New Orleans, LA - An Italian study presented this week at the American Heart Association Scientific Sessions 2004 has shown that skipping the emergency room altogether—and moving directly from the ambulance to the cath lab—is an effective process that can reduce door-to-balloon times in ST-elevation myocardial infarction (STEMI) patients. By activating the cath lab in parallel with patient transport and essentially eliminating the ER delay, investigators showed that direct transfer could decrease reperfusion delays.

Presenting the results of his study, Dr Giovanni Melandri (University of Bologna, Italy) pointed out that despite existing ESC/AHA/ACC guidelines, time continues to remain a factor in STEMI patients, with the recommended 90-minute window for primary PCI typically exceeded. "When it comes to the real world, almost all principal registries show a suboptimal performance, indicating the need for more effective clinical pathways," he said.

To minimize the door-to-balloon time, Melandri measured the efficiency of direct transport from the ambulance to the cath lab vs usual care through the ER. Given the availability of 24-hour catheterization facilities in Bologna, direct transport from the ambulance to the cath lab was compared with the existing hub-spoke model: that is, against transport first to the local area hospital (spoke hospital) and then onto the cath-lab-equipped hospital (hub hospital) or transport directly to the hub hospital ER.

Melandri explained that to facilitate door-to-balloon times, a prehospital ambulance triage of STEMI patients was implemented in 2004. Upon arrival of the ambulance, a 12-lead is acquired on the scene and transmitted electronically to cardiology care units. This method of acting in parallel and confirming ST elevation while the patient is in transit allows the ambulance to directly transport the patient to the cath lab while simultaneously alerting the cath-lab team, he said.

In this analysis, door-to-balloon time was the primary measurement. There were no significant differences in baseline characteristics, risk profile, or site of infarction in the STEMI patients taken directly to cath lab, the spoke ER, or to the hub hospital ER.

Melandri noted, however, that the time of first contact to balloon—that is, the first contact with the patient until PCI—is still suboptimal. Using this measurement, 70% of patients taken to the cath lab are treated within 90 minutes and 21% within 60 minutes, said Melandri, opening the window for prehospital treatment. Home ECG recordings sent directly to the hub hospital did not decrease the time of first contact to balloon, despite reductions in the door-to-balloon times, Melandri noted.

"In the context of this retrospective analysis, we believe that direct transfer from the ambulance to the cath lab is quick, effective, and reduces the door-to-balloon time, without an increase in the number of false-positive cases," he reported.