Regional ST-segment Elevation Myocardial Infarction Research Articles

Response to Letter Regarding Article, “Bivalirudin for Primary Percutaneous Coronary Interventions: Outcome Assessment in the Ottawa STEMI Registry”

We welcome the insightful and constructive comments by our colleagues, Dr Thomas Johnson et al, with regard to our recent report on bleeding outcomes with various antithrombotic regimens used in the Ottawa ST-segment–elevation myocardial infarction registry.1 As highlighted in our article, patients were recruited between 2006 and 2010, during which the publication of the Harmonizing Outcomes With Revascularization and Stents in Acute Myocardial Infarction (HORIZONS-AMI)2 study occurred, resulting in an increased use of bivalirudin by operators in our center. Moreover, as a nonrandomized study, important differences in bleeding reduction strategies, such as radial access,3 existed …

Implementation of multiple strategies for improved door-to-balloon time in patients with ST-segment elevation myocardial infarction

Several strategies have been found to be associated with a significant reduction in door-to-balloon (D2B) time in the management of ST-segment elevation myocardial infarction (STEMI). The objective of this retrospective cohort study was to assess D2B time before and after specific hospital strategies, including a computerized provider order entry (CPOE), were implemented to reduce D2B time. Patients who presented to the emergency department within 12 h of STEMI were enrolled. Strategies adopted included: (1) electrocardiography during triage for patients with chest pain; (2) implementing a CPOE; (3) activating the catheterization laboratory by sending a cell phone notification via the computer system; (4) using an open real-time on-line STEMI registry; and (5) conducting a monthly meeting to review registration. A total of 134 patients were included in the study (preintervention, n = 69; postintervention, n = 65). Median D2B time improved from 83 to 63 min after the new strategies were implemented (P = 0.001). Median door-to-electrocardiogram (5-2 min) and door-to-laboratory time (60-41 min) also significantly improved (P < 0.001). The proportion of patients with a D2B time within 90 min increased from 59.4 % to 98.5 % (P < 0.001). In conclusion, our findings suggest that implementing specific strategies can substantially improve D2B time for patients with STEMI and increase the proportion of patients with D2B time less than 90 min.

Renal dysfunction in STEMI-patients undergoing primary angioplasty: higher prevalence but equal prognostic impact in female patients; an observational cohort study from the Belgian STEMI registry

BackgroundMortality in female patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary angioplasty (pPCI) is higher than in men. We examined gender differences in the prevalence and prognostic performance of renal dysfunction at admission in this setting.MethodsA multicenter retrospective sub-analysis of the Belgian STEMI-registry identified 1,638 patients (20.6% women, 79.4% men) treated with pPCI in 8 tertiary care hospitals (January 2007-February 2011). The estimated glomerular filtration rate (eGFR) was calculated using the CKD-EPI equation. Main outcome measure was in-hospital mortality.ResultsMore women than men suffered from renal dysfunction at admission (42.3% vs. 25.3%, p < 0.001). Mortality in women was doubled as compared to men (9.5 vs. 4.7%, OR (95% CI) = 2.12 (1.36-3.32), p<0.001). In-hospital mortality for men and women with vs. without renal dysfunction was much higher (10.7 and 15.3 vs. 2.3 and 2.4%, p < 0.001). In a multivariable regression analysis, adjusting for age, gender, peripheral artery disease (PAD), coronary artery disease (CAD), hypertension, diabetes and low body weight (<67 kg), female gender was associated with renal dysfunction at admission (OR (95% CI) 1.65 (1.20-2.25), p = 0.002). In a multivariable model including TIMI risk score and renal dysfunction, renal dysfunction was an independent predictor of in-hospital mortality in both men (OR (95% CI) = 2.39 (1.27-4.51), p = 0.007) and women (OR (95% CI) = 4.03 (1.26-12.92), p = 0.02), with a comparable impact for men and women (p for interaction = 0.69).ConclusionsFemale gender was independently associated with renal dysfunction at admission in pPCI treated patients. Renal dysfunction was equally associated with higher in-hospital mortality in both men and women.

