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Emergency transport directly to a PCI center significantly reduced mortality
Emergency transportation of patients with STEMI directly to a primary PCI center yielded a nearly 50% reduction in mortality compared with patients taken to the emergency room first in a recent study.
Paramedics in Ottawa, Canada, can bypass the emergency room and transport patients with STEMI to a PCI-capable center, allowing researchers to compare the mortality rates for patients taken directly to such a center with those who were not.
In all, 1,389 consecutive patients with STEMI were assessed by paramedics specially trained to interpret 12-point ECGs and then bypass emergency departments and go directly to the PCI center. In this group, 822 patients (59.2%) were referred directly to a PCI center, and 567 (40.8%) were transported to a non-PCI-capable hospital first.
At 180 days, the rate of mortality was 5% for patients transferred directly from the field and 11.5% for patients transported from the field to a non-PCI-capable hospital (P<.0001). Mortality remained lower among patients referred directly from the field to the PCI center after adjusting for multivariate factors (OR=0.52; 95% CI, 0.31-0.88).
The results support the concept of STEMI systems that include pre-hospital referral by EMS, the researchers noted.
“These data support the position taken by the [American College of Cardiology/American Heart Association] guidelines that every minute counts and that the time to treatment should be ‘as soon as possible,’ rather than simply accepting the standard door-to-balloon of <90 min as satisfactory,” they wrote.
Perspective
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In this report, Le May and colleagues summarize the systems of care to treat STEMI patients implemented in Ottawa, Canada. These findings have implications for the broader medical community and will require available resources, time and money in order to develop a restructured, sophisticated system of care for such patients. In order to achieve optimal symptom-to-balloon times and also change regional care patterns, a number of wholesale changes to the health care community are required that will necessitate either progressive physician leadership or stringent government legislation. These include developing systems in the United States that directly triage STEMI patients to capable PCI centers (similar to trauma centers). We should enable EMS providers to diagnose and activate a code STEMI from the field, which can be achieved either through additional training or transmission of 12-lead ECGs. Lastly, to reduce door-to-balloon times, receiving PCI centers must be fully committed to 24/7 primary PCI and efficient care processes. This work by Le May and colleagues demonstrates an approach that is associated with improved clinical outcomes for high-risk STEMI patients.