doi: 10.1161/CIRCULATIONAHA.107.710970
(Circulation. 2007;116:6-9.)
© 2007 American Heart Association, Inc.
Editorial |
The ST-Segment–Elevation Myocardial Infarction Chain of Survival
From the Department of Emergency Medicine, Virginia Commonwealth University, Richmond.
Correspondence to Joseph P. Ornato, MD, Virginia Commonwealth University, Department of Emergency Medicine, 1201 East Marshall St, AD Williams 2nd Floor, Richmond, VA 23298-0401. E-mail ornato{at}aol.com
Key Words: Editorials • infarction • myocardium
The benefit of expertly performed, timely, primary percutaneous coronary intervention (PCI) over fibrinolysis is clear for patients with ST-segment–elevation myocardial infarction (STEMI). Primary PCI is superior to fibrinolysis for reduction of overall short-term mortality, nonfatal reinfarction, stroke, and the combined end point of death, nonfatal reinfarction, and stroke.1 These results remain valid during long-term follow-up and are independent of both the type of fibrinolytic used and whether the patient is transferred for primary PCI.
Article p 67
Although the relationship between time delay from hospital emergency department arrival to fibrinolytic treatment and increasing mortality has been firmly established,2 a similar relationship for primary PCI treatment has been proven only recently. De Luca et al3 assessed the relationship between ischemic time and 1-year mortality in 1791 primary PCI-treated STEMI patients. After adjustment for age, gender, diabetes, and previous revascularization, these investigators showed that every 30 minutes of primary PCI treatment delay is associated with a 7.5% (95% CI, 1.008 to 1.15; P=0.041) relative increase in 1-year mortality. With use of hierarchical models adjusted for patient characteristics to evaluate the effect of door-to-balloon time on in-hospital mortality on 29 222 PCI-treated STEMI patients treated in 
6 hours of presentation at 395 hospitals that participated in the National Registry of Myocardial Infarction–3 and –4 from 1999 to 2002, McNamara et al4 found that a longer door-to-balloon time interval is associated with increased in-hospital mortality. Adjusted for patient characteristics, patients with a door-to-balloon time interval >90 minutes were more likely to die (odds ratio, 1.42; 95% CI, 1.24 to 1.62) compared with patients who had a door-to-balloon time interval 90 minutes. These findings provide evidence-based support for the goal of a door-to-balloon time interval "within 90 minutes" cited in the 2004 American College of Cardiology/American Heart Association (ACC/AHA) guidelines for the management of patients with STEMI5 and serve as a foundation for the ACC’s Guidelines Applied in Practice Door-to-Balloon (GAP-D2B) campaign goal of a door-to-balloon time interval of 90 minutes in 75% of PCI-treated STEMI patients at participating hospitals nationwide.6
On the ACC President’s Page, Nissen et al6 described the new GAP-D2B campaign and stated:
In successful hospitals, the arrival of a STEMI patient initiates a chain of well-orchestrated events, including activation of the catheterization laboratory directly by an emergency department physician with a single phone call to the interventional cardiologist on call. The catheterization laboratory team is expected to arrive within 20 to 30 minutes. Programs with the best outcomes employ a multidisciplinary team-based approach that includes committed administrators, physician champions, and nurse champions, along with mechanisms for rapid data feedback. This collaboration can extend to the local and regional emergency medical systems (EMS). In some successful hospitals, the catheterization laboratory is activated based on a prehospital electrocardiography.
In this issue of Circulation, Khot et al7 report on their experience before and after implementation of STEMI GAP-D2B–like strategies in a 591-bed, tertiary care, Indianapolis-area, community hospital that consists of 2 separate campuses 7 miles apart (a 13-minute drive). Although they began their program long before the recently announced ACC initiative, Khot et al7 instituted most of the GAP-D2B recommendations on the basis of characteristics of best-performing National Registry of Myocardial Infarction hospitals.8–10 Critical elements of their new system included empowerment of emergency physicians to activate the catheterization laboratory and team without cardiology consultation as well as implementation of an in-house transfer team. Their new strategy reduced the median door-to-balloon time interval significantly during normal and off-duty work hours, even for patients who had to be transferred physically from 1 facility to another, which thus increased the percentage of patients treated within the 90-minute door-to-balloon goal from 28% to 71%. And, as predicted by the relationship between time to treatment and outcome, there were significant improvements in mean infarct size, hospital length of stay, and total hospital cost per admission.