Integrated Regional Networks for ST-Segment–Elevation Myocardial Infarction Care in Developing Countries

Regionalized integrated networks for ST-segment-elevation myocardial infarction (STEMI) care have been proposed as a step forward in overcoming real-world obstacles, but data are lacking on its performance in developing countries. We describe an integrated regional STEMI network in Salvador, Bahia, Brazil. The network was created in 2009. It was coordinated by the prehospital emergency medical service and encompassed the public emergency system (prehospital mobile units, community-based emergency units, general hospitals, and cardiology reference centers). The 12-lead ECGs are interpreted via telemedicine. This network operates as follows: The Telemedicine Center sends each ECG suggestive of STEMI to a Regional STEMI Alert Team, which, together with emergency medical services, offers support for thrombolysis or immediate transfer for primary percutaneous coronary intervention. In 14 months, there were 433 suspected victims, of which in 287 (76.5%) the STEMI could be confirmed (age, 62.1±12.5 years; 63.4% men). Most of them were self-transported. The median pain-to-admission time was 180 minutes (interquartile range, 90-473 minutes), and the median admission-to-ECG time was 159.5 minutes (interquartile range, 83.5-340 minutes). The median interval time between the ECG and the telemedicine report was 31 minutes (interquartile range, 21-44 minutes). For those who sought medical attention and had an ECG performed within 12 hours after symptoms onset (n=119), the reperfusion rate was 75.6% (34.4% by thrombolysis and 65.6% by primary percutaneous coronary intervention). Regional STEMI networks may be feasible in developing countries. Preliminary results showed this network to be effective, achieving primary reperfusion rtes comparable with those reported internationally despite the obstacles faced.

Improved Survival Associated With Pre-Hospital Triage Strategy in a Large Regional ST-Segment Elevation Myocardial Infarction Program

This study sought to compare the 1-year survival of patients diagnosed with ST-segment elevation myocardial infarction (STEMI) and transferred via pre-hospital triage strategy for primary percutaneous coronary intervention (PCI) with those transferred via inter-hospital transfer within a large suburban region in Canada. Primary angioplasty is the preferred therapy for STEMI if it is done within 90 min of door-to-balloon time by an experienced team in a high-volume center. Patients identified to have STEMI on the ambulances equipped with electrocardiography bypassed the local hospitals and were sent directly to the PCI center, whereas other patients that were picked up by ambulances without electrocardiographic equipment were transported to the local hospitals where the diagnosis of STEMI was made and were re-routed to the PCI center. Patient demographic data, clinical presentation, procedural data, in-hospital course, and vital statistics were prospectively recorded in a provincial cardiac registry. A total of 167 patients were brought into the PCI center via pre-hospital triage strategy, and 427 patients were brought in via inter-hospital transfer during a 2-year study period. Baseline demographic data, infarct location, cardiovascular history, and hemodynamic status were similar between the 2 groups. When compared with the inter-hospital transfer group, a significantly higher proportion of pre-hospital triaged patients achieved the 90-min door-to-balloon time benchmark (80.4% vs. 8.7%, p < 0.001) and post-procedural Thrombolysis In Myocardial Infarction flow grade 3 after the emergency procedure (97.6% vs. 91.4%, p = 0.02). In addition, the pre-hospital triage strategy was associated with a significantly lower 30-day (5.4% vs. 13.3%, p = 0.006) and 1-year (6.6% vs. 17.5%, p = 0.019) mortality. Pre-hospital triage was an independent predictor for survival at 1 year (hazard ratio: 0.37, 95% confidence interval: 0.18 to 0.75, p = 0.006). Pre-hospital triage strategy was associated with improved survival rate in patients undergoing primary PCI in a regional STEMI program.

