Implications of the Mechanical (PCI) vs Thrombolytic Controversy for ST Segment Elevation Myocardial Infarction on the Organization of Emergency Medical Services

ST-segment-elevation myocardial infarction (STEMI) presents a true medical emergency, where the relationship between treatment (reperfusion) and mortality is measured in minutes. Fortunately, when administered early in properly selected patients, both fibrinolytic therapy and primary percutaneous coronary intervention (PCI) have been associated with significant reductions in mortality. 1,2 Unfortunately, it has become increasingly clear that only a minority of STEMI patients receive fibrinolytic therapy within 30 minutes from door-to-needle or receive primary PCI within 90 minutes from door-to-balloon as recommended by the guidelines from the American College of Cardiology/American Heart Association (AHA). 3 Articles pp 721 and 729Moreover, as enthusiasm for primary PCI as the preferred reperfusion modality has escalated, the importance of time to treatment has gained increased recognition. Door-to-balloon time is now included as 1 of the core quality measures collected and reported by the Centers for Medicare and Medicaid and The Joint Commission. Furthermore, although the performance of primary PCI has increased from 18% to 53% worldwide during the past 7 years (with an expected decrease in use of fibrinolytic therapy from 50% to 28%), nearly 30% of patients still do not receive either form of therapy even in the absence of contraindications. 4 It is these realities of the current status of reperfusion therapy that have fostered the concept of systems and centers of care for STEMI patients and interest in the exploration of the feasibility of establishment of regional STEMI networks. It is not surprising that healthcare systems and hospitals across the country are examining their standards of care and organizing quality improvement initiatives to decrease time to treatment and increase adherence to evidence-based therapies for patients with STEMI. 5,6 In this issue of Circulation, 2 pioneering model regional approaches that use integrated systems of care to increase the number of STEMI patients with timely access to a PCI facility are reported.Based on the premise that primary PCI is superior to fibrinolysis even when transfer from a non-PCI-capable facility to a primary PCI center is necessary, Henry and colleagues 7 developed a PCI-based treatment system with an integrated transfer program for STEMI patients at 30 hospitals within 210 miles from the Minneapolis Heart Institute at Abbott Northwestern Hospital. Participating hospitals were divided into zone 1 (Ͻ60 miles) and zone 2 (60 to Յ210 miles) from the Minneapolis Heart Institute. A standardized treatment protocol was developed on the basis of American College of Cardiology/AHA guidelines that was identical for the PCI center, zone 1, and zone 2 hospitals except that zone 2 patients received half-dose tenecteplase (in the absence of a contraindication to fibrinolytic therapy) in anticipation of a lengthy transfer time. At each hospital, training of all personnel (emergency medical services, emergency department, primary care physicians) was performed, t...

Section: Articles Pp 721 and 729mentioning

confidence: 99%

Regional Systems of Care for Patients With ST-Elevation Myocardial Infarction

Jacobs

2007

“…The first is the "bypass" model in which patients with a diagnosis of STEMI on a prehospital ECG are transported directly to a PCI center, bypassing a closer hospital without PCI capability. 22 The second is the "transfer" model in which interhospital transfer is accomplished rapidly through carefully established treatment protocols using integrated hospital systems. 23 Another option is to establish primary PCI programs without onsite surgery, but it is unclear whether this option really increases access to primary PCI by skilled operators and experienced teams.…”

Section: Primary Pci Strategy Limitations Accessmentioning

confidence: 99%

Commentary: The Role of Percutaneous Coronary Intervention in ST-Segment–Elevation Myocardial Infarction

Nallamothu¹

2008

I n this issue of Circulation, Dr Gregg Stone offers a thorough review of percutaneous coronary intervention (PCI) strategies to treat ST-segment-elevation myocardial infarction (STEMI). 1,2 All of the major topics are addressed and comprehensively referenced, and the figures provide a concise summary of much of the evidence base. His ultimate vision is the establishment of STEMI systems of care dedicated to primary PCI. Improving patient outcomes in STEMI is a critical goal, and we agree that continued efforts are needed to expand prehospital and hospital-based emergency medical systems for STEMI patients. However, we also continue to believe that there are currently substantial challenges to delivering primary PCI rapidly and reliably in real-world settings. Given that some of the opinions offered by Stone differ from recommendations made by professional societies, we offer a different perspective on this controversial subject and provide some of the background thinking that led to the development of the 2004 American College of Cardiology (ACC)/American Heart Association (AHA) Guidelines for the Management of Patients With STelevation Myocardial Infarction 3 and the subsequent 2007 focused update. 4 Our discussion also is informed by the ACC Door-to-Balloon (D2B) Alliance campaign 5 and the AHA Mission: Lifeline initiative. 6 Our goal is not to debate the points made by Stone but to place PCI for STEMI in the broader context of the patient and the healthcare system. We do this by providing additional insights into the development of PCI strategies in STEMI, examining the critical challenges that remain for delivering primary PCI, highlighting the difference between fibrinolytic therapy and a fibrinolytic strategy, and endorsing a new paradigm for reperfusion therapy. Articles pp 538 and 552 PCI Strategies in STEMI Primary PCIPrimary PCI is clearly preferred to fibrinolytic therapy when time-to-treatment delays are short and the patient presents to a high-volume, well-equipped center with expert interventional cardiologists. Compared with fibrinolytic therapy in randomized clinical trials, primary PCI produces higher rates of infarct artery patency, Thrombolysis in Myocardial Infarction (TIMI) grade 3 flow, and access site bleeding and lower rates of recurrent ischemia, reinfarction, emergency repeat revascularization procedures, intracranial hemorrhage, and death. 7 Early, successful PCI also greatly decreases the complications of STEMI that result from longer ischemic times or unsuccessful fibrinolytic therapy, allowing earlier hospital discharge and resumption of daily activities. These advantages were recognized in the 2004 ACC/AHA STEMI guidelines 3 that elevated primary PCI to the preferred strategy for reperfusion therapy when performed in a timely fashion (door-to-balloon time within 90 minutes) by persons skilled in the procedure (Ͼ75 PCI procedures per year) in cardiac catheterization laboratories that performed at least 200 PCI procedures a year (including 36 primary PCI procedures a year). In the 1...

