. Fosbol EL , Granger CB , Jollis JG , Monk L , Lin L , Lytle BL , et al . The impact of a statewide pre-hospital STEMI strategy to bypass hospitals without percutaneous coronary intervention capability on treatment times . Circulation . 2013 ; 127 ( 5 ): 604 - 12 .

Considering the major difficulty of access in the only hospital with the capacity to perform PPCI, less than half of the patients arrive within the 12-hour window from the onset of symptoms; the expressive underuse of fibrinolytics in the state of Sergipe can be considered an indicator of a very deficient care practice contributing to the high mortality observed in our records. The mean rate of fibrinolytic use of 2.6% differs greatly from other national and international records, ¹⁷17. Rosselló X , Huo Y , Pocock S , Werf FV , Chin CT , Danchin N , et al . Global geographical variations in ST-segment elevation myocardial infarction management and post-discharge mortality . Int J Cardiol . 2017 ;( 245 ): 27 - 34 . , ¹⁸18. Vora AN , Holmes DN , Rokos I , Roe MT , Granger CB , French WJ , et al . Fibrinolysis use among patients requiring interhospital transfer for ST-segment elevation myocardial infarction care: a report from the US National Cardiovascular Data Registry . JAMA . 2015 ; 175 ( 2 ): 207 - 15 . and, in the scenario of difficult access to the only hospital capable of performing PPCI, it unequivocally exposes the important weakness and inefficiency of STEMI care in our state. ⁴4. Gershlick AH , Banning AP , Myat A , Verheugt WA , Gersh BJ . Reperfusion therapy for STEMI: is there still a role for thrombolysis in the era of primary percutaneous coronary intervention? . Lancet . 2013 ; 382 ( 9892 ): 624 - 32 . Our findings could be even more critical, if the population studied was composed of all patients with STEMI in the state, that is, those who stayed in primary and secondary hospitals, without access to the tertiary hospital. Incorporating the network of regional hospitals with the capacity to perform thrombolysis in the scenario may increase the total rate of patients who are reperfused and reduce mortality in this setting.

Although primary angioplasty is the treatment of choice for these patients, in this study, only 45.8% of the patients underwent this therapy, reaching more striking values from the perspective of the Glória region, with 17.1%. These rates are below those found in other studies. ¹⁹19. Aguirre FV , Varghese JJ , Kelley MP , Lam W , Lucore CL , Gill JB , et al . Rural interhospital transfer of ST-elevation myocardial infarction patients for percutaneous coronary revascularization: the Stat Heart Program . Circulation . 2008 ; 117 ( 9 ): 1145 - 52 .

20. Ibanez B , James S , Agewall S , Antunes MJ , Bucciarelli-Ducci C , Bueno H , et al . Task Force on the management of ST-segment elevation acute myocardial infarction of the European Society of Cardiology (ESC). ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation . Eur Heart J . 2018 ; 39 ( 2 ): 119 - 77 .

21. O’Gara PT , Kushner FG , Ascheim DD , Casey DE Jr , Chung MK , de Lemos JA , et al . 2013 ACCF/AHA Guideline for the Management of ST Elevation Myocardial Infarction: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines . Circulation . 2013 ; 127 ( 4 ): 362 - 425 . - ²²22. Santos J , Meira KC , Camacho AR , Salvador PT , Guimaraes RM , Pierin AM , et al . Mortalidade por infarto agudo do miocárdio no Brasil e suas regiões geográficas: análise do efeito da idade-período-coorte . Cien Saud Colet . 2018 ;( 23 ): 1621 - 34 . Despite the variability across the regions, it was only possible to observe a statistical difference when comparing the Lagarto region to Aracaju.

The discrepancies found both in the PPCI rate and in the time to access this method are justified by the same failures in the health care network. A study conducted in the United Kingdom showed that, in the second half of 2011, 94% of the patients with STEMI were treated by PPCI, a significant increase when compared to the rate of 46% in 2008. Among the elements responsible for this progression are the following: direct transportation of patients to centers with PPCI, professional training for pre-hospital diagnosis, data collection regarding quality of care, and, finally, creation of national policies in order to facilitate access to the health care network. ²³23. Mclenachan JM , Gray HH , Belder MA , Ludman PF , Cunningham D , Birkhead J . Developing primary PCI as a national reperfusion strategy for patients with ST-elevation myocardial infarction: the UK experience . EuroIntervention . 2012 ;( 8 ): 99 - 107 .