Bivalirudin for Primary Percutaneous Coronary Interventions

Data from randomized trials has demonstrated the superiority of bivalirudin to glycoprotein IIb/IIIa inhibitors plus heparin in patients undergoing primary percutaneous coronary intervention. Real-world performance of bivalirudin in primary percutaneous coronary intervention and the benefit of bivalirudin over heparin remain unknown in an era of routine dual antiplatelet therapy. From July 2004 to December 2010, 2317 consecutive patients were indexed in the University of Ottawa Heart Institute ST-segment-elevation myocardial infarction registry. During this period 748 patients received bivalirudin, 699 patients received glycoprotein IIb/IIIa inhibitors, and 676 patients received unfractionated heparin alone. The primary outcome was the rate of noncoronary artery bypass graft related thrombolysis in myocardial infarction major bleeding. Bivalirudin significantly reduced the primary outcome compared with heparin plus glycoprotein IIb/IIIa inhibitors (2.7% versus 7.3%, adjusted OR 2.96, 95% CI: 1.61-5.45, P<0.001) and the composite end point of death, stroke, reinfarction and major bleed (OR 1.66, 95% CI: 1.12-2.45, P=0.01). Compared with heparin alone, a reduction in major bleeds (OR 1.21, 95% CI: 0.60-2.44, P=0.59) or the composite end point (1.05, 95% CI: 0.68-1.63, P=0.83) with bivalirudin could not be demonstrated. Notably, major bleeding was associated with a 5-fold increase in the risk of mortality both in-hospital (3.5% versus 20.6%) and out to 180 days (5.6% versus 25.8%). Bivalirudin use compared with glycoprotein IIb/IIIa inhibitors plus heparin as an antithrombotic strategy in primary percutaneous coronary intervention results in less major bleeding in contemporary practice. A benefit of bivalirudin over heparin could not be established with this registry and requires additional investigations to either confirm or refute.

264 Barriers to EMS Utilization During STEMI

ST-segment elevation myocardial infarction (STEMI) remains a significant cause of mortality and morbidity. Despite documented benefits of Emergency Medical Services (EMS) transport to hospital for patients with STEMI, 40% still present via other methods and risk less timely care with poorer outcomes. Public service campaigns have targeted improving symptom awareness with limited effects on increasing EMS use in this population. This study sought to identify novel barriers to EMS use during STEMI using a unique study design. Fifty-eight sequential post-STEMI in-patients who met inclusion criteria were identified through the hospital STEMI registry (SMART-AMI - ethics board #02-245). Semi-structured interviews, with EMS users and non-EMS users, were conducted by non-medical personnel during the index hospital admission. Unstable patients or those unable to communicate were excluded. Barriers and facilitators of EMS use were identified from the transcripts and the rates of each were compared using the Fisher's exact test. Misinterpretation of symptoms was similar among EMS users and non-EMS users (55%, 53%). Self-rated severity of symptoms and presence of chest pain were not statistically different between the two groups. Perception that EMS would take longer than self-transport was evident in 53% of the non-EMS group and none of the EMS users (p=0.0001), and was the most frequent reason identified for non-EMS use. Perception that EMS was faster was noted in 46% of EMS users and 4% of non-EMS users (p=0.0002). We found that reluctance to be a burden on the health care system or to waste resources was endorsed by 35% of non-EMS users, compared to 3% of EMS users (p=0.0005). Embarrassment about EMS arriving to the office or home was common to both groups (19%, 17%; p=NS). Cost of EMS was not a prominent barrier with only 1 non-user endorsing. We identified several novel barriers to EMS use among the STEMI population, not previously targeted for intervention. Symptom identification has been previously described as a barrier, and has been the focus of past public campaigns, but this was not significantly different between EMS users and non-EMS users. Perception of the speed of EMS appears to have greatly impacted the decision to use EMS or self-transport. The concern over waste appears to be important and must be further explored. Public campaigns to address patient perception of EMS effectiveness and speed, as well as fear of wasting resources, may be effective in improving EMS utilization in the STEMI population.

