From Concept to Reality
2012; Lippincott Williams & Wilkins; Volume: 126; Issue: 2 Linguagem: Inglês
10.1161/circulationaha.112.114140
ISSN1524-4539
Autores Tópico(s)Coronary Interventions and Diagnostics
ResumoHomeCirculationVol. 126, No. 2From Concept to Reality Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessEditorialPDF/EPUBFrom Concept to RealityA Decade of Progress in Regional ST-Elevation Myocardial Infarction Systems Timothy D. Henry, MD Timothy D. HenryTimothy D. Henry From the Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, MN. Originally published4 Jun 2012https://doi.org/10.1161/CIRCULATIONAHA.112.114140Circulation. 2012;126:166–168Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: January 1, 2012: Previous Version 1 Perseverance is not a long race: it is many short races one after another.—Walter Elliott, 19th Century spiritual writerThe treatment and outcome of patients with ST-segment elevation myocardial infarction (STEMI) has improved dramatically over the 30 years since I graduated from medical school. In 1982, bed rest, treatment of complications such as ventricular arrhythmias or mural thrombus and prayer (for those so inclined) were the standard of care. In the first decade, pharmacological therapy was developed, and the open artery hypothesis was confirmed. The Second International Study of Infarct Survival (ISIS-2) trial demonstrated the benefit of not only aspirin, but also the combination of aspirin and streptokinase1 leading to a series of randomized clinical trials to determine the preferred fibrinolytic and adjunctive medications. The second decade was filled with trials that compared fibrinolytic therapy with primary percutaneous coronary intervention (PCI), which ultimately confirmed primary PCI as the preferred method of reperfusion if performed in a timely manner in high-volume centers.2 European trials extended the benefits of PCI to STEMI patients who presented to non-PCI centers requiring transfer for primary PCI.3,4 In particular, the Danish Multicenter Randomized Study on Thrombolytic Therapy versus Acute Coronary Angioplasty in Acute Myocardial Infarction (DANAMI-2), a well-designed, multicenter, randomized trial including 24 referral hospitals and 5 PCI centers in Denmark, was stopped early when it demonstrated a significant reduction in the primary end point of death, reinfarction, and stroke at 30 days (8% for primary PCI versus 13.7% for fibrinolysis, P 90%. Only patients for whom the therapy would be inappropriate (those with advanced dementia or metastatic cancer) and the rare patient who presents too late (12 or 24 hours after onset) would not undergo reperfusion therapy.Time to TreatmentConsistent with national trends, door-to-device times for patients presenting directly to PCI hospitals continued to improve, achieving the excellent median of 59 minutes.13 More importantly, the time from first door-to-device for patients transferred from a non-PCI for PCI improved to 103 minutes with 39% of patients treated within 90 minutes. As expected, the time from first door to device was related to distance.Primary PCI ReperfusionThe number of patients receiving primary PCI as their primary reperfusion method increased from 52% to 66%. Still, 31% of eligible patients were treated with fibrinolytics before transfer. It is unclear how many of these patients subsequently underwent cardiac catheterization and PCI (or the timing if they did). Results of recent randomized clinical trials and regional STEMI systems indicate that a pharmacoinvasive strategy has the potential to provide a PCI-based reperfusion strategy to almost the entire US population.9,14DataA major challenge to improving the care of STEMI patients in the United States has been the lack of accurate and comprehensive data. Data from the Joint Commission, Medicare, or registries such as National Cardiovascular Data Registry or National Registry for Myocardial Infarction are highly selective and do not include all STEMI patients.15 Incomplete data make it difficult to understand where improvements need to be made. The availability of complete STEMI results for an entire state is a tremendous accomplishment for RACE. This was made possible by the fact that all 119 hospitals voluntarily agreed to participate in Acute Coronary Treatment and Intervention Outcomes Network Registry – Get With The Guidelines (AR-G), which will continue to be a challenge nationally.Limitations and ChallengesOne important lesson learned from RACE is that a mixed strategy, in