Another study carried out in the United Kingdom using data from England and Wales, with a total of 228 hospitals and a sample of 34,722 patients with STEMI, showed that the use of aspirin at admission and thrombolysis outside the hospital are the strongest predictors of in-hospital survival. In addition to that, factors such as heart rate and systolic blood pressure at admission also impact 30-day mortality due to STEMI. ³3. Gale CP , Cattle BA , Woolston A , Baxter PD , West TH , Simms AD , et al . Resolving inequalities in care? Reduced mortality in the elderly after acute coronary syndromes. The Myocardial Ischaemia National Audit Project 2003–2010 . Eur Heart J . 2011 ; 33 ( 5 ): 630 - 9 .

Limitations

In view of the precariousness of well-documented records in some of the regions, data acquisition was supplemented through interviews, and part of these were self-reported, which can lead to inaccuracies in the time measures. It is also worth noting that many SUS users are unaware of their previous health status, making it difficult to accurately measure the prevalence of comorbidities; this fact hinders adjustment of the risk across the different populations of the regions under study. Finally, this study restricted data collection to the hospital with PPCI, as it is the only reference in the treatment of STEMI in the state. This fact limits the results to the patients who had access to the reference center. However, we emphasize that, by limiting the population to the reference center, the observed scenario represents the best quality of care provided by the SUS in the state of Sergipe.

Conclusion

The VICTIM Register identified a glaring lack of sufficient access to PPCI in the state, recording a primary time window of access almost double that which is considered borderline, which was even worse in some sub-regions. In addition, there is marked underuse of fibrinolytics, as an alternative reperfusion therapy for STEMI, in all regions. High mortality rates persist, despite the therapeutic advances in cardiovascular science in the era of myocardial reperfusion. Together, our data demonstrate great inefficiency of the SUS in terms of assistance to patients with STEMI in the state of Sergipe. Our results should be investigated in other states and regions of the country to assess whether the precarious indicators herein observed are peculiar to Sergipe and the inserted region, or whether they represent “standard” care in the Brazilian public health system.

