Development of Systems of Care for ST-Elevation Myocardial Infarction Patients

Abstract

The establishment of ST-elevation myocardial infarction (STEMI) systems of care that are intended to increase timely access to primary percutaneous coronary intervention (PCI) will affect the US healthcare system in a broad and fundamental way. The key reason for establishing STEMI systems of care is that although primary PCI is superior to fibrinolytic therapy when performed rapidly, timely access to primary PCI is currently limited. By establishing these systems, it is believed that patients with STEMI can be directed to PCI-capable hospitals through prehospital emergency medical services (EMS) protocols and emergency interhospital transfer arrangements, and as a consequence, outcomes will be improved. The establishment of STEMI systems of care in the United States will be challenging, however, and their success will be predicated on the ability to overcome a number of practical barriers.1 In this article, we discuss several of these barriers, as well as the potential for STEMI systems of care to reduce mortality and their overall implications for the US healthcare system. The overall benefit of directing patients with STEMI to PCI-capable hospitals with prehospital EMS protocols or interhospital transfer arrangements has not been demonstrated definitively in the United States and raises concerns from a clinical perspective that need to be considered. First, the inherent delays required for performing primary PCI may limit its effectiveness when long transport times are anticipated and may influence the choice between reperfusion therapies.2–5 Thus, STEMI systems of care that divert patients to PCI-capable hospitals may delay the delivery of reperfusion therapy for many patients compared with prompt treatment with fibrinolytic therapy at the closest hospital. At some point, the additional time required to perform primary PCI will eliminate its advantages over fibrinolytic therapy, and in some scenarios it could lead to higher mortality rates. Some studies suggest that primary PCI …