Medford, OR - Physicians in southern Oregon are boasting remarkable reductions in mortality and time to PCI for patients with acute ST-segment-elevation MI (STEMI) after implementing a strategy of paramedic-diagnosed STEMI, followed by direct transfer to a single PCI center [1]. The new protocol, created in collaboration with four community hospitals and two cardiology practices, incorporates some of the recommendations set out in the recent ACC/AHA-backed "D2B" initiative, despite being launched in June 2003, before the D2B program was announced.

"What we noticed over the years as we started to do more and more interventions for acute MI was that folks who got interventions just seemed to get better more quickly," lead author on the study, Dr Brian Gross (Heart Clinic of Southern Oregon and Northern California), told heartwire. "So it was always frustrating when we'd hear that a patient was out there with a heart attack and we wanted to get him here to the PCI hospital, yet we were experiencing those same types of delays that others have reported. It's just the way the system is set up in the US—it always takes forever. . . . We decided there must be a better way."

Gross et al report the results of their study in the May 15, 2007 issue of the American Journal of Cardiology.

According to Gross, he and his coinvestigators were able to convince local hospitals to "relinquish" their STEMI patients and persuade local paramedic units to obtain electrocardiograms in the field to look for STEMI, alert the PCI team at the PCI hospital, and then transfer the patient directly to that hospital. Unstable-angina patients, however, would still be taken to the nearest hospital, a strategic decision to help soothe any rumpled feathers at the non-PCI hospitals. "We wanted to be sure that we didn't step on toes and offend other hospitals," he said.

A similar protocol was put in place for walk-in patients at non-PCI hospitals, whereby they would be transferred directly from the non-PCI hospital emergency rooms directly to the cath lab at the PCI hospital.

Between June 2003 and December 2004, 233 consecutive patients were managed according to the new protocol. As Gross et al report, paramedics identified 35% of patients with STEMI, while an additional 16% presented directly to the PCI center, and 49% presented to one of the referring hospitals. Delay times were shortest for patients who were diagnosed by paramedics and taken directly to the alerted PCI hospital and longest for patients who walked into one of the referring hospitals. Likewise, the percentage of patients being treated within the recommended 90 minutes was greatest among those identified by paramedics as having STEMI and lowest among patients who presented first to a referring hospital.

Importantly, mortality rates not only followed this pattern—and, in fact, were 0% among paramedic-identified STEMI patients—but were also radically lower than mortality rates for "like hospitals" (similar staff and capabilities to the PCI hospital in Gross et al's study) and for the PCI hospital prior to the adoption of the new strategy, according to the National Registry of Myocardial Infarction database.

Interventionalists at other cath labs have asked Gross how he and his colleagues were able to achieve such improvements; Gross is quick to acknowledge that the changes were delicate ones and might not work everywhere.

"The answer is, we're big enough that we have enough resources to do it, but we're small enough that we can do it. I think this becomes highly problematic in a bigger city, where you have all of these geopolitical issues competing with one another. That's the reality. Everyone wants to do STEMIs. . . . We were able to do this because we were a cooperative-enough community. A lot of regions have geopolitical differences where the attitude is, if you're not with us, you're against us."

It's a point reiterated by Dr Elizabeth Bradley (Yale School of Public Health, New Haven, CT), who has done much of the pioneering research used in the D2B recommendations. "Orchestrating the prehospital ECG and paramedic-triage process, as this study does, can be difficult in some regions," she told heartwire.

As for the study as a whole, she called the findings "not surprising."

"The evidence that activation of the cath team while the patient was en route is consistent with our previous paper and existing evidence," she said.

Additional, more "central" strategies would also help, Bradley added, including activating the cath lab with a single call from the emergency department, having a system in place to track door-to-balloon times and provide that feedback to members of the team, and expecting the cath team to be ready to start a procedure within 30 minutes of being paged. The paper by Gross et al does not state whether or not any or all of these were done in the Oregon setting, she notes.

"We believe that with all these strategies firmly in place, hospitals can meet the 90-minute guideline in 75% or more of the cases," she said. "This study met the guideline, even in the best case of paramedic triage, less than 60% of the time. It is a good performance, but it may be possible to wring out a few more minutes routinely with some of the other D2B Alliance recommendations implemented as well."

And in fact, Gross told heartwire that the protocol in southern Oregon has been tweaked to the point that now 92% of patients who are diagnosed with STEMI by paramedics, then transferred to the PCI hospital, are treated within 90 minutes.

"Educating the public to call 911 is important," he observed.

But there are other barriers to implementing a model like that developed by Gross et al, among them gaining the cooperation of smaller hospitals, many of which are calling for the right to provide primary PCI.

"Then the issue will come down to, how efficiently can this be done?" Gross argues. "In small hospitals that see just a couple STEMIs a year, when you don't have the rapid SWAT-team mentality, yes, you can do PCI for STEMI, and yes, you can get them through with a very low mortality, but is an extra five- or 10-minute drive to a place that does hundreds of PCIs a year a more efficient option? A small hospital that isn't doing a lot of these may not have the full array of catheter equipment and expertise. Because it's more than just a cardiologist, it's a team."