Referências

¹
Farshid A , Allada C , Chandrasekhar J , Marley P , McGill D , O’Connor S , et al .. Shorter ischaemic time and improved survival with pre-hospital STEMI diagnosis and direct transfer for primary PCI . Heart Lung Circ . 2015 ; 24 ( 3 ): 234 - 40 .
²
França AVC . Atenção Hospitalar no Estado de Sergipe: Saberes e tecnologias para implantação de uma política . In: França AVC . Atenção Hospitalar no Estado de Sergipe . Sergipe: Sergipe : Fundação Estadual de Saúde ; 2021 .p. 1 - 188
³
Gale CP , Cattle BA , Woolston A , Baxter PD , West TH , Simms AD , et al . Resolving inequalities in care? Reduced mortality in the elderly after acute coronary syndromes. The Myocardial Ischaemia National Audit Project 2003–2010 . Eur Heart J . 2011 ; 33 ( 5 ): 630 - 9 .
⁴
Gershlick AH , Banning AP , Myat A , Verheugt WA , Gersh BJ . Reperfusion therapy for STEMI: is there still a role for thrombolysis in the era of primary percutaneous coronary intervention? . Lancet . 2013 ; 382 ( 9892 ): 624 - 32 .
⁵
Oliveira JC , Santos MA , Oliveira JC , Oliveira LC , Barreto ID , Lima TC , et al . Disparities in Access and Mortality of Patients With ST-Segment elevation Myocardial Infarction Using the Brazilian Public Healthcare System: VICTIM Register . J Am HeartAssoc . 2019 ; 8 ( 20 ): e013057 .
⁶
Piegas LS , Timerman A , Feitosa GS , Nicolau JC , Mattos LA , Andrade MD , et al . V Diretriz da Sociedade Brasileira de Cardiologia sobre Tratamento do Infarto Agudo do Miocárdio com Supradesnível do Segmento ST . Arq Bras Cardiol . 2015 ; 105 ( 2 ): 1 - 105 .
⁷
InstitutoBrasileiro de Geografia e Estatística.(IBGE) . Estimativa populacional 2018 . Disponível em: < https://www.ibge.gov.br/estatísticas-ovoportal/sociais/populacao/9103-estimativas-de-populacao.html?=&t=downloads> . Acesso em: 06 de fevereiro de 2018 .
» https://www.ibge.gov.br/estatísticas-ovoportal/sociais/populacao/9103-estimativas-de-populacao.html?=&t=downloads>
⁸
Carvalho G , Rassi S , Guerios N , Curado FA , Bastos AT . Striving to meet targets for ideal treatment of acute myocardial infarction in Brazil: Data from the Midwest region . J Interv Cardiol . 2018 ; 31 ( 4 ): 450 - 4 .
⁹
Piegas LS e Haddad N . Intervenção coronariana percutânea no Brasil: resultados do Sistema Único de Saúde . Arq Bras Cardiol . 2011 ; 96 ( 4 ): 317 - 24 .
¹⁰
Kristensen SD , Laut KG , Fajadet J , Kaifoszova Z , Kala P , Mario C , et al . Reperfusion therapy for ST elevation acute myocardial infarction 2010/2011: current status in 37 ESC countries . Eur Heart J . 2014 ; 35 ( 29 ): 1957 - 70 .
¹¹
Puymirat E , Simon T , Steg PG , Schiele F , Gueret P , Blanchard D , et al . Association of changes in clinical characteristics and management with improvement in survival among patients with ST-elevation myocardial infarction . JAMA . 2012 ; 308 ( 10 ): 998 - 1006 .
¹²
Halon DA , Adawi S , Dobrecky-Mery I , Lewis BS . Importance of increasing age on the presentation and outcome of acute coronary syndromes in elderly patients . J Am Coll Cardiol . 2004 ; 43 ( 3 ): 346 - 52 .
¹³
Tran CT , Laupacis A , Mamdani MM , Tu JV . Effect of age on the use of evidence-based therapies for acute myocardial infarction . Am Heart J . 2004 ; 148 ( 5 ): 834 - 41 .
¹⁴
Blankenship JC , Skelding KA , Scott TD , Berger PB , Parise H , Brodie BR , et al . Predictors of reperfusion delay in patients with acute myocardial infarction undergoing primary percutaneous coronary intervention from the HORIZONS-AMI trial . Am J Cardiol . 2010 ; 106 ( 11 ): 1527 - 33 .
¹⁵
Postma S , Dambrink JH , Boer MJ , Gosselink AT , Ottervanger JP , Koopmans PC , et al . The influence of residential distance on time to treatment in ST-elevation myocardial infarction patients . Neth Heart J . 2014 ; 22 ( 11 ): 513 - 19 .
¹⁶
Fosbol EL , Granger CB , Jollis JG , Monk L , Lin L , Lytle BL , et al . The impact of a statewide pre-hospital STEMI strategy to bypass hospitals without percutaneous coronary intervention capability on treatment times . Circulation . 2013 ; 127 ( 5 ): 604 - 12 .
¹⁷
Rosselló X , Huo Y , Pocock S , Werf FV , Chin CT , Danchin N , et al . Global geographical variations in ST-segment elevation myocardial infarction management and post-discharge mortality . Int J Cardiol . 2017 ;( 245 ): 27 - 34 .
¹⁸
Vora AN , Holmes DN , Rokos I , Roe MT , Granger CB , French WJ , et al . Fibrinolysis use among patients requiring interhospital transfer for ST-segment elevation myocardial infarction care: a report from the US National Cardiovascular Data Registry . JAMA . 2015 ; 175 ( 2 ): 207 - 15 .
¹⁹
Aguirre FV , Varghese JJ , Kelley MP , Lam W , Lucore CL , Gill JB , et al . Rural interhospital transfer of ST-elevation myocardial infarction patients for percutaneous coronary revascularization: the Stat Heart Program . Circulation . 2008 ; 117 ( 9 ): 1145 - 52 .
²⁰
Ibanez B , James S , Agewall S , Antunes MJ , Bucciarelli-Ducci C , Bueno H , et al . Task Force on the management of ST-segment elevation acute myocardial infarction of the European Society of Cardiology (ESC). ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation . Eur Heart J . 2018 ; 39 ( 2 ): 119 - 77 .
²¹
O’Gara PT , Kushner FG , Ascheim DD , Casey DE Jr , Chung MK , de Lemos JA , et al . 2013 ACCF/AHA Guideline for the Management of ST Elevation Myocardial Infarction: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines . Circulation . 2013 ; 127 ( 4 ): 362 - 425 .
²²
Santos J , Meira KC , Camacho AR , Salvador PT , Guimaraes RM , Pierin AM , et al . Mortalidade por infarto agudo do miocárdio no Brasil e suas regiões geográficas: análise do efeito da idade-período-coorte . Cien Saud Colet . 2018 ;( 23 ): 1621 - 34 .
²³
Mclenachan JM , Gray HH , Belder MA , Ludman PF , Cunningham D , Birkhead J . Developing primary PCI as a national reperfusion strategy for patients with ST-elevation myocardial infarction: the UK experience . EuroIntervention . 2012 ;( 8 ): 99 - 107 .

