The American Heart Association is leading a major national effort to improve and expedite treatment for ST-segment elevation myocardial infarction.
Using the logo Mission: Lifeline, reminiscent of the television show, “Mission: Impossible,” the AHA, in collaboration with other organizations, is establishing the criteria and, ultimately, certifying all members of the STEMI “treatment train” from emergency medical services through referring hospitals to the hospital that can perform emergency percutaneous coronary intervention 24/7.
To achieve the targeted goals of fibrinolytic therapy in less than 30 minutes and PCI therapy within 90 minutes for STEMI, the nation’s entire EMS and hospital referral system must improve.
There are excellent community systems upon which future national plans can be modeled, but creating a uniform system is a challenge, given the wide variety of players.
Unlike the European systems, uniform in their configuration and, for the most part, federally funded and very successful at expediting care for STEMI, the U.S. system is a helter-skelter assortment of private and voluntary players, bent on preserving their individual priorities and control.
Only 6% of American EMS systems are hospital based. The rest are provided by fire departments, volunteers, and private operators. State governments control EMS operations, which are certified for different levels of care and are variably equipped to deal with cardiac emergencies.
In fact, Americans use EMS systems in less than 25% of instances to obtain emergency care for STEMI. In spite of extensive public education, Americans still do not understand the need for rapid response to chest pain symptoms.
“Although the performance of primary PCI has increased from 18% to 53%” nearly 30% of patients with STEMI fail to receive either fibrinolytic therapy or PCI, said Dr. Alice Jacobs, former president of the AHA, who is leading the Mission: Lifeline effort (Circulation 2007;116:689-92). Most patients with STEMI symptoms seek medical help at hospitals that are not equipped to perform primary PCI.
To expand the number of PCI-approved hospitals, the requirement to have on-site cardiac surgery in such hospitals will have to be dropped. But rapid transfer to PCI hospitals can be achieved if systems are in place.
to achieve the targeted goals of fibrinolytic therapy, the nation’s entire ems and hospital referral system must improve.
Such systems must be established to expedite patient transfer when time and logistics permit, or to initiate fibrinolytic therapy when primary PCI is neither feasible nor appropriate.