Excerpt from: Chapter 19. STEMI Interventions - Future Perspectives
Imagine a patient involved in an automobile accident on the Florida turnpike while driving from Miami to Orlando, and sustaining a laceration and a thigh fracture. Within minutes, Emergency Medical Services (EMS) will rescue and transport the patient to the closest Level 1 Trauma Center, where an expert team of trauma surgeons rushes the patient to the operating room to treat the laceration and the fracture. If all goes well, discharge from the hospital occurs on day 3; a few weeks later after a short course of rehabilitation, the patient is discharged home, and six months later, resumes his regular singles tennis schedule.
This is quality care provided within the American medical system. It is made possible by a superb national trauma system which works in a coordinated fashion to triage the patient to the appropriate institution for adequate care.
In contrast, let us now assume our patient is having an ST-elevation myocardial infarction (STEMI) while making the same drive. We could imagine the pain beginning early in the morning, but it was intermittent and temporarily subsided; our patient may have attributed the discomfort to his gastro-esophageal reflux and decided to continue the drive. Six hours later, as he drives on the interstate, the pain returns and becomes unbearable, and he pulls over and calls 911. Once again, EMS responds urgently, the paramedics diagnose STEMI, stabilize the patient, and transport him to the nearest ER, just off the next exit on the turnpike. It is a small, community hospital without an available cath lab nearby. In consultation with a cardiologist, the emergency room physician administers a thrombolytic agent. The patient is admitted to the 2-bed CCU and continues to have lingering pain. Treatment now includes supplemental oxygen, telemetry, anti-platelets and anti-coagulants, and intravenous nitroglycerine is administered. Later in the night, the patient requires morphine for relief of recurrent chest pain. A follow-up ECG in the morning demonstrates persistent ST-segment elevation and the cardiologist arranges for a transfer to the nearest hospital for a coronary angiogram. Transfer occurs in the afternoon uneventfully, and soon after arrival, a coronary angiogram reveals an ulcerated 90% proximal left anterior descending artery (LAD) lesion and TIMI-2 flow, the anterior wall and apex are severely hypokinetic, and left ventricular ejection fraction (LVEF) is 35%. A successful percutaneous coronary intervention (PCI) is performed and a drug-eluting stent is placed, restoring flow in the LAD. Discharge from the hospital occurs on the fourth day. The patient is discharged on multiple medications. One month after his acute myocardial infarction (MI), the patient continues to have significant dyspnea with exertion, is unable to return to work and is considering disability. A follow-up echocardiogram demonstrated no significant improvement in left ventricular systolic function with severe apical hypokinesis.
This is an example of suboptimal American medicine. Compared to the former example, the poor care in the latter example is a result of the disparate treatment of acute MI compared to trauma and from the lack of a National Heart Attack Response System.
…We are likely on the verge of witnessing a massive restructuring of healthcare resources and priorities, nationally and globally, as we strive to provide STEMI interventions universally, in an efficient, scientific, standardized and cost-effective manner. Looking beyond the cardiovascular laboratory and assessing the ongoing dramatic changes in the management of STEMI occurring within the general community requires us to briefly review the present status of STEMI triage and treatment. There are three specific issues which must be addressed:
1. Achieve a consensus about the role of the three major global STEMI strategies: Pre-hospital thrombolysis, pharmaco-invasive strategies and pure invasive strategies (Table 1).
2. Logistics notwithstanding, is a default PCI strategy not the best way to treat STEMI globally?
3. What should be the mechanisms of delivering the appropriate strategy and in incorporating the EMS —specifically, do we need a national STEMI policy?
Barriers to an Integrated STEMI System and National STEMI Policy
Figure 1 summarizes the three groups of barriers that appear predominantly responsible in preventing formations of more successful integrated STEMI systems. It is felt that all three components are critical — indeed, some countries may find one barrier more challenging than the others. In his visionary introduction to this textbook, Dr. King also cites logistics as the major barrier to success. The author strongly agrees with this assessment and refers readers to the outstanding work done by the Yale investigators in this area.1 A review of the superb Mayo Clinic STEMI program answers another important issue. The Mayo investigators incorporated four of the six recommendations made by the Yale researchers.2 Indeed, this pattern is visible at various other integrated programs wherein investigators are cultivating their programs in response to their specific challenges. Some institutions are hesitating on the need for a cardiologist in-house and about the different methodologies of EMS alert of the emergency department, the cath lab and the cardiologist.
The issue of paying for the care of the millions of indigent patients will also require careful address by community, state and federal agencies. As mentioned before in the SINCERE (Single INdividual Community Experience REgistry for Primary PCI) database chapter, about 23% of patients within the database had no insurance. Who pays for the burgeoning numbers of these patients presenting with STEMI? Is it fair for a cardiologist who is providing this care, often at off-hours, to not be fairly compensated for the efforts that often border on being heroic? Often this care is provided in the midst of the very legally-challenging environment that exist in numerous emergency rooms. As hospitals develop STEMI programs and as policies are being developed, the care of indigent patients and of adequate physician compensation and liability protection will need to be addressed.