The ACC’s GAP-D2B initiative stands on even more solid ground as a result of the Indiana Heart Physicians/St. Francis Heart Center experience reported by Khot et al.7 The common element shared by both is choreographed multidisciplinary teamwork with effective communication among different disciplines of healthcare providers, rather than the traditional linear progression of care most patients experience as they pass through a series of hospital units that operate as individual silos. Both initiatives are focused on the portion of STEMI patient treatment delay that is potentially most changeable by hospital-based healthcare providers—that which occurs after a patient presents to the hospital. This is clearly the right place to start, but it represents only part of a broader community-based opportunity to improve STEMI patient care.
In 1991, the AHA adopted a metaphor—the "Chain of Survival"—to describe the sequence of events that must occur for the best likelihood of successful resuscitation from hospital cardiopulmonary arrest.11 This educational construct, which consists of early access, early cardiopulmonary resuscitation, early defibrillation, and early advanced cardiac life support, now serves as the structural foundation for improvements in the community approach to sudden cardiac death worldwide. It may now be appropriate for the AHA to consider adoption of a similar metaphor—the "STEMI Chain of Survival" (Figure)—that can be used to target global improvements in STEMI patient care. This approach is very similar to that which has been followed for >25 years by the American College of Surgeons Committee on Trauma, as it has led our nation to develop one of the finest and most effective trauma care systems in the world. The new STEMI chain begins with an emphasis on the role of the patient in the recognition of early or prodromal heart attack symptoms and immediate request for help, preferably by calling 911 and accessing the EMS system12,13; the chain works its way through the critical elements of prehospital, emergency department, and reperfusion care.
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There is presently no uniform national STEMI triage and treatment system equivalent to the system that directs major trauma victims to verified trauma centers in the United States. Because the majority of US hospitals do not have primary PCI capability, many communities struggle to decide whether they should direct EMS-transported, prehospital, 12-lead ECG–identified STEMI patients to only primary PCI facilities to bypass nonprimary PCI hospitals. Unfortunately, the majority of STEMI patients do not use the 911 ambulance system for transport to the hospital, the national paramedic training curriculum considers 12-lead ECG training as an enhanced rather than core skill, and not all EMS ambulances currently have 12-lead ECG capability.14 Many US hospitals continue to use fibrinolysis as their primary reperfusion strategy with transfer to an interventional facility for rescue when needed. Other hospitals transfer patients more regularly for primary PCI, but even the most recently published National Registry of Myocardial Infarction data on 4278 patients transferred to 419 hospitals for primary PCI show a median initial hospital door-to-balloon time of 180 minutes, with only 4.2% of patients treated with reperfusion in <90 minutes, the benchmark recommended by national quality guidelines.15 Khot et al7 have shown us that this challenging time interval also can be decreased dramatically by an organized transfer and PCI treatment team that can be activated by emergency physicians.
Our national challenge to provide optimal STEMI care needs to be solved at 2 levels: the community and the hospital. We must continue to educate the public on the signs and symptoms of a myocardial infarction and reinforce the National Heart Attack Alert Program and AHA message to "Call 911, Call Fast."16 The community needs to be organized into a system of care that directs STEMI patients quickly and efficiently to primary PCI centers whenever possible, and all hospitals, whether primary PCI-capable or not, need to have a system in place to avoid unnecessary delays, just like that which has been implemented by Khot et al.7
The AHA’s Acute Myocardial Infarction Advisory Working Group recently released recommendations on how to increase the number of STEMI patients who have timely access to primary PCI.17 The group commissioned PricewaterhouseCoopers to conduct national market research, and the Working Group interviewed a wide variety of key stakeholders (such as patients, physicians, nurses, EMS representatives, community hospitals, primary PCI facilities, payers, and evaluation/outcomes organizations such as the Agency for Healthcare Research and Quality, the Food and Drug Administration, and the Joint Commission on Accreditation of Healthcare Organizations) to determine the desirability, feasibility, and potential effectiveness of establishment of regional systems and/or centers of care for STEMI patients with a focus on whether and how this might improve patient access to quality care and outcomes. The researchers found that key stakeholders would support a national primary PCI certification program with the understanding that some nonprimary PCI hospitals would experience a modest decline in revenue. On the basis of these findings, the AHA hosted a national stakeholder meeting in 2006 to continue development of a more detailed plan for a national system of STEMI patient care. As has been suggested, this is an idea whose time may have come.18
Many communities are currently developing organized STEMI care plans. Three sites—a major city, a large region of a state, and an entire state—already have model community STEMI systems in place based on the trauma care system model. In 2003, Boston, Mass., implemented a comprehensive system of care in which STEMI patients identified by paramedics with the use of prehospital 12-lead ECGs were transported only to designated PCI centers.19 Participating PCI centers agreed to collect and submit performance measures data to a Central Data Coordinating Center on all EMS- and non-EMS–transported STEMI patients. System oversight was provided by a Steering Committee with representatives from 9 area hospitals and the Boston EMS, which developed their performance indicators and minimum standards on the basis of nationally accepted guidelines. A central Data Coordinating Center at Tufts–New England Medical Center received and tabulated data from EMS and area hospitals to provide aggregated data reports with receiving hospitals designated only A, B, C, D, etc, rather than by name. The reports were reviewed by an independent Data and Safety Monitoring Board composed of highly respected cardiologists and a statistician. After discussion between the hospital and Data and Safety Monitoring Board and review by the Steering Committee, any hospital that did not meet preestablished quality treatment, door-to-balloon, and outcome goals for 2 successive 6-month periods could be excluded from receiving EMS-transported STEMI patients for the next 6-month period.