Study Association

This article is part of the thesis of master submitted by Jeferson Cunha Oliveira, from Universidade Federal de Sergipe.

Sources of Funding
There were no external funding sources for this study.

Publication Dates

Publication in this collection
26 July 2021
Date of issue
July 2021

History

Received
06 Jan 2020
Reviewed
04 June 2020
Accepted
05 Aug 2020

This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

[1] ¹
Farshid A , Allada C , Chandrasekhar J , Marley P , McGill D , O’Connor S , et al .. Shorter ischaemic time and improved survival with pre-hospital STEMI diagnosis and direct transfer for primary PCI . Heart Lung Circ . 2015 ; 24 ( 3 ): 234 - 40 .

[2] ²
França AVC . Atenção Hospitalar no Estado de Sergipe: Saberes e tecnologias para implantação de uma política . In: França AVC . Atenção Hospitalar no Estado de Sergipe . Sergipe: Sergipe : Fundação Estadual de Saúde ; 2021 .p. 1 - 188

[3] ³
Gale CP , Cattle BA , Woolston A , Baxter PD , West TH , Simms AD , et al . Resolving inequalities in care? Reduced mortality in the elderly after acute coronary syndromes. The Myocardial Ischaemia National Audit Project 2003–2010 . Eur Heart J . 2011 ; 33 ( 5 ): 630 - 9 .

[4] ⁴
Gershlick AH , Banning AP , Myat A , Verheugt WA , Gersh BJ . Reperfusion therapy for STEMI: is there still a role for thrombolysis in the era of primary percutaneous coronary intervention? . Lancet . 2013 ; 382 ( 9892 ): 624 - 32 .

[5] ⁵
Oliveira JC , Santos MA , Oliveira JC , Oliveira LC , Barreto ID , Lima TC , et al . Disparities in Access and Mortality of Patients With ST-Segment elevation Myocardial Infarction Using the Brazilian Public Healthcare System: VICTIM Register . J Am HeartAssoc . 2019 ; 8 ( 20 ): e013057 .

[6] ⁶
Piegas LS , Timerman A , Feitosa GS , Nicolau JC , Mattos LA , Andrade MD , et al . V Diretriz da Sociedade Brasileira de Cardiologia sobre Tratamento do Infarto Agudo do Miocárdio com Supradesnível do Segmento ST . Arq Bras Cardiol . 2015 ; 105 ( 2 ): 1 - 105 .

[7] ⁷
InstitutoBrasileiro de Geografia e Estatística.(IBGE) . Estimativa populacional 2018 . Disponível em: < https://www.ibge.gov.br/estatísticas-ovoportal/sociais/populacao/9103-estimativas-de-populacao.html?=&t=downloads> . Acesso em: 06 de fevereiro de 2018 .
» https://www.ibge.gov.br/estatísticas-ovoportal/sociais/populacao/9103-estimativas-de-populacao.html?=&t=downloads>

[8] ⁸
Carvalho G , Rassi S , Guerios N , Curado FA , Bastos AT . Striving to meet targets for ideal treatment of acute myocardial infarction in Brazil: Data from the Midwest region . J Interv Cardiol . 2018 ; 31 ( 4 ): 450 - 4 .

