Modest Improvement of Reperfusion Times Across Multiple ST-Segment–Elevation Myocardial Infarction Networks With Rapid Care Process Implementation but no Effect on Mortality
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- percutaneous coronary intervention
- quality improvement
- reperfusion times
- ST-segment–elevation myocardial infarction
- systems of care
In patients with ST-segment–elevation myocardial infarction (STEMI) delay between symptom onset and reperfusion has been associated with poor outcomes.1,2 In particular, in adjusted analyses, for every 30-minute delay, there is a 7.5% increase in mortality.1 However, the National Registry of Myocardial Infarction demonstrated discordance between symptom onset and balloon time, which did not correlate with mortality, in contrast with the strong relationship between door-to-balloon time and mortality (especially with <2-hour delays).3 The authors suggested that door-to-balloon times may be surrogates for quality of care and that the time between symptom onset and the start of therapy is the major determinant of the duration of ischemia and extent of salvage. Another explanation was that door-to-balloon times are dependent on the severity of illness, and sicker patients may have longer door-to-balloon times because of the need for additional procedures.
See Article by Fordyce et al
In this issue of Circulation: Cardiovascular Interventions, Fordyce et al4 describe the effects of the American Heart Association Mission: Lifeline STEMI Systems Accelerator program5 on improving system performance in 16 metropolitan areas over 2 years involving 23 498 patients with the uptake of 4 key processes shown to be associated with shorter reperfusion times.6 The key processes were prehospital cardiac catheterization laboratory activation, single call transfer protocol from an outside facility, emergency department bypass for emergency medical services for direct presenters, and transfers. Implementation was documented by surveys at the beginning and at the end of the program.
On average, the program increased implementation by 22%. All median times improved significantly (P<0.001; Figure). The time from first medical contact (FMC)-to-device with implementation of prehospital activation of the catheterization laboratory improved by 10 minutes (88 versus 98 minutes). Institution of single call transfer protocols from an outside facility was …