From March 2003 to May 2005, 448 STEMI patients were transferred from 31 community hospitals by paramedic-staffed ambulance (n=149) or paramedic/critical care nurse–staffed helicopter (n=299) to the Minneapolis Heart Institute in Minneapolis, Minn., for primary PCI. A standardized protocol with accompanying checklists was developed on the basis of national guidelines. Community hospitals were required to transfer all patients with STEMI or new left bundle–branch block within 12 hours of symptom onset to the regional interventional center. A level 1 myocardial infarction protocol was developed and used to specify the sequence of events, diagnostic tests, and treatments. Patients are preregistered by admitting personnel prior to arrival by use of a demographic form faxed from the referring hospital. On arrival at the primary PCI center, patients are admitted directly to the cardiac catheterization laboratory and thus bypass the emergency department except in rare circumstances, such as when 2 STEMI patients arrive simultaneously. Prompt verbal and written feedback (which includes 1-month and 1-year follow-up phone calls) is provided to the referring hospital physician and nursing staff, and the time intervals, clinical and angiographic data, and clinical outcomes are entered into a database. Time and outcome summary reports meeting Joint Commission on Accreditation of Healthcare Organizations requirements are sent to each community hospital on a quarterly basis.
Patient treatment times and outcomes have been superb with this regional STEMI care system. No STEMI patients were excluded from transfer, even those with cardiogenic shock (13.7%), cardiac arrest (9.9%), and the elderly (17%, >80 years of age). No patient died during transport. The median total door-to-balloon time was reduced from >3 hours before implementation of the regional system to 97 minutes for 11 participating hospitals located 70 miles (zone 1) after implementation.18,20 The median total door-to-balloon time was 117 minutes with use of a facilitated PCI protocol in 17 participating hospitals located 210 miles (zone 2) from the interventional center. The improvements in time to treatment were accompanied by low 30-day mortality rates of 4.3% in zone 1 and 3.4% in zone 2.
The common denominator of these 2 models is that they are based on a community system of care rather than centered only on 1 hospital. A third model is the Reperfusion of Acute Myocardial Infarction in Carolina Emergency Departments (RACE) project, which is a collaborative effort to increase the rate and speed of coronary reperfusion through systematic changes in emergency care. The project is based on the collaborative efforts of EMS personnel, physicians, nurses, administrators, and payers from 5 regions and 68 hospitals throughout North Carolina. The recommendations of this project are based on established national guidelines, published data, and the knowledge and experience of numerous individuals who specialize in STEMI patient care. Detailed information about the program, such as transfer criteria, protocols, training materials, and educational posters, are available on the North Carolina ACC Chapter Web site (http://www.nccacc.org/race.html).
In summary, cardiologists (and interventionalists), emergency physicians, nurses, and EMS providers must work together to establish effective regional community systems of STEMI patient care similar to the well-developed and highly successful systems that direct major trauma victims to verified trauma centers in the United States. All hospitals, whether primary PCI–capable or not, should develop a STEMI protocol that includes procedures to expedite time to reperfusion treatment modeled after concepts inherent in the GAP-D2B program and the Indiana Heart Physicians/St. Francis Heart Center experience. A multidisciplinary committee should oversee the process and provide performance improvement suggestions based on continuous data collection and analysis.
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Acknowledgments |
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Disclosures
Dr Ornato has served on the science advisory board for the National Registry of Myocardial Infarction, which is funded by Genentech.
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Footnotes |
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The opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.
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