From Concept to Reality

Abstract

Perseverance is not a long race: it is many short races one after another.-Walter Elliott, 19th Century spiritual writer T he treatment and outcome of patients with ST-segment elevation myocardial infarction (STEMI) has improved dramatically over the 30 years since I graduated from medical school. In 1982, bed rest, treatment of complications such as ventricular arrhythmias or mural thrombus and prayer (for those so inclined) were the standard of care. In the first decade, pharmacological therapy was developed, and the open artery hypothesis was confirmed. The Second International Study of Infarct Survival (ISIS-2) trial demonstrated the benefit of not only aspirin, but also the combination of aspirin and streptokinase 1 leading to a series of randomized clinical trials to determine the preferred fibrinolytic and adjunctive medications. The second decade was filled with trials that compared fibrinolytic therapy with primary percutaneous coronary intervention (PCI), which ultimately confirmed primary PCI as the preferred method of reperfusion if performed in a timely manner in high-volume centers. 2 European trials extended the benefits of PCI to STEMI patients who presented to non-PCI centers requiring transfer for primary PCI. 3,4 In particular, the Danish Multicenter Randomized Study on Thrombolytic Therapy versus Acute Coronary Angioplasty in Acute Myocardial Infarction (DANAMI-2), a well-designed, multicenter, randomized trial including 24 referral hospitals and 5 PCI centers in Denmark, was stopped early when it demonstrated a significant reduction in the primary end point of death, reinfarction, and stroke at 30 days (8% for primary PCI versus 13.7% for fibrinolysis, PϽ0.001). 4 Article see p 189These randomized clinical trials stimulated interest in regional STEMI systems in the United States, but many believed it would be challenging to replicate the results seen in a small European country with short-duration transfers (mean, 34 miles) and an organized national emergency medical system (EMS). 5 In 2002, we modeled the Minneapolis Heart Institute's Level 1 Regional STEMI system after the successful regional trauma systems in the United States and the preliminary results from DANAMI-2. 6,7 After a presentation of our early results, Henning R. Anderson, MD, the principal investigator of DANAMI-2, wrote an encouraging letter, with this statement: "When I present the DANAMI-2 experience to a US audience, the most frequent comment is that in the US system it is very, very difficult to implement such a strategy."The early skepticism and resistance to the development of US regional STEMI systems were indeed challenging at times, but were surpassed by the tangible benefits that were evident daily in our patients. Benefits that we now know extend beyond the reduction in death, reinfarction, and stroke confirmed by randomized clinical trials. 7-9 Regional Approach to Cardiovascular Emergencies-RACEExpanding on their initial project of 65 hospitals (10 PCI and 55 non-PCI), 10 in this issue of Circulation, the Regio...

Relationship of the Distance Between Non-PCI Hospitals and Primary PCI Centers, Mode of Transport, and Reperfusion Time Among Ground and Air Interhospital Transfers Using NCDR’s ACTION Registry-GWTG

“…20 Such integrated systems of care based on direct EMS transport of STEMI patients to high-volume PCI centers has shown promise 23,35 and have demonstrated success even when serving extensive rural areas, achieving FD2B times significantly below the national average. 18,[35][36][37] Multiple efforts to regionalize revascularization services have demonstrated that further improvements are possible at a state-wide level, resulting in a decrease in FD2B time to 103 minutes, with 39% of patients achieving FD2B ≤90 minutes.…”

Effectiveness of regionalized systems for stroke and myocardial infarction

“…(2007) stressed that the study was not designed to examine mortality and that inferences based on their outcomes should be made with great caution. Henry (2012) described the RACE program as a model case of voluntary participation of all hospitals statewide. Glickman et al.…”

Direct Transfer From the Referring Hospitals to the Catheterization Laboratory to Minimize Reperfusion Delays for Primary Percutaneous Coronary Intervention

“…Continued efforts to coordinate care and facilitate real-time decision-making between STEMI referral hospitals, emergency medical services, and STEMI receiving hospitals should help mitigate these logistic barriers. 26 Fortunately, since 2008, the proportion of patients transferred directly to the cath lab has increased significantly ( Figure 2). Finally, a previous study found a statewide prehospital STEMI strategy to bypass closer hospitals without PCI capability resulted in substantially shortened reperfusion delays, 25 yet this strategy is not possible for all patients and geographic areas.…”