Providing optimal regional care for ST-segment elevation myocardial infarction: a prospective cohort study of patients in the Hamilton Niagara Haldimand Brant Local Health Integration Network

Abstract

CMAJ OPEN, 3(1) E1 S T-segment elevation myocardial infarction (STEMI) is a cause of significant morbidity and mortality. 1Whereas early myocardial reperfusion is crucial in treating STEMI, 2 the clinical characteristics of patients and available resources both determine how this is best achieved. Choosing the best course of STEMI care requires the co ordination of various services, including prehospital emergency medical services, emergency medicine and interventional cardiology. When it can be accomplished in a timely manner, reperfusion with primary percutaneous coronary intervention (PCI) is considered the evidence-based standard of care.3 However, primary PCI may not be feasible for all patients because of population-based geographic distribution of resources, patient comorbidity and resource constraints. 4 Certain patients may benefit from timely fibrinolysis coupled with a pharmacoinvasive approach, 3,5 because fibrinolysis is available in all emergency departments (and some prehospital settings) and available to a broader population without the need for additional infrastructure. Thus, a regional STEMI program seeking to maximize patient and population outcomes requires a system approach devoted to ensuring that the best available treatment is provided given the context under which it is delivered. Background: Although considered the evidence-based best therapy for ST-segment elevation myocardial infarction (STEMI), many patients do not receive primary percutaneous coronary intervention (PCI) because of health care resource distribution and constraints. This study describes the clinical management and outcomes of all patients identified with STEMI within a region, including those who did not receive primary PCI.

Early Observations During the COVID-19 Pandemic in Cardiac Catheterization Procedures for ST-Elevation Myocardial Infarction Across Ontario

“…Ongoing surveillance and monitoring are needed as it is not clear at this time that the processes that contributed to increased FMC-to-balloon time would not also adversely affect door-to-needle time. Nevertheless, a pharmacoinvasive strategy may need to be reconsidered regardless of COVID-19 prevalence, for patients who present at hospitals across Ontario without PPCI where substantial treatment delays with PPCI are expected ( 16 ).…”

“…Nevertheless, a pharmacoinvasive strategy might need to be reconsidered regardless of COVID-19 prevalence, for patients who present at hospitals across Ontario without PPCI capabilities, where substantial PPCI treatment delays are expected. 16…”

2019 Canadian Cardiovascular Society/Canadian Association of Interventional Cardiology Guidelines on the Acute Management of ST-Elevation Myocardial Infarction: Focused Update on Regionalization and Reperfusion

“…Many regions and STEMI care networks in Canada have shown improvements in reperfusion times and clinical outcomes in STEMI patients who have been treated through the development of organized regional STEMI programs that emphasize prehospital electrocardiogram (ECG) diagnosis, EMS bypass of nonePCI-capable hospitals, and geographic and resource-based decision-making regarding the choice of an upfront reperfusion strategy. [22][23][24][25][26] The Ottawa program showed that EMS diagnosis of STEMI in the field with direct transfer to a PPCI centre was associated with a reduction in in-hospital mortality compared with treatment at the nearest hospital. 17 It has been suggested that prehospital STEMI diagnosis in conjunction with prehospital fibrinolysis could also be similarly driven by EMS.…”

Clinical Performance Feedback to Paramedics: What They Receive and What They Need

“…The paramedic group consists of 324 paramedics, including 138 advanced care paramedics and 186 primary care paramedics. This population was chosen because of the formal Strategic Management of Acute Reperfusion and Therapies in Acute Myocardial Infarction (SMART‐AMI) feedback system and CPR feedback systems, which already existed in that region. The SMART‐AMI feedback form is described in the Appendix 1.…”