which providers could choose PCI or fibrinolysis, may not be the ideal approach. A mixed strategy was used in 15 hospitals and resulted in substantially longer first door-to-device times, although times did improve from 195 to 138 minutes. It appears preferable to choose a strategy and have a backup plan. A pharmacoinvasive, PCI-based strategy would theoretically solve this problem.7,9,14 Following the initial RACE publication, questions were raised regarding the lack of clear mortality benefits. Although the authors address this issue in this article, it is worth remembering that the proven benefit of primary PCI over fibrinolysis was demonstrated in randomized clinical trials. Therefore, our goal continues to be expanding access to primary PCI. The improvements in RACE were made on top of a preexisting system in which primary PCI had already been used for appropriate patients for many years.The RACE investigators should be congratulated for not only the first successful statewide network and outstanding results, but also for successfully obtaining the funding to complete this monumental task. This remains a major challenge for most regions of the United States. The EMS, in particular, is underfunded. Data collection, although invaluable, is also expensive and duplicative in many hospitals. Is it realistic to believe entire statewide systems can be developed throughout the United States?Growth in Regional STEMI NetworksA Mission: Lifeline survey found that in 2010 there were 381 unique STEMI systems including 899 PCI hospitals in 47 states.16 These findings are encouraging and likely underestimate the true extent of growth and development of regional STEMI systems. The survey indicated that the funding was provided by the primary PCI hospital (84%) or cardiology practice (23%) in the majority of cases. The most common barriers to implementation of regional STEMI systems were self-reported to be the hospital administration (37%), cardiology group competition (21%), and emergency medical services (EMS, transport, and finances) (26%). The American Heart Association Mission: Lifeline program was designed to increase timely access to PCI for STEMI patients17 and was recently expanded to include patients without of hospital cardiac arrest. Ideally, STEMI systems of care will be expanded regionally to include all cardiovascular emergencies.18Lessons Learned From a Decade Developing Regional STEMI SystemsMajor advances in health care occur not from results of randomized clinical trials or real-world registries, but from the application of those results to complex healthcare systems, which requires the successful interaction of healthcare workers with their patients. The growth and success of regional STEMI systems over the past decade represents such an advance.Specific lessons learned watching this remarkable achievement are worth noting. The development of a system is based on the use of standardized protocols and order sets designed by use of guideline-based therapies. Yet, the same system needs to allow flexibility to address the individual needs of patients and physicians. The system requires prearranged and individualized reperfusion and transfer plans for each community/hospital, which necessitates close coordination and communication between EMS, non-PCI centers, and PCI centers. Teamwork is essential. Every member of the team is critical, and the improvements require input and leadership at every level. The need for education, training, and retraining cannot be underestimated because of the large number of people involved and ongoing changes in both personnel and new data. Feedback is a key component including the transporting paramedics observing the angiogram, the interventional cardiologist calling the emergency department physician immediately following the procedure, and communication the following day between the STEMI coordinator and EMS/emergency department managers, and the primary cardiologist with the primary care physician, as well. Monthly, quarterly, and yearly quality reports provide ongoing and systemwide quality improvement. Financial and moral support from hospital administration are essential and, if missing, can create a major stumbling block. Perhaps the most important link in the chain is a passionate leader at every level.The growth of regional STEMI systems in the United States over the past decade has clearly exceeded our expectations. Seven years ago, we published an article raising the question whether it was time for a national