Should Patients with an Acute MI be Transferred to a Site that Performs Primary PCI?

Sang Do Shin, MD, PhD

Department of Emergency Medicine, Seoul National University Hospital, Seoul Korea

Introduction
Regionalization of the care of acute ST-segment elevation myocardial infarction (STEMI) has gained momentum recently in
Modern Emergency Health Care System. Optimal treatment of STEMI which are fibrinolysis, primary angioplasty and
intervention, coronary care unit care, and miscellaneous treatment options involves balancing time to treatment and
reperfusion options. Primary percutaneous coronary intervention (PCI) with a timely fashion, has been shown to be more
effective and safer than fibrinolysis. However, numerous practical barriers prohibit many STEMI patients from receiving
primary percutaneous coronary intervention. Resource-based problem, lack of evidence, technical error to detect the STEMI
(false positive), and immature system to do optimal care within time window are related with these barriers. Most of important
thing will be community development to perform appropriate performance. I will present various perspectives and issues that
Decision makers and system organizers must address properly before deciding whether to adopt this new model of care; costeffective and safe community regional AMI protocol

Main issues: What are recommended for the optimal management for acute myocardial infarction? What
are remained as uncertain?

Emergency care system often aims to provide timely management and acute intervention with in time window (Gold
standard) for target conditions, which usually shows narrow time-dependent outcome relationship, such as stroke, cardiac
arrest, sepsis, respiratory failure, traumatic brain injury, and acute myocardial infarction. However, the time window can be
changed according to new knowledge on pathophysiology, development of diagnostic technology, evidence from clinical
trials, and treatment capacity to do all.

Target

Acute myocardial infarction remains a major health care problem and serves as a target for quality improvement in most of

communities. Especially, numerous investigations for the improvement of hospital capacity (emergency and definite care)
were performed, which aimed to reduce the door to ballooning time. Unfortunately, the target was only ST elevation MI, not
all acute coronary syndromes (ACS) like unstable angina, variant angina, and non-ST elevation MI. Majority of acute chest
pain are proven with non-specific diagnosis regardless of rigorous laboratory test and repeated evaluation using ECG and
myocardial enzyme in most of ED. Acute coronary syndrome should be searched among these false positive conditions.
Among those ACS conditions, a few ST elevation MI is there. From a view community level, and regionalization strategy,
more sensitive and specific decision making will be need to detect STEMI cases preciksely.

Time window

The ACC/AHA guidelines recommend that chemical reperfusion with fibrinolytic therapy occur within 30 minutes of arrival
in the emergency department (ED) or that primary percutaneous coronary intervention be performed within 90 minutes of
arrival. These protocol is based on the nationwide observational study or well-designed controlled trials. However, this study
protocol has starting point, arrival at ED. The door to balloon time is critical index but for hospital capacity, not for community
capacity or EMS capacity. In recent, the EMS to balloon time (E2B) was introduced to scientific field to overcome this
limitation. However, it has not fully investigated. No sound evidence for E2B has reported in a nationwide observation study.

EMS capacity

EMS system has wide variation in terms of system design, provider and service level, performance, and quality control. For
example, physician-running system like Franco-German model is very different from those of North America, where EMS
can act as a mobile ED because the emergency physician and the critical care nurse can run to field. In contrast, EMT-running
system with basic level service in many eastern Asian Countries like Korea, Japan, Taiwan, and Singapore shows the limited
performance to make a prehospital decision. No standardized model EMS exists in the real world. However, most of study
focused in well organized, performing standard protocol in the best practice model.

Community Capacity

Contemporary registry data show that the majority of sites in the World are not achieving these desired target times to
treatment. In most community even though developed countries, selective major hospitals have the staff (interventional

cardiologists, specialty nurses, technicians, and others) and resources to perform primary percutaneous coronary intervention
on STEMI patients.
To achieve the optimal community capacity, the health care revision should be done in some minor area or some major area.
Minor area will be changing of role of EMS from transport to ED early with conventional management to making decision for
destination hospital using 12 lead ECG interpretation or transmission. Major revision will be making hospital networking or
all-resource networking to primary, secondary, and tertiary center for STEMI. This major strategy should contain the interfacility transportation and agreement among hospitals with established protocol. However private market for health care
service is not willing to this model, when there is any false positive case (overestimated with STEMI). However, this
limitation has not been fully investigated.

Conclusion
To build up optimal care system for acute myocardial infarction, further investigation should be done in real world, not in best
practice model. The proportion of STEMI is very small in emergency care system. Time window focused on only hospital
performance, not EMS and community capacity. Finally EMS and community capacity should be considered on the basis of a
social infrastructure.

Reference

1. Nissen SE, Brush JE Jr, Krumholz HM. Presidents page: GAP-D2B: an alliance for quality. J Am Coll Cardiol. 2006;48:
1911-1912.
2. Mensah GA, Hand MM, Antman EM, et al. Development of systems of care for ST-elevation myocardial infarction
patients: the patient and public perspective. Circulation. 2007;116:e33-38.
3. Moyer P, Ornato JP, Brady WJ Jr, et al. Development of systems of care for ST-elevation myocardial infarction patients: the
emergency medical services and emergency department perspective. Circulation. 2007;116:e43-48.
4. Ellrodt G, Sadwin LB, Aversano T, et al. Development of systems of care for ST-elevation myocardial infarction patients:
the nonpercutaneous coronary intervention-capable (ST-elevation myocardial infarction referral) hospital perspective.
Circulation. 2007;116:e49-54.
5. Faxon DP. Development of systems of care for ST-elevation myocardial infarction patients: current state of ST-elevation
myocardial infarction care. Circulation. 2007;116:e29-32.

6. Fenter T, Golash T, Jensen N. Development of systems of care for ST-elevation myocardial infarction patients: the payer
perspective. Circulation. 2007;116:e60-63.
7. Granger CB, Henry TD, Bates WE, et al. Development of systems of care for ST-elevation myocardial infarction patients:
the primary percutaneous coronary intervention (ST-elevation myocardial infarction-receiving) hospital perspective.
Circulation. 2007;116: e55-59.
8. Henry TD, Sharkey SW, Burke MN, et al. A regional system to provide timely access to percutaneous coronary intervention
for ST-elevation myocardial infarction. Circulation. 2007;116:721- 728.
9. Jacobs AK, Antman EM, Faxon DP, et al. Development of systems of care for ST-elevation myocardial infarction patients:
executive summary. Circulation. 2007;116:217-230.
10. Antman EM, Anbe DT, Armstrong PW, et al. ACC/AHA guidelines for the management of patients with ST-elevation
myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice
Guidelines (Committee to Revise the 1999 Guidelines for the Management of Patients With Acute Myocardial Infarction). J
Am Coll Cardiol. 2004;44:E1-E211.