[9] ⁹
Piegas LS e Haddad N . Intervenção coronariana percutânea no Brasil: resultados do Sistema Único de Saúde . Arq Bras Cardiol . 2011 ; 96 ( 4 ): 317 - 24 .

[10] ¹⁰
Kristensen SD , Laut KG , Fajadet J , Kaifoszova Z , Kala P , Mario C , et al . Reperfusion therapy for ST elevation acute myocardial infarction 2010/2011: current status in 37 ESC countries . Eur Heart J . 2014 ; 35 ( 29 ): 1957 - 70 .

[11] ¹¹
Puymirat E , Simon T , Steg PG , Schiele F , Gueret P , Blanchard D , et al . Association of changes in clinical characteristics and management with improvement in survival among patients with ST-elevation myocardial infarction . JAMA . 2012 ; 308 ( 10 ): 998 - 1006 .

[12] ¹²
Halon DA , Adawi S , Dobrecky-Mery I , Lewis BS . Importance of increasing age on the presentation and outcome of acute coronary syndromes in elderly patients . J Am Coll Cardiol . 2004 ; 43 ( 3 ): 346 - 52 .

[13] ¹³
Tran CT , Laupacis A , Mamdani MM , Tu JV . Effect of age on the use of evidence-based therapies for acute myocardial infarction . Am Heart J . 2004 ; 148 ( 5 ): 834 - 41 .

[14] ¹⁴
Blankenship JC , Skelding KA , Scott TD , Berger PB , Parise H , Brodie BR , et al . Predictors of reperfusion delay in patients with acute myocardial infarction undergoing primary percutaneous coronary intervention from the HORIZONS-AMI trial . Am J Cardiol . 2010 ; 106 ( 11 ): 1527 - 33 .

[15] ¹⁵
Postma S , Dambrink JH , Boer MJ , Gosselink AT , Ottervanger JP , Koopmans PC , et al . The influence of residential distance on time to treatment in ST-elevation myocardial infarction patients . Neth Heart J . 2014 ; 22 ( 11 ): 513 - 19 .

[16] ¹⁶
Fosbol EL , Granger CB , Jollis JG , Monk L , Lin L , Lytle BL , et al . The impact of a statewide pre-hospital STEMI strategy to bypass hospitals without percutaneous coronary intervention capability on treatment times . Circulation . 2013 ; 127 ( 5 ): 604 - 12 .

[17] ¹⁷
Rosselló X , Huo Y , Pocock S , Werf FV , Chin CT , Danchin N , et al . Global geographical variations in ST-segment elevation myocardial infarction management and post-discharge mortality . Int J Cardiol . 2017 ;( 245 ): 27 - 34 .

[18] ¹⁸
Vora AN , Holmes DN , Rokos I , Roe MT , Granger CB , French WJ , et al . Fibrinolysis use among patients requiring interhospital transfer for ST-segment elevation myocardial infarction care: a report from the US National Cardiovascular Data Registry . JAMA . 2015 ; 175 ( 2 ): 207 - 15 .

[19] ¹⁹
Aguirre FV , Varghese JJ , Kelley MP , Lam W , Lucore CL , Gill JB , et al . Rural interhospital transfer of ST-elevation myocardial infarction patients for percutaneous coronary revascularization: the Stat Heart Program . Circulation . 2008 ; 117 ( 9 ): 1145 - 52 .

[20] ²⁰
Ibanez B , James S , Agewall S , Antunes MJ , Bucciarelli-Ducci C , Bueno H , et al . Task Force on the management of ST-segment elevation acute myocardial infarction of the European Society of Cardiology (ESC). ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation . Eur Heart J . 2018 ; 39 ( 2 ): 119 - 77 .

[21] ²¹
O’Gara PT , Kushner FG , Ascheim DD , Casey DE Jr , Chung MK , de Lemos JA , et al . 2013 ACCF/AHA Guideline for the Management of ST Elevation Myocardial Infarction: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines . Circulation . 2013 ; 127 ( 4 ): 362 - 425 .

