Rationale and strategies for implementing community-based transfer protocols for primary percutaneous coronary intervention for acute ST-segment elevation myocardial infarction

Abstract

The focus for the initial approach to the treatment of acute ST-segment elevation myocardial infarction (STEMI) has shifted toward extending the benefits of mechanical reperfusion with primary percutaneous coronary intervention (PCI) to patients who present to community hospitals that have no interventional capabilities. Several randomized clinical trials have shown that transferring STEMI patients to tertiary centers for primary PCI leads to better outcomes than when fibrinolytic therapy is administered at community hospitals. Furthermore, potent pharmacologic reperfusion regimens that enhance early reperfusion of the infarct vessel before primary PCI may enhance the positive result of the transfer approach. Despite these promising findings, several obstacles have hindered the adoption of patient-transfer strategies in the U.S., including greater distances between community and tertiary hospitals, a lack of integrated emergency medical services, and the medical community's limited experience with centralized acute myocardial infarction (AMI) care networks. Nonetheless, the implementation of system-wide changes in the care of STEMI patients analogous to the creation of trauma networks could facilitate the creation and ongoing evaluation of dedicated patient transfer strategies and better early invasive care in the U.S. Within this context, a systematic, stepwise approach to the creation of AMI care networks and to the development of standard nomenclature and performance indicators is necessary to guide quality assurance monitoring and future research efforts as the care of STEMI patients is redefined. Consequently, this current evolution of reperfusion strategies has the potential to further reduce morbidity and mortality for patients presenting with STEMI.

Impact of emergency services and ambulance type on pain-to-balloon time in the acute myocardial infarction: an observational study

“…In Turkey, to date, no investigations into the medical transport-chain and transport durations have been conducted. In addition, it was recently reported that the development of city-wide transport protocols and the establishment of hospital networks could shorten pain-to-balloon time in some countries (25)(26)(27)(28)(29)(30). In contrast, in Turkey, no transport-chain protocol has been proposed by the municipality or health ministry.…”

Expedited transfer for primary percutaneous coronary intervention: a program evaluation

“…19,20,24 The implementation of various multidisciplinary pathways to facilitate patient transfer for this procedure has been described recently. 20,[25][26][27][28] Protocols used by top hospitals in the United States that have achieved rapid door-to-balloon times are similar in key features to the cur- rent pathway we have described. 29 More recent registry and clinical trial data would suggest that reperfusion times might be improving.…”

The Case for Community Hospital Angioplasty

“…[32][33][34][35][36][37][38][39][40][41][42][43][44][45][46][47][48][49] Weaver and coworkers 34,35 compared the outcomes of 472 patients with AMI treated with primary PCI in hospitals without on-site cardiac surgery with those of 592 patients with AMI in hospitals with surgery backup, using data from the Myocardial Infarction Triage and Intervention (MITI) Registry. The median times to treatment, procedural success rates, and in-hospital and 1-year mortality rates were not different for the 2 types of hospitals.…”

“…These 2 studies, which report an aggregate of 2796 primary PCI procedures performed without on-site surgery, were thus not considered by the STEMI guidelines committee. In addition, the studies by Sanborn et al, 46 Singh et al, 47 and Wharton et al 48 were published only 1 month before the STEMI guidelines were released. Thus, the STEMI guidelines committee may not have been able to fully consider the implications of these 3 other studies, which report an aggregate of 2474 more primary PCI procedures.…”