Regional Systems of Care to Optimize Timeliness of Reperfusion Therapy for ST-Elevation Myocardial Infarction: The Mayo Clinic STEMI Protocol

MBA, Division of Cardiovascular Diseases, Mayo Clinic, 200 First St SW, Rochester, MN 55905. .
Circulation (Impact Factor: 14.43). 08/2007; 116(7):729-36. DOI: 10.1161/CIRCULATIONAHA.107.699934
Source: PubMed


Quality improvement efforts have focused on strategies to improve the timeliness of reperfusion therapy in ST-elevation myocardial infarction patients who present to hospitals with and without percutaneous coronary intervention (PCI) capability. We implemented and evaluated a protocol to optimize the timeliness of reperfusion therapy and to coordinate systems of care for a PCI center and 28 regional hospitals located up to 150 miles away across 3 states.
The present study focused on a prospective, observational cohort of 597 patients who presented with ST-segment elevation and within 12 hours of symptom onset to Saint Marys Hospital and 28 regional hospitals up to 150 miles away between May 2004 and December 2006. The Mayo Clinic ST-elevation myocardial infarction protocol implemented strategies to improve timeliness of reperfusion therapy and to coordinate systems of care for transfer between hospitals. The study sample consisted of 258 patients who presented to Saint Marys Hospital and were treated with primary PCI (group A), 105 patients who presented to a regional hospital with symptom onset >3 hours and then were transferred for primary PCI (group B), and 131 patients who presented to a regional hospital with symptom onset <3 hours and were treated with full-dose fibrinolytic therapy (group C). For groups A and B, median door-to-balloon times were 71 and 116 minutes, respectively. Door-to-balloon time <90 minutes was achieved in 75% of group A and 12% of group B. Median door-to-needle time was 25 minutes for group C, and 70% had door-to-needle time <30 minutes.
The Mayo Clinic ST-elevation myocardial infarction protocol demonstrates the feasibility of implementing strategies to optimize the timeliness of reperfusion therapy and the times that can be achieved through coordinated systems of care for ST-elevation myocardial infarction patients presenting to a PCI center (Saint Marys Hospital) and 28 regional hospitals without PCI capability located up to 150 miles away across 3 states.

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    • "To avoid unacceptable time delays, STEMI guidelines as well as recent overviews have outlined the importance of organized systems of care network in order to shorten the time delay from electrocardiogram (ECG) diagnosis, as the first medical contact, to the first balloon dilatation in an efficient catheter laboratory by experienced personnel (15-18). However, time delays are not always important for patients referred for primary PCI , and short and longer time delays have been shown to lead to similar mortality rates in mechanically reperfused patients (15, 19-21), while success of fibrinolytic therapy is always time dependent (11, 15, 16). The aim of the present study was to evaluate one year follow up of clinical outcomes in regard to 30 days and, one year mortality rates, 30 days re-infarction, target vessel revascularization, stroke and mechanical complications including acute mitral regurgitation, ventricular septal defect, and free wall rupture after primary PCI. "
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    ABSTRACT: The aim of this study was to evaluate the clinical outcomes, one year after primary percutaneous coronary intervention(PCI). From September 2009 to March 2012, primary PCI was performed on 70 cases, and the data relating to their catheterization were recorded. Peri-interventional treatment data included PCI with drug-eluting or bare-metal stent or balloon angioplasty alone. The mean age of the patients was 61.34+11.31 years, and 72.9% of them were males. The ratios of patients with diabetes, hypertension and, hyperlipidemia were 61.4%, 71.4%, and 52.9% respectively. In clinical follow-up, total incidence of death was 4.3%, with no death occurring during 30 days. However, 3 patients died after one-year, of which one patient (1.4%) had cardiac problem and the other 2 (2.9%) died because of non-cardiac reasons. Target vessel revascularization, reinfarction within 30 days, and mechanical complication or stroke were not found in any of the patients. Patients with hypertension (6%) and those with LAD ST-elevation myocardial infarction (5%) died after one year (P= 0.263 and P= 0.319 respectively). However, no mortality was reported in patients with RCA and LCX ST-elevation myocardial infarction. Of subjects with multivessel disease, 7% died after one-year (P= 0.161), but there was no reported mortality in those with single vessel disease. The prognosis was satisfactory in patients undergoing PCI after one year clinical follow up.
    International Cardiovascular Research Journal 03/2013; 7(1):21-4.
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    • "Within these models, diagnosis is expedited and patients are transferred directly to PCI facilities. Regional care models are currently being implemented and tested across North America14-17 and internationally.5,18,19 "
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    ABSTRACT: Primary percutaneous coronary intervention (PCI) is preferred over fibrinolysis for the treatment of ST-segment elevation myocardial infarction (STEMI). In the United States, nearly 80% of people aged 18 years and older have access to a PCI facility within 60 minutes. We conducted this study to evaluate the areas in Canada and the proportion of the population aged 40 years and older with access to a PCI facility within 60, 90 and 120 minutes. We used geographic information systems to estimate travel times by ground transport to PCI facilities across Canada. Time to dispatch, time to patient and time at the scene were considered in the overall access times. Using 2006 Canadian census data, we extracted the number of adults aged 40 years and older who lived in areas with access to a PCI facility within 60, 90 and 120 minutes. We also examined the effect on these estimates of the hypothetical addition of new PCI facilities in underserved areas. Only a small proportion of the country's geographic area was within 60 minutes of a PCI facility. Despite this, 63.9% of Canadians aged 40 and older had such access. This proportion varied widely across provinces, from a low of 15.8% in New Brunswick to a high of 72.6% in Ontario. The hypothetical addition of a single facility to each of 4 selected provinces could increase the proportion by 3.2% to 4.3%, depending on the province. About 470 000 adults would gain access in such a scenario of new facilities. We found that nearly two-thirds of Canada's population aged 40 years and older had timely access to PCI facilities. The proportion varied widely across the country. Such information can inform the development of regionalized STEMI care models.
    Open Medicine 02/2010; 4(1):e13-21.
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    • "Various communities have been successful in establishing effective protocols based on either an inter-hospital transfer system or pre-hospital cardiac triage. Interhospital transfer has been demonstrated effective in various communities, most prominently in Minnesota (Henry et al., 2007; Ting et al., 2007). Pre-hospital cardiac triage of STEMI patients to centers offering PPCI has also effective in various communities, and requires a pre-hospital 12-lead ECG (Gross et al., 2007; Le May et al., 2006; Swor et al., 2006). "
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    ABSTRACT: Primary angioplasty decreases mortality and improves long-term outcomes for patients with STEMI. To be most effective, it needs to be performed expediently, with door-to-balloon times (D2B) less than 90 min. From January 2005 to presently, 420 short D2B STEMI interventions were performed at 5 community hospitals by a single experienced operator creating the SINCERE (Single INdividual Community Experience REgistry) database. Median D2B time was 78 min, median procedure time (local anesthesia to recanalization) was 13 min; 85.2% of procedures had D2B time <90 min; 95% of the procedures were successful - relief of chest pain, >70% ST segment resolution, TIMI 3 flow and Myocardial Perfusion Grade 3. Primary PCI with high success rates and predictable short D2B times can be performed with standardized techniques in community hospitals.
    10/2009; 21(4):229-43. DOI:10.1016/j.jsha.2009.10.006
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