[22] ²²
Santos J , Meira KC , Camacho AR , Salvador PT , Guimaraes RM , Pierin AM , et al . Mortalidade por infarto agudo do miocárdio no Brasil e suas regiões geográficas: análise do efeito da idade-período-coorte . Cien Saud Colet . 2018 ;( 23 ): 1621 - 34 .

[23] ²³
Mclenachan JM , Gray HH , Belder MA , Ludman PF , Cunningham D , Birkhead J . Developing primary PCI as a national reperfusion strategy for patients with ST-elevation myocardial infarction: the UK experience . EuroIntervention . 2012 ;( 8 ): 99 - 107 .

Demography	All	Aracaju	Itabaiana	Estância	Lagarto	Socorro	Glória	Propriá	p value
Demography	(n=844)	(n=294)	(n=102)	(n=119)	(n=122)	(n=119)	(n=41)	(n=47)	p value
Age - years old*	61 (52-70)	59 (50-68)	63,5 (50.75-71)	66 (55-74)§//	65 (57-73)§//	60 (51-67)	58 (51,5-69.5)	60 (54-67)	<0.001
Sex n (%)
Male	561 (66.5)	199 (67.7)	77 (75.5)	69 (58.0)	83 (68.0)	72 (60.5)	28 (68.3)	33 (70.2)	0.118
Female	283 (33.5)	95 (32.3)	25 (24.5)	50 (42.0)	39 (32.0)	47 (39.5)	13 (31.7)	14 (29.8)
Social class† n (%)
A	3 (0.4)	3 (1.1)	0 (0)	0 (0)	0 (0)	0 (0)	0 (0)	0 (0)	0.025
B	17 (2.2)	12 (4.3)	1 (1.1)	1 (0.9)	2 (1.8)	0 (0)	1 (2.9)	0 (0)
C	74 (9.4)	35 (12.5)	9 (9.8)	7 (6.3)	7 (6.2)	11 (9.9)	1 (2.9)	4 (8.9)
D	240 (30.5)	97 (34.6)	26 (28.3)	30 (27)	26 (23)	39 (35.1)	12 (34.3)	10 (22.2)
E	453 (57.6)	133 (47.5)	56 (60.9)	73 (65.8)§	78 (69)§	61 (55)	21 (60)	31 (68.9)
Ethnicity n (%)
White	248 (30)	85 (29.4)	36 (35.3)	31 (27.7)	45 (36.9)//	21 (18.3)	17 (42.5)//	13 (28.3)	0.020
Non-white	578 (70)	204 (70.6)	66 (64.7)	81 (72.3)	77 (63.1)//	94 (81.7)	23 (57.5)//	33 (71.7)
Schooling n (%)
Never studied	225 (26.7)	49 (16.7)	38 (37.3)§	41 (34.5)§	50 (41)§¶	28 (23.5)	12 (29.3)	7 (14.9) ‡	<0.001
Elementary school	457 (54.1)	153 (52)	48 (47.1)	70 (58.8)	61 (50)	67 (56.3)	24 (58.5)	34 (72.3)
High school	121 (14.3)	69 (23.5)	11 (10.8)	7 (5.9)§	8 (6.6)§	19 (16)	4 (9.8)	3 (6.4)
Higher education	32 (3.8)	20 (6.8)	3 (2.9)	1 (0.8)	3 (2.5)	3 (2.5)	0 (0)	2 (4.3)
Graduate degree	9 (1.1)	3 (1)	2 (2)	0 (0)	0 (0)	2 (1.7)	1 (2.4)	1 (2.1)
Marital Status n (%)
Single	115 (13.6)	45 (15.3)	10 (9.8)	15 (12.6)	18 (14.8)	18 (15.1)	4 (9.8)	5 (10.6)	0.050
Married	415 (49.2)	139 (47.3)	52 (51)	51 (42.9)	72 (59)	53 (44.5)	23 (56.1)	25 (53.2)
Lives with a partner	130 (15.4)	42 (14.3)	13 (12.7)	26 (21.8)	15 (12.3)	20 (16.8)	9 (22)	5 (10.6)
Divorced	73 (8.6)	33 (11.2)	10 (9.8)	4 (3.4)	7 (5.7)	8 (6.7)	4 (9.8)	7 (14.9)
Widowed	111 (13.2)	35 (11.9)	17 (16.7)	23 (19.3)	10 (8.2)	20 (16.8)	1 (2.4)	5 (10.6)

