|
Amanda Jekowsky , American College of
Cardiology, 202-375-6645, ajekowsk@acc.org
April
20, 2009
Integrated Regional Networks Give Communities
Rapid Access to Life-Saving Treatment of Heart Attacks
Specialized, coordinated emergency networks dramatically
reduce time-to-treatment for patients with ST-elevation myocardial
infarction (STEMI)—the most dangerous type of heart
attack— according to a new study published in the April
2009 issue of the Journal of the American College of Cardiology:
Cardiovascular Interventions.
STEMI involves the sudden blockage of one of the three big
coronary arteries that supply blood to the heart. Rapid intervention
with primary percutaneous coronary intervention (PCI) by specialists
performing balloon angioplasty and stenting restores blood
flow, saves heart muscle, and reduces the likelihood of death.
Although primary PCI in the cardiac cath lab is the best treatment
for a STEMI heart attack, it is a highly complex, multi-disciplinary
and time-sensitive intervention that is only available in
one out of five U.S. hospitals.
“This study shows that organized STEMI networks consistently
provide the fastest treatment of acute heart attacks,”
said Ivan Rokos, M.D., an emergency physician in Los Angeles
and lead researcher. “For decades, paramedics, emergency
departments and cardiology teams have co-existed, but we have
only recently recognized how important it is to coordinate
all three into one seamless unit that that delivers rapid
primary PCI and restores blood flow in a blocked coronary.”
Researchers performed a pooled analysis of 10 pioneering
STEMI heart attack networks involving 72 hospitals in Oregon,
California, Minnesota, Michigan, North Carolina and Georgia.
Each program independently implemented common approaches including:
universal access to 911; pre-hospital diagnosis of STEMI heart
attacks by paramedics using special electrocardiograms (ECGs);
early activation of the cath lab team at the nearest designated
STEMI hospital; and rapid transport via ambulance (with planned
bypass of hospitals without specialized cath lab capability).
“Whether it was big cities like Los Angeles or smaller
towns like Medford, Oregon, the creation of these networks
was feasible,” said Dr. Rokos. “Common to each
region was a spirit of multi-disciplinary collaboration, often
initiated by a small group of visionary healthcare providers,
who saw new opportunities to improve STEMI heart attack care
in their communities.”
To determine the efficacy of these networks in providing
timely treatment, researchers tracked door-to-balloon (D2B)
time. D2B is the time it takes for the patient to receive
definitive treatment, from the “door” of the emergency
department to the first cath lab “balloon inflation”
that opens the blocked artery. The national quality standard
is a D2B time of 90 minutes or less; each 15 minute delay
beyond these 90 minutes is associated with an increased risk
of death.
Researchers found that 86 percent of patients with STEMI
heart attack who called 911 and were treated within a coordinated
regional network received skilled coronary intervention within
90 minutes, which surpassed the American College of Cardiology
D2B Alliance target (a >75 percent rate of D2B = 90 min).
This is a marked improvement compared to registry data from
1999 to 2002 that showed less than half (40 percent) of patients
were treated within 90 minutes.
In 2006, the American College of Cardiology (ACC) launched
“D2B: An Alliance for Quality” to save times and
lives by reducing hospital door-to-balloon times. To date,
the more than 1,000 hospitals participating in the initiative
have received key evidence-based strategies and supporting
tools needed to reduce their D2B times, including access to
an online forum to share ideas and strategies. The strategies
at the core of the program include: emergency department activation
of the catheterization lab; one-call cath lab activation;
cath lab readiness within 20-30 minutes of page; prompt data
feedback; commitment to reducing D2B times by senior management;
a team-based approach; and an optional strategy of using a
pre-hospital electrocardiogram to activate the cath lab. “D2B:
Sustain the Gain” is the next phase of the D2B campaign.
The goal: to assist hospitals in continuing to implement the
strategies necessary to maintaining the gains made in reducing
D2B times.
“People need to dial 911 if they’re having chest
pain or other signs of a heart attack,” said Dr. Rokos,
explaining that half of patients elect to drive to the emergency
department and risk major delays in treatment. “As this
study shows, paramedics can diagnose STEMI heart attacks quickly
and can trigger the activation of an entire system, which
allows patients to enter a virtual express-lane to the cath
lab team at the nearest STEMI-hospital.”
In some of the networks, wireless transmission of the ECG
allowed physician diagnosis of STEMI prior to the patient’s
arrival at the hospital.
Dr. Rokos adds that ambulance transport of STEMI patients
is critically important in an era of hospital over-crowding,
which has gridlocked many of our nation’s emergency
departments.
“The most important lesson of this study is that reperfusion
with primary PCI can be provided more rapidly if EMS is placed
in its rightful position as the front line for integrated
STEMI care. Coordinated efforts between paramedics and hospitals
equipped to perform PCI can dramatically improve the care
of patients with heart attacks,” said Christopher Granger,
M.D., cardiologist, Duke University Medical Center, and author
of the accompanying editorial. “Still, we must find
ways to improve inter-hospital transfer for patients presenting
at hospitals without cath labs.”
Dr. Rokos said further study is needed using more sophisticated
data collection by existing national quality improvement registries,
such as the ACTION Registry ® – GWTG ™. Also,
the study findings suggest that inappropriate cath lab activations
can occur based on paramedic analysis of pre-hospital ECGs,
though the exact frequency could not be determined. The potential
to maximize system efficiency with wireless transmission of
the pre-hospital ECG to the receiving hospital is under study.
Dr. Rokos reports no conflict of interest.
Background: Approximately 5-10 percent of patient who have
severe chest pain suffer from a STEMI heart attack. Symptoms
can include pressure or pain in the center of the chest, discomfort
in other areas of the upper body such as in the arms, back,
jaw or stomach, and shortness of breath.
###
The American College of Cardiology is leading the way to optimal
cardiovascular care and disease prevention. The College is
a 36,000-member nonprofit medical society and bestows the
credential Fellow of the American College of Cardiology upon
physicians who meet its stringent qualifications. The College
is a leader in the formulation of health policy, standards
and guidelines, and is a staunch supporter of cardiovascular
research. The ACC provides professional education and operates
national registries for the measurement and improvement of
quality care. More information about the association is available
online at www.acc.org .
The American College of Cardiology (ACC) provides these news
reports of clinical studies published in the Journal of
the American College of Cardiology as a service to physicians,
the media, the public and other interested parties. However,
statements or opinions expressed in these reports reflect
the view of the author(s) and do not represent official policy
of the ACC unless stated so.
|