…Some exciting information technology (IT) modalities are delivering on-line data to the physicians. The role of these and other IT enhancements will increase efficiencies of the delivery systems. GPS guidance may speed physician arrival and navigation with traffic in urban locations. Transportation of the interventional cardiologist will need improvements, and helicopter transport, police-escort and permission to use sirens are some suggested methods. Of course, in-house 24/7 availability of the interventional cardiologist (the author’s preferred strategy at one of 5 SINCERE sites over a period of two years) and of the team are the ultimate logistical solutions. More critical is the need to address patient-related issues that delay STEMI access. Two studies have been cited in the figure and they provide a pragmatic framework to develop patient education and awareness models. The role of press, other media, pharmaceuticals, and of organizations such as American Medical Association (AMA), American Heart Association (AHA) and American College of Cardiology (ACC) is critical in this function. Backward integration of the STEMI model to educate the patient in seeking early care is almost as critical as the creation of an effective STEMI triage pathway. Institutions providing STEMI care must offer patient education — specifically about the two critical elements of seeking early care and using EMS to reach the hospital.
Five specific benefits from use of EMS should be advocated:
1. Prompt EKG diagnosis and EKG transmission;
2. Early pharmacologic management, including pre-hospital thrombolysis;
3. Management of complications;
4. Triage to STEMI institution;
5. Activation of ED and CVL teams at a primary PCI institution.
The final barrier is one presented by legislative hurdles — it is the author’s opinion that this specific area needs urgent collaborative work from the numerous stakeholders in STEMI — individual patients and their loved ones; the community to which they belong; local healthcare facility; EMS; pharmaceutical organizations and medical device manufacturers; payers — state, local, federal, managed care and private payers; educational organizations; legislators and politicians. There are not too many in any society that will remain unaffected by heart attacks amongst members and there are few issues that will invoke a greater urgency to action — it is up to the stakeholders to formulate the best local strategy to deliver timely and optimal STEMI care. Beyond local delivery of this care, a larger legislative approval process is needed to streamline the local process and to establish firm guidelines that monitor the standardized delivery of quality STEMI care to all citizens. The author firmly believes that the perfect model to follow for a national STEMI policy58-62 is one based on the existing trauma care.63-66
Table 5 provides a comparison between acute MI and a national trauma system.
Figure 2 proposes (the author’s constructed) basic nationwide STEMI triage pathway that incorporates patient activation of the EMS system, effective transport to a STEMI facility and standardized, guidelines-based delivery of the most effective STEMI treatment).
References (excerpted)
1. Nallamothu BK, Bradley EH, Krumholz HM. Time to Treatment in Primary Percutaneous Coronary Interventions. N Engl J Med 2007;357:1631-1638.
2. Henry TD, Sharkey SW. A regional system to provide timely access to percutaneous coronary intervention for ST-elevation myocardial infarction. Circulation 2007;116:721–728.
58. Carlsson J, James SN, Stahle E, et al. Outcome of percutaneous coronary intervention in hospitals with and without on-site cardiac surgery standby. Heart 2007;93:335-338.
59. Garvey JL, MacLeod BA, Sopko G, Hand MM. Pre-hospital 12-lead electrocardiography programs: a call for implementation by emergency medical services systems providing advanced life support–National Heart Attack Alert Program (NHAAP) Coordinating Committee; National Heart, Lung, and Blood Institute (NHLBI); National Institutes of Health. J Am Coll Cardiol 2006;47:485-491.
60. Henry TD, Atkins JM, Cunningham MS. ST-segment elevation myocardial infarction: recommendations on triage of patients to heart attack centers: is it time for a national policy for the treatment of ST-segment elevation myocardial infarction? J Am Coll Cardiol 2006;47:1339-1345.
61. Rathore SS, Epstein AJ, Nallamothu BK, Krumholz HM. Regionalization of ST-segment elevation acute coronary syndromes care: putting a national policy in proper perspective. J Am Coll Cardiol 2006;47:1346-1349.
62. Califf RM, Faxon DP. Need for centers to care for patients with acute coronary syndromes. Circulation 2003;107:1467-1470.
63. Cales RH, Trunkey DD. Preventable trauma deaths. A review of trauma care systems development. JAMA 1985; 254:1059-1063.
64. Pollock DA, McClain PW. Trauma registries. Current status and future prospects JAMA 1989;262:2280-2283.
65. Lowe DK, Gately HL, Goss JR, et al. Patterns of death, complication, and error in the management of motor vehicle accident victims implications for a regional system of trauma care. J Trauma 1983; 23:503-509.
66. Mullins RJ, Veum-Stone J, Helfand M, et al. Outcome of hospitalized injured patients after institution of a trauma system in an urban area JAMA 1994;271:1919–1924.