Clinical characteristics	All		Aracaju	Itabaiana	Estância	Lagarto	Socorro	Glória	Propriá	p value
Clinical characteristics	(n=844)		(n=294)	(n=102)	(n=119)	(n=122)		(n=41)	(n=47)	p value
Cardiovascular risk n (%)							(n=119)
Hypertension	530	(62.8)	176 (59.9)	61 (59.8)	72 (60.5)	76 (62.3)	86 (72.3)	26 (63.4)	33 (70.2)	0.282
Diabetes	275	(32.6)	104 (35.4)	24 (23.5)	46 (38.7)	35 (28.7)	39 (32.8)	7 (17.1)	20 (42.6)	0.026
Dyslipidemia	314	(37.2)	116 (39.5)	33 (32.4)	46 (38.7)	45 (36.9)	39 (32.8)	15 (36.6)	20 (42.6)	0.762
Smoking	282	(33.4)	102 (34.7)	37 (36.3)	32 (26.9)	32 (26.2)	45 (37.8)	20 (48.8)	14 (29.8)	0.078
Number of risk factors n (%)
0	100	(11.8)	38 (12.9)	14 (13.7)	15 (12.6)	20 (16.4)	6 (5)	3 (7.3)	4 (8.5)	0.255
1	279	(33.1)	90 (30.6)	36 (35.3)	39 (32.8)	44 (36.1)	42 (35.3)	15 (36.6)	13 (27.7)
2	297	(35.2)	100 (34)	38 (37.3)	40 (33.6)	35 (28.7)	50 (42)	18 (43.9)	16 (34)
≥ 3	168	(19.9)	66 (22.4)	14 (13.7)	25 (21)	23 (18.9)	21 (17.6)	5 (12.2)	14 (29.8)
Systemic blood pressure
Systolic blood pressure	140 (123-160)		145 (130-160.75)	140 (123.7-157.5)	135 (120-160)	140 (120,75-157)	140 (120.75-160)	130 (120-147)¶	140 (120-160)¶	0.016
Diastolic blood pressure	83 (75-96)		87,5 (78-99.25)	87 (76.75-93)	80 (70-99)	80 (71,75-90)	87 (77-98.5)	80(70-87.5)	80 (71-90)	0.007
Killip‡
I	716	(85.3)	245 (83.9)	92 (92)	101 (84.9)	102 (84.3)	104 (87.4)	35 (85.4)	37 (78.7)	0.557
II	92 (11)		35 (12)	7 (7)	14 (11.8)	14 (11.6)	10 (8.4)	5 (12.2)	7 (14.9)
III	18	(2.1)	7 (2.4)	1 (1)	3 (2.5)	2 (1.7)	1 (0.8)	1 (2.4)	3 (6.4)
IV	13	(1.5)	5 (1.7)	0 (0)	1 (0.8)	3 (2.5)	4 (3.4)	0 (0)	0 (0)
GRACE score§
< 140 (low risk)	392	(50.2)	154 (58.1)#	41 (45.1)	51 (45.1)	42 (35.6)	63 (56.3)#	23 (56.1)	18 (43.9)	0.001
> 140 (high risk)	389	(49.8)	111 (41.9)#	50 (54.9)	62 (54.9)	76 (64.4)	49 (43.8)#	18 (43.9)	23 (56.1)
Electrocardiogram//
Previous	527	(62.5)	198 (67.3)	63 (61.8)	71 (59.7)	74 (60.7)	68 (57.6)	22 (53.7)	31 (66)	0.384
Non-previous	316	(37.5)	96 (32.7)	39 (38.2)	48 (40.3)	48 (39.3)	50 (42.4)	19 (46.3)	16 (34)

