Making Up For Lost Time: STEMI Care in 2012

As I write this, it’s Monday after a relatively busy weekend on call. Kicking off the weekend, last Friday morning we had our monthly “Acute Myocardial Infarction — 911” meeting, our lingo for the door-to-balloon initiative. For the past 10 years, we meet like clockwork throughout the year, with the committee comprised of cardiology attendings, trainees, physician assistants, nurses, administration, telecommunications, as well as staff from the cardiac catheterization laboratory, coronary care unit, and emergency room. Together we review all cases of acute ST-elevation myocardial infarction, using a spreadsheet to look at all the component times that made up the total door-to-balloon time for each patient. If we see it took a few minutes too long to obtain an EKG, identify the ST-elevations and/or activate the team, or for the team to arrive  and/or open the artery, we go back and look deeper. Questions are asked and problems addressed.

The program, for the most part, is quite rewarding. The bringing together of a diverse team for a unified purpose of improving or saving a person’s life when they are at their weakest is a great thing, and we all feel the beauty of it. And, importantly, such outcomes are not only important for the patient, but are also being used as quality metrics, determining hospital-wide reimbursement year to year. Indeed, such initiatives have become vital in every sense of the word.

So, after a wonderful meeting on Friday where we reviewed our door-to-balloon times, and micromanaged every last clinical or administrative detail, I went on to 3 days of on-call duty. Coincidentally, 3 patients with ST-elevation myocardial infarction presented to the hospital during my watch. And, to a tee, all 3 patients presented 2-3 days late, long after the initiation of symptoms and, presumably, the initiation of myocardial damage. All, as a result, had heavy thrombus burden and less than ideal final TIMI flow grade, indicating relatively long-standing injury, microvascular dysfunction, and tissue edema, despite ongoing ischemia and injury.

On the last case, a particularly difficult one, I finished the case and turned to the patient at the head of the table. The look of frustration, I’m sure, was evident on my face. I told him that everything went well, but that as hard as we try to fix things in the lab, most of the damage was already done. I asked him why he hadn’t come in sooner, and although there were reasons that made sense, the bottom line is that he was in denial and just didn’t want to come in.

So, in effect, all of our work including getting the patient identified quickly in the ER, getting the team activated, getting all of the team in from the corners of Long Island and Manhattan, and then finally opening up the artery within 90 minutes, is all to make up for lost time. But, when that lost time is 1, 2, or 3 days, I’m not exactly sure “we” are doing our best. Sure, as long as there is evidence of ongoing injury, we are likely reducing reinfarction, arrhythmia and mechanical complications, but we are probably not impacting final ventricular function or the inception of heart failure as much as we think. We cannot truly make up for lost time.

All of this begs the question of where we absolutely must go next. Yes, we can control our own microcosm of hospital dynamics once a patient hits the door, but we need to start thinking about the world outside our white picket fences and start working on delays to presentation. These are tougher and include a widespread culture of denial, sometimes blatant distrust of the health-care system, and also a sense that we doctors can fix anything no matter how late in the game. But, these are indeed the issues we must tackle if we are to get the right ST-elevation patients on our table, those who recognize their symptoms quickly and call EMS.

This wasn’t a bad weekend by any stretch, though; my sense of doing something really meaningful has not been shaken. But I would love to see more patients come in right away, allowing us to truly open the artery within 90 minutes, see normal TIMI 3 flow and peak CKs less than 1000, and thereby get all patients out of the hospital on day 3 with preserved ejection fraction. That would certainly be a much better weekend all around.

Dr Srihari S. Naidu is Director of the Cardiac Catheterization Laboratory, Interventional Cardiology Fellowship Program and Hypertrophic Cardiomyopathy Treatment Center at Winthrop University Hospital on Long Island, and Associate Professor of Medicine at SUNY – Stony Brook School of Medicine. He is a Trustee of the Society for Cardiovascular Angiography and Interventions (SCAI) and Appointed Member of the American College of Cardiology Cardiovascular Leadership Institute (ACC-CLI) and Interventional Scientific Council (ACC-ISC). He can be reached at ssnaidu@winthrop.org.