Comparing transradial with transfemoral approaches for STEMI patients: the importance of time-to-intervention

Abstract

Efforts to improve reperfusion strategies for patients presenting with ST-segment elevation myocardial infarction (STEMI) have been the focus of several quality initiatives directed by the American College of Cardiology (ACC; who set up the Door-to-Balloon [D2B] Alliance) and, more recently, the American Heart Association (AHA; who set up the Mission Lifeline). Paradigms designed to improve early recognition and diagnosis (i.e., performing and transmitting a 12-lead ECG from the field), along with improvements in coordinating an interventional cardiology team (i.e., a ‘one-page’ system), have in part contributed to the success of these programs. The ability to create a system that capitalizes on the concept of ‘shared governance’, which includes paramedics, emergency medicine physicians, nurses, interventional cardiologists and hospital administrators, is one of the challenging (yet clinically rewarding) issues facing the creation of STEMI programs. Given the need for changes in practice patterns, the benefits of creating a program that fosters a collaborative and trusting environment cannot be overemphasized. Trained paramedics or emergency medicine physicians – the group of first medical contacts – prove to be an integral component of a process by which early activation of a STEMI system achieves significant reductions in D2B. Changes in how we identify and triage a STEMI patient have translated into improvements in patient care and outcome. As hospitals search to advance strategies that focus on time-to-reperfusion, the benchmark continues to be debated and modified. Internationally recognized STEMI guidelines have defined optimal (within 90 min) D2B for all patients, although consideration for reducing D2B for patients with larger amounts of myocardium at risk [101]. The issue relating to D2B for patients initially presenting to non-percutaneous coronary intervention (PCI)-capable sites has proved challenging. Recognition of PCI-related time delay, which potentially mitigates the benefits of mechanical reperfusion (over fibrinolytic therapy), continues to pose concern for healthcare providers as it relates to the ideal reperfusion therapy for an individual patient. Many cardiologists have challenged current guideline targets leading efforts to make ‘60 the new 90’. While operational efforts designed to reduce D2B have concentrated principally on protocols outside the purview of the cardiac catheterization laboratory, if the system is to change, the question arises as to what the interventional team can offer to further reduce D2B. More specifically, should the interventional cardiologist approach the STEMI patient differently in an effort to improve the time to infarct-related artery reperfusion?