policy concerning the treatment of STEMI patients.5 Today, we are no closer to that policy, but I am no longer certain it is either necessary or if it would be helpful. Certainly state and national legislation to support our financially strapped EMS would be welcome, including a 12-lead ECG in each ambulance, automated external defibrillator in all public places, and support for both EMS training and data collection, as well. Public policy changes to provide financial incentives for more rational use of resources to support regional STEMI systems rather than building more catheterization laboratories would also be helpful.19,20 The driving force behind this remarkable improvement in US STEMI care has been passionate individuals dedicated to improving the quality of care for their communities. Individual paramedics, STEMI nurse coordinators, hospital administrations, and emergency department and interventional physicians all are doing their part to improve the entire system.Ideally, the entire US population will have locally designed regional systems not only to provide timely access to PCI for all STEMI patients, but also to care for all acute cardiovascular emergencies. This lofty goal is not only possible, but within our grasp in the next decade.DisclosuresNone.FootnotesThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.Correspondence to Timothy D. Henry, MD, Minneapolis Heart Institute Foundation, 920 East 28th St, Suite 100, Minneapolis, MN 55407. E-mail [email protected]eduReferences1. ISIS-2 Collaborative Group. Randomised trial of intravenous streptokinase, oral aspirin, both, or neither among 17 187 cases of suspected acute myocardial infarction: ISIS-2. ISIS-2 (Second International Study of Infarct Survival) Collaborative Group.. Lancet.1988; 2:349–360.MedlineGoogle Scholar2. Keeley EC, Boura JA, Grines CL. Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomised trials. Lancet. 2003; 361:13–20.CrossrefMedlineGoogle Scholar3. Dalby M, Bouzamondo A, Lechat P, Montalescot G. 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Am J Cardiol. 2012; 109:1582–1588.CrossrefMedlineGoogle Scholar15. Campbell AR, Satran D, Larson DM, Chavez IJ, Unger BT, Chacko BP, Decker J, Kapsner C, Henry TD. ST-elevation myocardial infarction: which patients do quality assurance programs include? Circ Cardiovasc Qual Outcomes. 2009; 2:648–655.LinkGoogle Scholar16. Jollis JG, Granger CB, Henry TD, Antman EM, Berger PB, Moyer PH, Pratt FD, Rokos IC, Acuňa AR, Roettig ML, Jacobs AK. Systems of care for ST-segment-elevation myocardial infarction: a report from the American Heart Association's Mission: Lifeline.Circ Cardiovasc Qual Outcomes.May22, 2012. doi: 10.1161/CIRCOUTCOMES.111.964668. http://circoutomes.ahajournals.org.Accessed May 25, 2012.Google Scholar17. Jacobs AK, Antman EM, Faxon DP, Gregory T, Solis P. Development of systems for care for ST-elevation myocardial infarction patients: executive summary. Circulation. 2007; 116:217–230.LinkGoogle Scholar18. 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Circ Cardiovasc Qual Outcomes. 2010; 3:441–443.LinkGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Yildiz M, Wade S and Henry T (2021) STEMI care 2021: Addressing the knowledge gaps, American Heart Journal Plus: Cardiology Research and Practice, 10.1016/j.ahjo.2021.100044, 11, (100044), Online publication date: 1-Nov-2021. Karacsonyi J, Schmidt C, Okeson B, Garcia S, Henry T, Nikolakopoulos I, Vemmou E, Xenogiannis I, Sharkey S, Aguirre F, Tannenbaum M, Nicholas Burke M, Goessl M, Sorajja P, Traverse J, Wang Y and Brilakis E (2021) Comparison of Outcomes of Patients with vs without Previous Coronary Artery Bypass Graft Surgery Presenting with ST-Segment Elevation Acute Myocardial Infarction, The American Journal of Cardiology, 10.1016/j.amjcard.2021.05.041, 154, (33-40), Online publication date: 1-Sep-2021. Yildiz M, Sharkey S, Aguirre F, Tannenbaum M, Garberich R, Smith T, Shivapour D, Schmidt C, Pacheco-Coronado R, Rohm H, Chambers J, Coulson T, Garcia S and Henry T (2021) The Midwest ST-Elevation Myocardial Infarction Consortium: Design and Rationale, Cardiovascular Revascularization Medicine, 10.1016/j.carrev.2020.08.019, 23, (86-90), Online publication date: 1-Feb-2021. Mengal N, Saghir T, Hassan Rizvi S, Khan N, Qamar N, Masood S and Badini A Acute ST-Elevation Myocardial Infarction Before and During the COVID-19 Pandemic: What is the Clinically Significant Difference?, Cureus, 10.7759/cureus.10523 Mahmud E, Dauerman H, Welt F, Messenger J, Rao