283 Temporal Trends in the Management and Outcomes of ST-Segment Elevation Myocardial Infarction (STEMI) in Ontario, 2007 to 2010

283 Temporal Trends in the Management and Outcomes of ST-Segment Elevation Myocardial Infarction (STEMI) in Ontario, 2007 to 2010

Circulation: Clinical Summaries

<i>Circulation:</i> Clinical Summaries

Expansion of a Regional ST-Segment–Elevation Myocardial Infarction System to an Entire State

Despite national guidelines calling for timely coronary artery reperfusion, treatment is often delayed, particularly for patients requiring interhospital transfer. One hundred nineteen North Carolina hospitals developed coordinated plans to rapidly treat patients with ST-segment-elevation myocardial infarction according to presentation: walk-in, ambulance, or hospital transfer. A total of 6841 patients with ST-segment-elevation myocardial infarction (3907 directly presenting to 21 percutaneous coronary intervention hospitals, 2933 transferred from 98 non-percutaneous coronary intervention hospitals) were treated between July 2008 and December 2009 (age, 59 years; 30% women; 19% uninsured; chest pain duration, 91 minutes; shock, 9.2%). The rate of patients not receiving reperfusion fell from 5.4% to 4.0% (P=0.04). Treatment times for hospital transfer patients substantially improved. First-hospital-door-to-device time for hospitals that adopted a "transfer for percutaneous coronary intervention" reperfusion strategy fell from 117 to 103 minutes (P=0.0008), whereas times at hospitals with a mixed strategy of transfer or fibrinolysis fell from 195 to 138 minutes (P=0.002). Median door-to-device times for patients presenting directly to PCI hospitals fell from 64 to 59 minutes (P<0.001). Emergency medical services-transported patients were most likely to reach door-to-device goals, with 91% treated within 90 minutes and 52% being treated with 60 minutes. Patients treated within guideline goals had a mortality of 2.2% compared with 5.7% for those exceeding guideline recommendations (P<0.001). Through extension of regional coordination to an entire state, rapid diagnosis and treatment of ST-segment-elevation myocardial infarction has become an established standard of care independently of healthcare setting or geographic location.

Circulation: Clinical Summaries

<i>Circulation:</i> Clinical Summaries

Causes of Delay and Associated Mortality in Patients Transferred With ST-Segment–Elevation Myocardial Infarction

Regional ST-segment-elevation myocardial infarction systems are being developed to improve timely access to primary percutaneous coronary intervention (PCI). System delays may diminish the mortality benefit achieved with primary PCI in ST-segment-elevation myocardial infarction patients, but the specific reasons for and clinical impact of delays in patients transferred for PCI are unknown. This was a prospective, observational study of 2034 patients transferred for primary PCI at a single center as part of a regional ST-segment-elevation myocardial infarction system from March 2003 to December 2009. Despite long-distance transfers, 30.4% of patients (n=613) were treated in ≤ 90 minutes and 65.7% (n=1324) were treated in ≤ 120 minutes. Delays occurred most frequently at the referral hospital (64.0%, n=1298), followed by the PCI center (15.7%, n=317) and transport (12.6%, n=255). For the referral hospital, the most common reasons for delay were awaiting transport (26.4%, n=535) and emergency department delays (14.3%, n=289). Diagnostic dilemmas (median, 95.5 minutes; 25th and 75th percentiles, 72-127 minutes) and nondiagnostic initial ECGs (81 minutes; 64-110.5 minutes) led to delays of the greatest magnitude. Delays caused by cardiac arrest and/or cardiogenic shock had the highest in-hospital mortality (30.6%), in contrast with nondiagnostic initial ECGs, which, despite long treatment delays, did not affect mortality (0%). Significant variation in both the magnitude and clinical impact of delays also occurred during the transport and PCI center segments. Treatment delays occur even in efficient systems for ST-segment-elevation myocardial infarction care. The clinical impact of specific delays in interhospital transfer for PCI varies according to the cause of the delay.