Procedure‡	All	Aracaju	Itabaiana	Estância	Lagarto	Socorro	Glória	Propriá	p value
Procedure‡	(n=844)	(n=294)	(n=102)	(n=119)	(n=122)	(n=119)	(n=41)	(n=47)	p value
Fibrinolytic n (%)	22 (2.6)	3 (1)	3 (2.9)	5 (4.2)	5 (4.1)	4 (3.4)	1 (2.4)	1 (2.1)	0.477
Primary PCI n (%)	386 (45.8)	151 (51.4)†	51 (50)†	55 (46.6)†	53 (43.4)	51 (42.9)	7 (17.1)	18 (38.3)	0.003
Non-primary PCI n (%)	275 (32.6)	84 (28.6)	31 (30.4)	44 (37)	37 (30.3)	43 (36.1)	21 (51.2)	15 (31.9)	0.092
Did not perform PCI n (%)	212 (25.1)	67 (22.8)	23 (22.5)	29 (24.6)	36 (29.5)	29 (24.4)	13 (31.7)	15 (31.9)	0.595
Myocardial revascularization surgery	24 (2.8)	7 (2.4)	5 (4.9)	3 (2.5)	2 (1.6)	2 (1.7)	3 (7.3)	2 (4.3)	0.383

	All	Aracaju	Itabaiana	Estância	Lagarto	Socorro	Glória	Propriá	p value
	(n=844)	(n=294)	(n=102)	(n=119)	(n=122)	(n=119)	(n=41)	(n=47)	p value
Timeline *†
Time A	30’ (10’-2h)	30’ (10’-2h37’)	30’ (15’-2h)	30’ (10’-2h)	30’ (15’-2h)	30’ (10’-2h)	30’ (17’-4h)	1h (10’-2h)	0,808
Time B	30’ (20’-1h)	30’ (15’-48’)	30’ (20’-1h)	30’ (20’-1h)	30’ (15’-50’)	30’ (18’-1h)	30’ (20’-1h)	30’ (20’-1h)	0,038
Time C	7h37’ (4h51’-18h)	6h30’ (3h30’-15h40’)	7h30’ (4h53’-13h)	7h50’ (5h20’-11h16’)	8h34’ (5h28’-21h25’) ‡	8h17’ (4h40’-28h15’)	12h40’ (6h45’-26h56’)‡	8h57’ (6h35’-14h30’)	<0,001
Time D	10h22’ (6h30’-22h52’)	9h (5h7’-21h32’)	10h (6h9’-15h47’)	10h30’ (7h10’-19h45’)	11h31’ (7h3’-25h20’)	12h40’ (6h30’-32h)‡	16h (8h30’-32h01’)‡	12h27’ (7h50’-18h08’)	0,001
No. of units visited
0	14 (1,7)	9 (3,1)	1 (1)	1 (0,8)	2 (1,6)	1 (0,8)	0 (0)	0 (0)	0,483
1	685 (81,2)	248 (84,4)	85 (83,3)	91 (76,5)	100 (82)	93 (78,2)	31 (75,6)	37 (78,7)
2	125 (14,8)	32 (10,9)	14 (13,7)	24 (20,2)	17 (13,9)	20 (16,8)	9 (22)	9 (19,1)
≥ 3	20 (2,4)	5 (1,7)	2 (2)	3 (2,5)	3 (2,5)	5 (4,2)	1 (2,4)	1 (2,1)

Health regions	Mortality N (%)	Non-adjusted mortality OR (95%CI)	Adjusted mortality OR (95%CI)	p value
Aracaju*	27 (9.4) 27 (9.4)	1	1
Itabaiana	9 (9.2)	0.98 (0,44-2.16)	0.93 (0.32-2.70)	0.900
Estância	22 (18.6)	2.22 (1.20-4.08)	1.70 (0.74-3.92)	0.214
Lagarto	22 (18.5)	2.19 (1.19-4.03)	2.07 (0.93-4.61)	0.074
Socorro	15 (12.7)	1.41 (0.72-2.75)	2.04 (0.86-4.87)	0.106
Glória	3 (7.5)	0.78 (0.23-4.68)	0.66 (0.13-3.48)	0.625
Propriá	8 (17)	1.98 (0.84-4.68)	1.93 (0.61-6.11)	0.263