US emergency angioplasty guidelines ‘not sufficient’

By Piriya Mahendra

The coordinated regional system of care for severe myocardial infarction in North Carolina, USA, should be established nationally, researchers say in Circulation.

The Reperfusion of Acute Myocardial Infarction in Carolina Emergency Departments-Emergency Response (RACE-ER) project significantly improved survival rates in patients with ST-segment-elevation myocardial infarction (STEMI).

"The most important care decisions for heart attack patients are made long before they get to the hospital," commented lead author James Jollis (Duke University, Durham, North Carolina) in a press statement. "These coordinated care systems should be in every single hospital and every single EMS system in the country."

The RACE-ER intervention involves regional care systems that support voluntary contributions between emergency medical services (EMS) and hospitals. It is based on the American Heart Association's Mission: Lifeline STEMI program, which aims to treat patients using revascularization within 90 minutes of their first contact with the healthcare system (paramedics or hospital emergency department).

Between July 2008 and December 2009, the RACE-ER intervention decreased the time from first medical contact to medical treatment from 103 minutes to 91 minutes among patients who were bought by EMS directly to hospitals that performed percutaneous coronary intervention (PCI). Of these patients, 52% were treated within 60 minutes.

Treatment times for patients who were transferred from non-PCI hospitals to PCI hospitals improved significantly from 117 minutes to 103 minutes (p=0.0008). Moreover, 39% of these patients were treated within 90 minutes by December 2009.

Treatment times at hospitals with a mixed strategy of transfer or fibrinolysis fell from 195 minutes to 138 minutes (p=0.002).

Patients who were treated within times suggested by US guidelines (which recommend door-to-device time of 90 minutes) had a mortality rate of 2.2% versus 5.7% among those whose treatment times exceeded these guideline recommendations.

"Our intervention demonstrates how competing healthcare entities can work together to overcome the systematic barriers that prevent timely heart attack treatment," said Jollis.

"We were able to embed a standard of care that was independent of what hospital the patient was brought to or where the heart attack occurred. By the end of our intervention, our protocols were adopted by state regulation for all EMS agencies, and all hospitals agreed to continue supporting regional care."

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