In-Hospital Outcomes of a Regional ST-Segment Elevation Myocardial Infarction Acute Transfer and Repatriation Program

Background Primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI) presents challenges in a large geographic area for achieving treatment time targets and creates demands on the PCI centre resources. Objective We compare the in-hospital mortality rate of patients presenting with STEMI and referred for PCI from 11 transfer hospitals with those presenting to the cardiac centre in a regional STEMI program with a selective repatriation strategy. Methods Between June 1, 2003, and June 30, 2007, clinical and procedural data of all STEMI patients who were referred to the catheterization laboratory were prospectively collected. Patients who sustained prolonged cardiac arrest were excluded. Results A total of 1154 patients from regional hospitals and 325 patients initially presenting to the PCI centre were referred for acute intervention. There was no significant in-hospital mortality difference between the 2 groups (3.7% vs 4.0%, respectively; P = 0.87). Multiple logistic regression analysis showed that advanced age, female gender, multivessel coronary disease, history of hypertension, low ejection fraction, increased left ventricular end-diastolic pressure, and thrombolytic pretreatment, but not transfer status, were independent predictors for mortality. Among the 1154 transfer patients, 937 patients (81.2%) returned immediately post procedure and had a lower mortality rate than the remaining 217 patients (18.2%) who required admission to the PCI centre following cardiac catheterization (1.9% vs 11.5%, P < 0.001). Conclusion A regional system of STEMI care based on rapid patient transfer to a PCI centre and repatriation was feasible and safe.

Therapeutic Hypothermia After Out-of-Hospital Cardiac Arrest

Background— Therapeutic hypothermia (TH) improves survival and confers neuroprotection in out-of-hospital cardiac arrest (OHCA), but TH is underutilized, and regional systems of care for OHCA that include TH are needed. Methods and Results— The Cool It protocol has established TH as the standard of care for OHCA across a regional network of hospitals transferring patients to a central TH-capable hospital. Between February 2006 and August 2009, 140 OHCA patients who remained unresponsive after return of spontaneous circulation were cooled and rewarmed with the use of an automated, noninvasive cooling device. Three quarters of the patients (n=107) were transferred to the TH-capable hospital from referring network hospitals. Positive neurological outcome was defined as Cerebral Performance Category 1 or 2 at discharge. Patients with non–ventricular fibrillation arrest or cardiogenic shock were included, and patients with concurrent ST-segment elevation myocardial infarction (n=68) received cardiac intervention and cooling simultaneously. Overall survival to hospital discharge was 56%, and 92% of survivors were discharged with a positive neurological outcome. Survival was similar in transferred and nontransferred patients. Non–ventricular fibrillation arrest and presence of cardiogenic shock were associated strongly with mortality, but survivors with these event characteristics had high rates of positive neurological recovery (100% and 89%, respectively). A 20% increase in the risk of death (95% confidence interval, 4% to 39%) was observed for every hour of delay to initiation of cooling. Conclusions— A comprehensive TH protocol can be integrated into a regional ST-segment elevation myocardial infarction network and achieves broad dispersion of this essential therapy for OHCA.

STEMI Patients—The More You Bleed, the More You Die: A Comparison Between Classifications

In patients with acute coronary syndromes, an increase in hemorrhagic complications has been observed, and bleeding is now the most frequent noncardiac complication in these patients. Clinical trials and registries have used different scales to classify the severity of bleeding; so far, none of them has been developed for ST-segment elevation myocardial infarction (STEMI) patients in the era of primary percutaneous coronary intervention. We analyzed data from our Intensive Cardiac Care Florence STEMI Registry, comprising 991 STEMI patients consecutively admitted to our intensive cardiac care unit after mechanical revascularization, to assess the clinical impact of both Thrombolysis In Myocardial Infarction (TIMI) and Acute Catheterization and Urgent Intervention Triage Strategy (ACUITY) classifications in identifying patients with major bleeding at higher risk for in-hospital mortality. Major bleeding events occurred in 8.9% of patients (88/991) in the TIMI classification and in 17.2% of patients (170/991) in the ACUITY classification. Among patients with major bleeding classified according to ACUITY, 82 patients did not meet the TIMI criteria for major bleeding. These patients represent the so-called gray zone, where no transfusion was performed and only 1 patient died. In STEMI patients who undergo primary percutaneous coronary intervention and receive dual antiplatelet therapy, TIMI is more capable than ACUITY in identifying patients with major bleeding at higher risk for early mortality. The presence of renal failure represents an independent predictor for major bleeding.

