The Impact of a Statewide Pre-Hospital STEMI Strategy to Bypass Hospitals Without Percutaneous Coronary Intervention Capability on Treatment Times

Study Questions:

What is the impact of a statewide ST-segment elevation myocardial infarction (STEMI) referral strategy on outcome of patients undergoing primary percutaneous coronary intervention (PCI)?


North Carolina has adopted a statewide STEMI referral strategy that advises paramedics to bypass local hospitals and transport STEMI patients directly to a PCI-capable hospital, even if a non-PCI-capable hospital is closer. The authors assessed the adherence of emergency medical services (EMS) to this STEMI protocol, and the impact on patient outcome among patients with STEMI who were treated between June 2008 and September 2010. Patients who were closer to the PCI hospital when reached by EMS, or those who presented directly to the hospital, were excluded.


Of a total of 6,010 patients with STEMI, 1,288 were eligible and included in the study population. Of these, 826 (64%) were transported directly to a PCI facility, whereas 462 (36%) were first taken to a non-PCI hospital and later transferred. Increases in differential driving time and cardiac arrest were associated with a lesser likelihood of being taken directly to a PCI center, whereas a history of PCI was associated with a higher likelihood of being taken directly to a PCI center. Patients taken to non-PCI centers were more likely to receive fibrinolytic therapy. Patients sent directly to a PCI center were more likely to have times between first medical contact and PCI within guideline recommendations. After adjusting for confounders, direct transport to a PCI hospital was not associated with statistically significant lower rates of clinical in-hospital outcomes (odds ratio for death, 0.87; 95% confidence interval, 0.68-1.11).


The authors concluded that a statewide system that bypasses non-PCI hospitals is associated with reduction in time to treatment, although this was not associated with a demonstrable improvement in clinical outcomes.


Rapid reperfusion, preferably in the form of primary PCI, is the optimal therapy for STEMI. This study demonstrates the feasibility of a systematic, statewide approach to STEMI referral. In this study, there was an improvement in time to reperfusion, although a reduction in mortality could not be demonstrated. The North Carolina model has been highly successful at optimizing timely delivery of primary PCI, and needs to be replicated across the United States.

Clinical Topics: Invasive Cardiovascular Angiography and Intervention

Keywords: Myocardial Infarction, North Carolina, Percutaneous Coronary Intervention

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