Rapid Transfer for ST-Elevation Myocardial Infarction PCI: It’s Just Not That Hard!

“Dost thou love life? Then do not squander time, for that is the stuff life is made of.” — Benjamin Franklin Seldom in medicine has an idea gained credence so rapidly as the idea that lives are saved by rapid reperfusion for ST-elevation myocardial infarction (STEMI) using percutaneous coronary intervention (PCI). Perhaps this is because it appeals to the best instincts of so many. Emergency medicine personnel are enthralled to be able to activate catheterization laboratories with pre-hospital 12-lead electrocardiograms (ECGs). Emergency physicians are happy to hand off care of these high-risk patients. Non-interventional cardiologists are just as happy to be out of the loop until the drama is over. Interventional cardiologists, action-oriented as they are, enjoy racing in to get the job done. And the patients themselves, especially those with severe pain, are thankful to have their heart attack treated so rapidly. STEMI care is a prime example of the rapid translation of research results1,2 into practice. This process has been helped along by institutions focused on quality. First, the Institute for Healthcare Improvement, then the cardiology societies’ guideline writing groups,3,4 and then the Joint Commission for Accreditation of Healthcare Organizations (JCAHO) and the Centers for Medicare and Medicaid Services (CMS) adopted time standards for rapid delivery of reperfusion to STEMI patients. To date, most of the attention has focused on the simpler task of rapidly treating patients who present directly to an angioplasty-hospital. Most programs aimed at accomplishing this have been successful. However, the task is harder when an inter-facility transfer is required. The National Registry of Myocardial Infarction from 1999–2002 reported a median door-to-balloon (D2B) time of 180 minutes for inter-hospital transfer patients.5 More recently, the American College of Cardiology National Cardiovascular Data Registry reported that for 2005–2006, the median D2B time had improved only to 152 minutes for transferred patients.6 Since then, several investigators have reported on STEMI transfer networks with median D2B times of 95–128 minutes7–12 (Table). Common elements in their success have included: 1) referring hospital commitment to rapid identification, triage, treatment and transfer of STEMI patients; (2) formalized transfer agreements with referring hospitals; (3) efficient transfer systems; and (4) efficient PCI programs at the angioplasty hospital. However, to date, all reports of patients transferred for STEMI PCI have median D2B times > 90 minutes, which was the original D2B goal. Subsequent guidelines have changed the goal to 90 minutes from first medical contact to PCI, although the original D2B is still more commonly used as the goal. In this issue of the Journal, Ahmed et al report on a STEMI program that may have set a new record for median D2B time for transferred patients.13 Cardiologists at the University of Vermont developed a relationship with a referring center 30 minutes’ driving time away. They agreed to transfer all STEMI patients from the referring center to the angioplasty hospital for emergency PCI. The current report details the results of the first 37 patients enrolled over 17 months in their program. The median D2B time was 82 minutes and 73% achieved a D2B time of From the *Department of Cardiology, Geisinger Medical Center, Danville Pennsylvania and §School of Medicine, University of Glasgow, Glasgow, Scotland, United Kingdom. The authors report no conflicts of interest regarding the content herein. Address for correspondence: James Blankenship, MD, Geisinger Medical Center, 100 N. Academy Drive, Danville, PA 17822. E-mail: jblankenship@geisinger.edu

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