Resultados de la estrategia farmacoinvasiva y de la angioplastia primaria en la reperfusión del infarto con elevación del segmento ST. Estudio con resonancia magnética cardiaca en la primera semana y en el sexto mes

Introduction and objectives Pharmacoinvasive strategy represents an attractive alternative to primary angioplasty. Using cardiovascular magnetic resonance imaging we compared the left ventricular outcome of the pharmacoinvasive strategy and primary angioplasty for the reperfusion of ST-segment elevation myocardial infarction. Methods Cardiovascular magnetic resonance was performed 1 week and 6 months after infarction in two consecutive cohorts of patients included in a prospective university hospital ST-segment elevation myocardial infarction registry. During the period 2004-2006, 151 patients were treated with pharmacoinvasive strategy (thrombolysis followed by routine non-immediate angioplasty). During the period 2007-2008, 93 patients were treated with primary angioplasty. A propensity score matched population was also evaluated. Results At 1-week cardiovascular magnetic resonance, pharmacoinvasive strategy and primary angioplasty patients showed a similar extent of area at risk (29 ± 15 vs. 29 ± 17%, P = .9). Non-significant differences were detected by cardiovascular magnetic resonance at 1 week and at 6 months in infarct size, salvaged myocardium, microvascular obstruction, ejection fraction, end-diastolic volume index and end-systolic volume index ( P > .2 in all cases). The same trend was observed in 1-to-1 propensity score matched patients. The rate of major adverse cardiac events (death and/or re-infarction) at 1 year was 6% in pharmacoinvasive strategy and 7% in primary angioplasty patients (P = .7). Conclusions A pharmacoinvasive strategy including thrombolysis and routine non-immediate angioplasty represents a widely available and logistically attractive approach that yields identical short-term and long-term cardiovascular magnetic resonance-derived left ventricular outcome compared to primary angioplasty. Full English text available from: www.revespcardiol.org

One-Week and 6-Month Cardiovascular Magnetic Resonance Outcome of the Pharmacoinvasive Strategy and Primary Angioplasty for the Reperfusion of ST-Segment Elevation Myocardial Infarction

Introduction and objectives Pharmacoinvasive strategy represents an attractive alternative to primary angioplasty. Using cardiovascular magnetic resonance imaging we compared the left ventricular outcome of the pharmacoinvasive strategy and primary angioplasty for the reperfusion of ST-segment elevation myocardial infarction. Methods Cardiovascular magnetic resonance was performed 1 week and 6 months after infarction in two consecutive cohorts of patients included in a prospective university hospital ST-segment elevation myocardial infarction registry. During the period 2004–2006, 151 patients were treated with pharmacoinvasive strategy (thrombolysis followed by routine non-immediate angioplasty). During the period 2007–2008, 93 patients were treated with primary angioplasty. A propensity score matched population was also evaluated. Results At 1-week cardiovascular magnetic resonance, pharmacoinvasive strategy and primary angioplasty patients showed a similar extent of area at risk (29 ± 15 vs. 29 ± 17%, P = .9). Non-significant differences were detected by cardiovascular magnetic resonance at 1 week and at 6 months in infarct size, salvaged myocardium, microvascular obstruction, ejection fraction, end-diastolic volume index and end-systolic volume index ( P > .2 in all cases). The same trend was observed in 1-to-1 propensity score matched patients. The rate of major adverse cardiac events (death and/or re-infarction) at 1 year was 6% in pharmacoinvasive strategy and 7% in primary angioplasty patients ( P = .7). Conclusions A pharmacoinvasive strategy including thrombolysis and routine non-immediate angioplasty represents a widely available and logistically attractive approach that yields identical short-term and long-term cardiovascular magnetic resonance-derived left ventricular outcome compared to primary angioplasty.