“…29 Other communities, typically urban in location, have adopted a strategy of direct transportation for all STEMI patients to a dedicated primary PCI center that is available 24 hours a day, 7 days per week. 4 No large-scale randomized trials comparing such reperfusion strategies have been reported to date; however, it is recognized by the writing committee for the ACC/AHA Guidelines for the Management of Patients With STEMI and the AWG that the critical considerations in the delivery of primary PCI are the interrelated issues of timeliness and access. If timely access to primary PCI is available, the evidence suggests that PCI is the preferred reperfusion strategy, especially in those presenting late after symptom onset, those who are considered high risk, and those in whom fibrinolysis is contraindicated.…”

Section: The Time From Onset Of Symptoms Data Exist That Indicatementioning

confidence: 99%

“…In fact, several regions have established both triage and transfer protocols for PCI in patients with STEMI. 4,5 The AHA, which is dedicated to reducing disability and death due to cardiovascular diseases and stroke, has recog-*The opinions expressed in this manuscript are those of the authors and should not be construed as necessarily representing an official position of the Centers for Disease Control and Prevention, the United States Department of Health and Human Services, or the United States Government.The American Heart Association makes every effort to avoid any actual or potential conflicts of interest that may arise as a result of an outside relationship or a personal, professional, or business interest of a member of the writing panel. Specifically, all members of the writing group are required to complete and submit a Disclosure Questionnaire showing all such relationships that might be perceived as real or potential conflicts of interest.…”

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confidence: 99%

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confidence: 99%

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Recommendation to Develop Strategies to Increase the Number of ST-Segment–Elevation Myocardial Infarction Patients With Timely Access to Primary Percutaneous Coronary Intervention

Jacobs¹,

Antman²,

Ellrodt³

et al. 2006

Self Cite

141

Abstract-Although evidence suggests that primary percutaneous coronary intervention (PCI) is the preferred reperfusion strategy in the majority of patients with ST-segment-elevation myocardial infarction (STEMI), only a minority of patients with STEMI are treated with primary PCI, and of those, only a minority receive the treatment within the recommended 90 minutes after entry into the medical system. Market research conducted by the American Heart Association revealed that those involved in the care of patients with STEMI recognize the multiple barriers that prevent the prompt delivery of primary PCI and agree that it is necessary to develop systems or centers of care that will allow STEMI patients to benefit from primary PCI. The American Heart Association will convene a group of stakeholders (representing the interests of patients, physicians, emergency medical systems, community hospitals, tertiary hospitals, and payers) and quality-of-care and outcomes experts to identify the gaps between the existing and ideal delivery of care for STEMI patients, as well as the requisite policy implications. Working within a framework of guiding principles, the group will recommend strategies to increase the number of STEMI patients with timely access to primary PCI. Key Words: AHA Consensus Statements Ⅲ myocardial infarction Ⅲ revascularization Ⅲ quality of health care Ⅲ triage M ounting evidence from randomized trials suggests that for patients with ST-segment-elevation myocardial infarction (STEMI), primary percutaneous coronary intervention (PCI) is superior to fibrinolytic therapy alone in reducing the composite end points of death, reinfarction, intracranial bleeding, reocclusion of the infarct artery, and recurrent ischemia. The benefits of primary PCI are greatest if it is performed in an expeditious manner after the onset of symptoms. This requires a highly coordinated effort, especially when interhospital transport is needed to provide PCI. 1,2 In the United States, however, only a minority of patients with STEMI receive primary PCI, and in those who do, fewer than 40% are treated within 90 minutes after arrival at the initial hospital as recommended (as a goal) by the American College of Cardiology (ACC)/American Heart Association (AHA) guidelines. 3 Given that the majority of hospitals do not have PCI capability, physicians, hospitals, and the Department of Public Health in several states have been faced with the challenge of providing primary PCI to STEMI patients in a timely fashion. In fact, several regions have established both triage and transfer protocols for PCI in patients with STEMI. 4,5 The AHA, which is dedicated to reducing disability and death due to cardiovascular diseases and stroke, has recog-*The opinions expressed in this manuscript are those of the authors and should not be construed as necessarily representing an official position of the Centers for Disease Control and Prevention, the United States Department of Health and Human Services, or the United States Government.The American Heart As...