Centers of Excellence
Drs Califf and Faxon1 and Topol and Kereiakes2 have made a strong case for the creation of Special Centers of Excellence for the rapid and effective treatment of acute myocardial infarction in patients. Their reviews have summarized advances in cardiovascular medicine that have shown that interventional therapy with angioplasty and stents provide improved outcomes for patients with ST-segment elevation myocardial infarcts. Carefully selected patients may also benefit from thrombolytic therapy in combination with potent antiplatelet therapies. Patients with unstable angina and non–ST-segment elevation infarcts should be treated intensively with medications that prevent sustained thrombosis and vasoconstriction. Those with increases in serum troponins with unstable angina and those with increases in serum C-reactive protein with unstable angina and non–ST-segment elevation infarcts benefit from potent antithrombotic medications and coronary artery revascularization. Time is of the essence, however, especially for those patients with acute myocardial infarctions, and the more rapidly one can open the infarct-related artery in patients with ST-segment elevation infarcts and prevent repetitive and/or sustained coronary artery occlusions in those with non–ST-segment elevation infarcts, the better for the individual patient.
The educated opinions expressed in this issue by the experienced physician-scientists cited above1,2 need to be taken seriously by hospitals, community leaders, and our government. The real issue is not whether the creation of Specialized Centers for the care of these patients would provide an important advance, but rather how to create them. The transport of patients over long distances with consequent extended delays in their treatment will not be beneficial in reducing morbidity and mortality. The future focus needs to be on preventive therapy for patients at risk, improved emergency ambulance systems (on the ground and in the air), and the creation of Centers of Excellence for patients with acute coronary syndromes (ACS).
Creative approaches to the problem are needed. Current financial considerations have a constraining effect. I believe that in large communities, one should be able to establish specific criteria for Centers of Excellence at existing hospitals where there is clearly the necessary experience and commitment to treat patients with ACS optimally. What is needed is an agreement that certain capabilities in the care of these patients must be present for patients with ACS to be taken to a particular hospital location. Medical societies and local governments working together are probably in the best position to establish objective, fair, and forward-looking specifications for Centers of Excellence in the care of patients with ACS.
However, this is only part of the problem. Much of our country (and other countries) includes large areas that are sparsely populated with long distances required to travel to a city where a Center of Excellence may exist. Thus, it will also be necessary to identify regional rural hospitals where the best possible medical therapies are established and experienced physicians can be made available to administer these therapies. In some cases, therapy may be limited to thrombolytic options when physicians trained and experienced in angioplasty and stent placement are not available. In other instances, it may be possible to rapidly transport well-trained physicians to community outreach hospitals.
It is important that we develop the care paradigms and create these Centers of Excellence as soon as possible. I believe this can be done in such a manner that major additional medical care costs are not incurred beyond what specific procedures otherwise cost. Community outreach programs should be the responsibility of hospitals, large and small, in various parts of the United States, and regional leaders need to work together and to plan wisely and unselfishly for improving care of patients with ACS.
Finally, we must continue to work toward the ultimate goal of prevention of ACS. We need to discover the gene(s) and proteins that predict patients at risk for premature ACS. We must insist our citizens be informed about and engage in individual health protection that includes cessation of smoking, weight loss, regular exercise, and control of blood pressure and serum lipids. Monitoring programs need to consider the role that inflammation plays in the development of ACS and provide periodic tests of serum C-reactive protein values (and possibly other biomarkers that predict future risks) in patients believed to be at increased risk for ACS. Appropriate medical therapies that are antithrombotic and lipid lowering need to be utilized in patients believed to be at risk for ACS. Emergency ambulance care systems need to be further developed that are capable of getting to and treating patients rapidly and correctly en route to Centers of Excellence. This includes the ability to correctly and safely deliver thrombolytic therapy when indicated to patients with ST-segment elevation infarcts and appropriate antithrombotic therapy to those with unstable angina and non–ST-segment elevation infarcts.
The issues addressed by Drs Califf, Faxon, Topol, and Kereiakes are the result of advances in medical therapy that have positioned physicians and caregivers generally to treat patients with ACS in increasingly protective ways, thereby reducing their morbidity and mortality. However, the ultimate goal is prevention of ACS, and we should keep that constantly in mind as we work to improve our medical care facilities today.
The opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.