Incidence and Predictors of Malignant Ventricular Arrhythmias in Asian STEMI Patients

Background: Malignant ventricular arrhythmias such as ventricular tachycardia (VT) or ventricular fibrillation (VF) in ST segment elevation myocardial infarction (STEMI) patients are associated with adverse outcomes. However there is limited data amongst our local Asian population. Aim: To evaluate the incidence and predictors of malignant ventricular arrhythmias in Asian STEMI patients. Method: Retrospective analysis of a single centre STEMI registry from 2006–2009 was carried out. Baseline characteristics of 942 STEMI patients were analysed. Results: There were 942 STEMI patients analysed. Incidence of VT/VF was 10.6%. Prevalence of risk factors of Hypertension, Diabetes Mellitus, Hyperlipidaemia and smoking were similar. There were statistically significant differences in the VT/VF group with higher numbers of patients with triple vessel disease (32.0% vs 22.7%, p=0.038), Killip class >3 (46.0% vs 11.2%, p 3 was an independent predictor of developing VT/VF. Conclusion: Incidence of VT/VF amongst our patients was higher. Killip class >3 was an independent predictor of developing VT/VF.

Primary Percutaneous Coronary Intervention for Patients Presenting With ST-Segment Elevation Myocardial Infarction: Process Improvement in a Rural ST-Segment Elevation Myocardial Infarction Receiving Center

Background Rural ST-segment elevation myocardial infarction (STEMI) care networks may be particularly disadvantaged in achieving a door-to-balloon time (D2B) of less than or equal to 90 minutes recommended in current guidelines. ST-Elevation Myocardial Infarction Process Upgrade Project A multidisciplinary STEMI process upgrade group at a rural percutaneous coronary intervention center implemented evidence-based strategies to reduce time to electrocardiogram (ECG) and D2B, including catheterization laboratory activation triggered by either a prehospital ECG demonstrating STEMI or an emergency department physician diagnosing STEMI, single-call catheterization laboratory activation, catheterization laboratory response time less than or equal to 30 minutes, and prompt data feedback. Evaluating success An ongoing regional STEMI registry was used to collect process time intervals, including time to ECG and D2B, in a consecutive series of STEMI patients presenting before (group 1) and after (group 2) strategy implementation. Significant reductions in time to first ECG in the emergency department and D2B were seen in group 2 compared with group 1. Conclusions Important improvement in the process of acute STEMI patient care was accomplished in the rural percutaneous coronary intervention center setting by implementing evidence-based strategies.

Moving Care Forward

In 1967, the modern era of prehospital emergency cardiac care began with Dr Frank Pantridge's publication of “A mobile intensive-care unit in the management of myocardial infarction.”1 Recognizing that myocardial infarction mortality could be reduced by interventions prior to hospital arrival, Dr Pantridge developed a specialized ambulance system in Belfast, Ireland to stabilize and transport patients with suspected acute myocardial infarction to the Royal Victoria Hospital. Within 3 years, Dr Pantridge's system was being replicated in the United States, first in Haywood County, NC and subsequently in Pittsburgh, Pa, Seattle, Wash, Miami, Fla, and Los Angeles, Calif. Dr Pantridge recognized the importance of collecting performance data and setting time standards, including a goal of 15 minutes from dispatch to patient arrival. His initial publication documented an improvement in the percentage of calls meeting this goal from 20% to 78%. Article see p 1464 Over 40 years later, prehospital emergency cardiac care has expanded in scope to provide rapid coronary artery reperfusion for ST-segment elevation myocardial infarction (STEMI). The essential elements include prehospital diagnosis and in-the-field catheterization laboratory activation. In the Acute Coronary Treatment and Intervention Outcomes Network (ACTION) registry, the 27% of patients with a prehospital ECG underwent faster coronary reperfusion (median time to primary percutaneous coronary intervention [PCI]: 61 minutes versus 75 minutes, P <0.0001; fibrinolysis:19 minutes versus 29 minutes, P =0.003) and had a trend toward lower mortality (adjusted odds ratio: 0.80, 95% confidence interval: 0.63 to 1.01).2 When the prehospital ECG is used to activate catheterization laboratories, treatment times are remarkably fast. Rokos and colleagues highlighted 10 regional STEMI systems that combined paramedic diagnosis with hospital activation resulting in half of patients undergoing coronary intervention within 60 minutes of hospital arrival.3 Recognizing the importance of prehospital care, both US and European guidelines establish primary …