Editor’s Commentary
2003; Lippincott Williams & Wilkins; Volume: 107; Issue: 11 Linguagem: Inglês
10.1161/01.cir.0000064356.86957.8f
ISSN1524-4539
Autores Tópico(s)Coronary Interventions and Diagnostics
ResumoHomeCirculationVol. 107, No. 11Editor's Commentary Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessReview ArticlePDF/EPUBEditor's CommentaryCenters of Excellence James T. Willerson James T. WillersonJames T. Willerson From St Luke's Episcopal Hospital/Texas Heart Institute, Houston. Originally published25 Mar 2003https://doi.org/10.1161/01.CIR.0000064356.86957.8FCirculation. 2003;107:1471–1472Drs 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.FootnotesCorrespondence to James T. Willerson, MD, SLEH/THI, 6720 Bertner Ave, Room B524 (MC 1-267), Houston, Texas 77030.References1 Califf RM, Faxon DP. Need for centers to care for patients with acute coronary syndromes. Circulation. 2003; 107: 1467–1470.LinkGoogle Scholar2 Topol EJ, Kereiakes DJ. Regionalization of care for acute ischemic heart disease: a call for specialized centers. Circulation. 2003; 107: 1463–1466.LinkGoogle Scholar eLetters(0)eLetters should relate to an article recently published in the journal and are not a forum for providing unpublished data. Comments are reviewed for appropriate use of tone and language. Comments are not peer-reviewed. Acceptable comments are posted to the journal website only. Comments are not published in an issue and are not indexed in PubMed. Comments should be no longer than 500 words and will only be posted online. References are limited to 10. Authors of the article cited in the comment will be invited to reply, as appropriate.Comments and feedback on AHA/ASA Scientific Statements and Guidelines should be directed to the AHA/ASA Manuscript Oversight Committee via its Correspondence page.Sign In to Submit a Response to This Article Previous Back to top Next FiguresReferencesRelatedDetailsCited BySolla D, de Mattos Paiva Filho I, Delisle J, Braga A, de Moura J, de Moraes X, Filgueiras N, Carvalho M, Martins M, Neto O, Filho P and de Souza Roriz P (2012) Integrated Regional Networks for ST-Segment–Elevation Myocardial Infarction Care in Developing Countries, Circulation: Cardiovascular Quality and Outcomes, 6:1, (9-17), Online publication date: 1-Jan-2013. Kereiakes D and Henry T (2012) Regional Centers of Excellence for the Care of Patients with Acute Ischemic Heart Disease Textbook of Interventional Cardiology, 10.1016/B978-1-4377-2358-8.00036-X, (467-478), . Henry T, Atkins J, Cunningham M, Francis G, Groh W, Hong R, Kern K, Larson D, Ohman E, Ornato J, Peberdy M, Rosenberg M and Weaver W (2006) ST-Segment Elevation Myocardial Infarction: Recommendations on Triage of Patients to Heart Attack Centers, Journal of the American College of Cardiology, 10.1016/j.jacc.2005.05.101, 47:7, (1339-1345), Online publication date: 1-Apr-2006. Garvey J, MacLeod B, Sopko G and Hand M (2006) Pre-Hospital 12-Lead Electrocardiography Programs, Journal of the American College of Cardiology, 10.1016/j.jacc.2005.08.072, 47:3, (485-491), Online publication date: 1-Feb-2006. Awaida J, Dupuis J, Théroux P, Pelletier G, Joyal M, De Guise P, Doucet S, Bilodeau L, Thibault B, Tanguay J, Gallo R, Grégoire J, L'Allier P, Macle L and Nigam A (2006) Demographics, treatment and outcome of acute coronary syndromes: 17 years of experience in a specialized cardiac centre, Canadian Journal of Cardiology, 10.1016/S0828-282X(06)70250-1, 22:2, (121-124), Online publication date: 1-Feb-2006. Faxon D (2005) Early reperfusion strategies after acute ST-segment elevation myocardial infarction: the importance of timing, Nature Clinical Practice Cardiovascular Medicine, 10.1038/ncpcardio0065, 2:1, (22-28), Online publication date: 1-Jan-2005. (2004) ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction, Circulation, 110:9, (e82-e292), Online publication date: 31-Aug-2004.Antman E, Anbe D, Armstrong P, Bates E, Green L, Hand M, Hochman J, Krumholz H, Kushner F, Lamas G, Mullany C, Ornato J, Pearle D, Sloan M, Smith S, Antman E, Smith S, Alpert J, Anderson J, Faxon D, Fuster V, Gibbons R, Gregoratos G, Halperin J, Hiratzka L, Hunt S, Jacobs A and Ornato J (2004) ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction—Executive Summary, Circulation, 110:5, (588-636), Online publication date: 3-Aug-2004. Antman E, Anbe D, Armstrong P, Bates E, Green L, Hand M, Hochman J, Krumholz H, Kushner F, Lamas G, Mullany C, Ornato J, Pearle D, Sloan M, Smith S, Antman E, Smith S, Alpert J, Anderson J, Faxon D, Fuster V, Gibbons R, Gregoratos G, Halperin J, Hiratzka L, Hunt S, Jacobs A and Ornato J (2004) ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction—Executive Summary, Journal of the American College of Cardiology, 10.1016/j.jacc.2004.07.002, 44:3, (671-719), Online publication date: 1-Aug-2004. Dehmer G and Gantt D (2004) Coronary intervention at hospitals without on-site cardiac surgery: are we pushing the envelope too far?**Editorials published in the Journal of the American College of Cardiologyreflect the views of the authors and do not necessarily represent the views of JACCor the American College of Cardiology., Journal of the American College of Cardiology, 10.1016/j.jacc.2003.11.008, 43:3, (343-345), Online publication date: 1-Feb-2004. Herrmann H (2003) Optimizing outcomes in ST-segment elevation myocardial infarction**Editorials published in the Journal of the American College of Cardiologyreflect the views of the authors and do not necessarily represent the views of JACCor the American College of Cardiology., Journal of the American College of Cardiology, 10.1016/S0735-1097(03)01048-9, 42:8, (1357-1359), Online publication date: 1-Oct-2003. March 25, 2003Vol 107, Issue 11 Advertisement Article InformationMetrics https://doi.org/10.1161/01.CIR.0000064356.86957.8FPMID: 12654601 Originally publishedMarch 25, 2003 PDF download Advertisement
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