Background-Percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI) is superior tofibrinolysis when performed in a timely manner in high-volume centers. Recent European trials suggest that transfer for PCI also may be superior to fibrinolysis and increase access to PCI. In the United States, transfer times are consistently long; therefore, many believe a transfer for PCI strategy for STEMI is not practical. Methods and Results-We

Background-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. Methods and Results-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 (nϭ613) were treated in Յ90 minutes and 65.7% (nϭ1324) were treated in Յ120 minutes. Delays occurred most frequently at the referral hospital (64.0%, nϭ1298), followed by the PCI center (15.7%, nϭ317) and transport (12.6%, nϭ255). For the referral hospital, the most common reasons for delay were awaiting transport (26.4%, nϭ535) and emergency department delays (14.3%, nϭ289). 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. Key Words: delays Ⅲ delivery of health care Ⅲ myocardial infarction Ⅲ angioplasty, balloon, coronary T imely reperfusion is the cornerstone of treatment in patients with ST-segment-elevation myocardial infarction (STEMI). Improving door-to-needle time for fibrinolytic therapy and door-to-balloon time for primary percutaneous coronary intervention (PCI) has been shown to decrease mortality in a linear fashion. [1][2][3] PCI is the preferred method of reperfusion if it can be performed in a timely manner at high-volume centers. 4 -7 Yet, only 25% of US hospitals have PCI capability. Both the American College of Cardiology/American Heart Association (ACC/AHA) and the European Society of Cardiology (ESC) guidelines currently recommend a door-to-balloon time of Յ90 minutes for primary PCI, although the ECS guidelines extend this to Ͻ120 minutes for transferred patients. 5,6 Clinical Perspective on p 1644 Conclusions-TreatmentThe mortality benefit achieved with primary PCI in STEMI patients is diminished by treatment delays. 8,9 It is therefore imperative to develop strategies that both increase access to primary PCI and improve door-to-balloon times. 10 -13 The ACC launched the D2B Alliance 14 to improve time to treatment in PCI hospitals, and the AHA established Mission: Lifeline 15 to develop STEMI systems of care that will improve timely access to PCI. The Joint Commission includes door-to-balloon times as a core quality assuran...

Reperfusion injury may offset the optimal salvage of myocardium achieved during primary coronary angioplasty. Thus, coronary reperfusion must be combined with cardioprotective adjunctive therapies in order to optimize myocardial salvage and minimize infarct size. Forty-three patients with their first ST-elevation myocardial infarction were randomized to myocardial postconditioning or standard of care at the time of primary coronary angioplasty. Postconditioning was performed immediately upon crossing the lesion with the guide wire and consisted of four cycles of 30 s occlusion followed by 30 s of reperfusion. End-points included infarct size, myocardial perfusion grade (MPG), left-ventricular ejection fraction (LVEF), and long-term clinical events (death and heart failure). Despite similar ischemic times (≅4.5 h) (p = 0.9) a reduction in infarct size was observed among patients treated with the postconditioning protocol. Peak creatine phosphokinase (CPK), as well as its myocardial band (MB) fraction, was significantly lower in the postconditioning group when compared with the control group (CPK--control, 2,444 ± 1,928 IU/L vs. PC, 2,182 ± 1,717 IU/L; CPK-MB--control, 242 ± 40 IU/L vs. PC, 195 ± 33 IU/L; p = 0.64 and p < 0.01, respectively). EF in the postconditioning group was improved when compared with the control group (control, 43% ± 15 vs. PC, 52% ± 9; p = 0.05). After a mean follow-up of 3.4 years, a 6-point absolute difference in LVEF was still evident in the postconditioning group (p = 0.18). MPG was better among patients treated with the postconditioning protocol compared with control (2.5 ± 0.5 vs. 2.1 ± 0.6; p = 0.02). Due to the small sample size no significant differences in clinical events were detected (p value for death = 0.9; p value for heart failure = 0.2). A simple postconditioning protocol applied at the onset of mechanical reperfusion, resulted in reduction of infarct size, better epicardial and myocardial flow, and improvement in left ventricular function. The beneficial effects of postconditioning on cardiac function persist beyond 3 years.