S, Grines C, Mattu A, Kirtane A, Jauhar R, Meraj P, Rokos I, Rumsfeld J and Henry T (2020) Management of Acute Myocardial Infarction During the COVID-19 Pandemic, Journal of the American College of Cardiology, 10.1016/j.jacc.2020.04.039, 76:11, (1375-1384), Online publication date: 1-Sep-2020. Mahmud E, Dauerman H, Welt F, Messenger J, Rao S, Grines C, Mattu A, Kirtane A, Jauhar R, Meraj P, Rokos I, Rumsfeld J and Henry T (2020) Management of acute myocardial infarction during the COVID ‐19 pandemic , Catheterization and Cardiovascular Interventions, 10.1002/ccd.28946, 96:2, (336-345), Online publication date: 1-Aug-2020. Lange D, Conte S, Pappas-Block E, Hildebrandt D, Nakamura M, Makkar R, Kar S, Torbati S, Geiderman J, McNeil N, Cercek B, Tabak S, Rokos I and Henry T (2018) Cancellation of the Cardiac Catheterization Lab After Activation for ST-Segment–Elevation Myocardial Infarction, Circulation: Cardiovascular Quality and Outcomes, 11:8, Online publication date: 1-Aug-2018. Mehta S, Granger C, Grines C, Jacobs A, Henry T, Rokos I, Lansky A, Baumbach A, Botelho R, Ferre A, Yepes I, Salwan R, Dalal J, Makkar J, Bhalla N, Mishra S, Vijan V and Hiremath S (2018) Confronting system barriers for ST- elevation MI in low and middle income countries with a focus on India, Indian Heart Journal, 10.1016/j.ihj.2017.06.020, 70:1, (185-190), Online publication date: 1-Jan-2018. Lange D, Larson D, Hildebrandt D and Henry T (2017) Creating Networks for Optimal STEMI Management Manual of STEMI Interventions, 10.1002/9781119095446.ch18, (299-314) Lange D, Rokos I, Garvey J, Larson D and Henry T (2016) False Activations for ST-Segment Elevation Myocardial Infarction, Interventional Cardiology Clinics, 10.1016/j.iccl.2016.06.002, 5:4, (451-469), Online publication date: 1-Oct-2016. Fordyce C, Henry T and Granger C (2016) Implementation of Regional ST-Segment Elevation Myocardial Infarction Systems of Care, Interventional Cardiology Clinics, 10.1016/j.iccl.2016.06.001, 5:4, (415-425), Online publication date: 1-Oct-2016. Meloni L, Floris R, Montisci R, De Candia G, Cadeddu M, Lai G, Sori P, Ruscazio M, Pinna G, Iasiello G and Pirisi R (2016) Care quality monitoring of a ST-segment elevation myocardial infarction programme over a 5-year period, Journal of Cardiovascular Medicine, 10.2459/JCM.0000000000000285, 17:7, (494-500), Online publication date: 1-Jul-2016. Rhudy J, Bakitas M, Hyrkäs K, Jablonski‐Jaudon R, Pryor E, Wang H and Alexandrov A (2015) Effectiveness of regionalized systems for stroke and myocardial infarction, Brain and Behavior, 10.1002/brb3.398, 5:10, Online publication date: 1-Oct-2015. Anderson L, French W, Peng S, Vora A, Henry T, Roe M, Kontos M, Granger C, Bates E, Hellkamp A and Wang T (2015) Direct Transfer From the Referring Hospitals to the Catheterization Laboratory to Minimize Reperfusion Delays for Primary Percutaneous Coronary Intervention, Circulation: Cardiovascular Interventions, 8:9, Online publication date: 1-Sep-2015.Aversano T (2014) Distance, Delay, and Discontent, Circulation: Cardiovascular Interventions, 7:6, (739-740), Online publication date: 1-Dec-2014.Nicholson B, Dhindsa H, Roe M, Chen A, Jollis J and Kontos M (2014) Relationship of the Distance Between Non-PCI Hospitals and Primary PCI Centers, Mode of Transport, and Reperfusion Time Among Ground and Air Interhospital Transfers Using NCDR's ACTION Registry-GWTG, Circulation: Cardiovascular Interventions, 7:6, (797-805), Online publication date: 1-Dec-2014. Henry T and Kereiakes D (2014) Volume driven performance metrics in STEMI care: Does practice make perfect?, Catheterization and Cardiovascular Interventions, 10.1002/ccd.25677, 84:6, (948-949), Online publication date: 15-Nov-2014. Teixeira R, Gonçalves L and Gersh B (2013) Acute myocardial infarction — Historical notes, International Journal of Cardiology, 10.1016/j.ijcard.2012.12.066, 167:5, (1825-1834), Online publication date: 1-Sep-2013. Concannon T, Nelson J, Kent D and Griffith J (2013) Evidence of Systematic Duplication by New Percutaneous Coronary Intervention Programs, Circulation: Cardiovascular Quality and Outcomes, 6:4, (400-408), Online publication date: 1-Jul-2013. July 10, 2012Vol 126, Issue 2 Advertisement Article InformationMetrics © 2012 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.112.114140PMID: 22665717 Originally publishedJune 4, 2012 KeywordsST elevation myocardial infarctionEditorialsPDF download Advertisement SubjectsMyocardial Infarction
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