Melissa Walton-Shirley


November 17, 2013

So says Dr Alice Jacobs, who probably knows more about where we are in the advances of primary PCI and reperfusion therapy for STEMI than just about anyone else in the US. "To answer the question, I'll take you back to where we have come from," she said. We saw a brief synopsis of the history of PCI, starting with James B Herrick (1861–1954), who wrote that "a short distance from its origin, the left coronary artery was completely obliterated by a red thrombus that had formed at a point of great narrowing," she read. "They thought back then that thrombus was a result instead of the cause of myocardial infarction. Later we could recanalize the vessel with a 0.038 guidewire, and even later we demonstrated that the duration of coronary occlusion caused a wavefront of necrosis from the epicardium to the endocardium," citing Circulation 1977. Then Dr Jacobs described the 1994 publication on fibrinolytic therapy vs placebo, where there was a staggering reduction in mortality. That was the spark ofcreation for Mission: LifeLine .

But with all of these accomplishments in STEMI care, one senses a deep undercurrent of dissatisfaction, a job not yet finished in Dr Jacob's description. There have been challenges and still are. Although many issues have been addressed, more issues still need improvement: Major access site bleeding is increased with PCI. Door–to-needle time is still prolonged, and door-to-balloon (D2B) time as well, in some systems. Despite there being 5000 acute-care hospitals in the US, more than 50% of patients do not access EMS. Some EMS systems still have no 12-lead ECG capability and transfer delays persist. Receiving hospitals are frequently on diversion, and there are financial disincentives for transfer, because cardiac patients mean money, she said.

So where are we now in 2103? Dr Jacobs explained that at the infancy of Mission: LifeLine, just 87 systems were registered, covering 24% of the population. Now over 700 systems are registered, covering over 70% of the US population. According to the ACTION registry, for the calendar year of 2012, there were 44 000 STEMIs. PCI was performed in 93% of patients. and only 0.5% go without therapy," she pointed out. But are we saving lives? "From 2003-2008, there was no change in mortality rates. Yes, the NCDR data from 2005–2009 [released two months ago] revealed that in 96 000 patients, D2B went down to 67 minutes—is it true that despite this improvement, the mortality remained flat?" Dr Jacobs offered several explanations for that phenomenon: "Patients with less complexity and risk are treated more quickly, whereas the most complex patients with much more to gain have delays. There is increased prehospital survival, neutralizing decreases in mortality. D2B is only one quality metric, so actually the mortality in 2005 and 2010 is very different," she pointed out.

Dr Jacobs then said, "Now we need to concentrate on the non-STEMI hospital. Only 32% can achieve a D2B time within 90 minutes. For the new 120-minute goal, only 66% of referring hospitals were able to accomplish a timely 'door-number-1- to-device time.' The 'door-in/door-out quality measure was 30 minutes, and only 9.7% made it out within the desired window," she said. Then there are the patients.

Little has changed in time taken for patients to activate EMS, first medical contact within 90 minutes of symptom onset occurs in only 50% of patients, noted Dr Jacobs, citing results from 2003–2008. The focus needs to move from the PCI-capable to the non–PCI-capable hospitals, and all communities should create and maintain a regional system of STEMI care. Total system time and total ischemic time must be improved. "So, is our mission accomplished? Not just yet," she concluded.

Then Dr P Gabriel Steg stepped to the microphone with a report on the "Western European experience," but more pointedly, how France is faring in the race to improve time to STEMI therapy. France has a centralized public SAMU (Service d'Aide Medicale Urgente [Urgent Medical Aid Service]) with either a physician or a trained paramedic on board, and trucks fully equipped for advanced CPR and STEMI therapy. He flashed a "NASA-like" control room with a phone liaison for central regulation. He displayed a map of France with 65 million inhabitants, 101 districts, 106 SAMUs, and 1000 mobile intensive-care units. So what else has France accomplished that have we haven't? More French citizens than US citizens are able to bypass the emergency department. In 2005, their SAMU was the first medical contact for 37% of STEMI patients, with 42% of patients who go through this system going directly to the cath lab. Going through the emergency department produced delays to the lab in 75% of cases, he stated. "Bypassing the emergency department cut time to cath lab by 30 minutes in one US study, whereas 100 minutes were saved in France by bypassing the emergency department," pointed out Dr Steg. Patients treated through the mobile French version of our EMS have a greater probability of reperfusion. He then referenced a 2010 French registry showing the number of providers involved added to the delays: whether the patient encountered one, two, or three providers prior to definitive therapy, their delays to PCI went up by 4.2%, 5.5% and 9.7%, respectively. Cutting back on the number of provider encounters decreased 30-day mortality from 20% to 5%. But he pointed out that the improving mortality rates is also related to patient behavior and profile and other forms of management.

Heart-failure class improved also because beta-blocker, statin, ACE inhibitor, and ARB use increased, not just use of PCI for reperfusion. He then referenced the Achilles' heel of his system, "Staffing the SAMUs with physicians is incredibly, incredibly expensive," he said.

It seems to me that we in the US need to focus on not only the non-PCI hospital, but also on the patient lying on their couch or sitting at their desk or those who wake up with an uncomfortable nagging sensation somewhere between their waist and their earlobes. For many, it crosses their mind that "this might be my heart," but the idea of a six-hour wait time in the local ER if they are wrong trumps their concern. The thought of the embarrassment of finding "it was only my hiatal hernia" or "indigestion" causes them to grab the Mylanta, chew a Tums, or roll over to try to go back to sleep. America keeps trying to burp its way out of accessing their local emergency departments, and it's killing us.

We need to go away from the fear of the punishment of being marooned in the waiting area of the local emergency department. We need to stop viewing ourselves as humans who still need to get up and go to work tomorrow, then make that trek into the ER to find welcome arms instead of smirks.

Since the focus on educating the patient on the symptoms of a heart attack has largely failed, it seems our next focus might be to totally change the culture of our emergency departments. We need more staff, less wait time, and less punishment for arriving at the ER for help "unnecessarily." As cardiologists, we need to drill down on delays that are inherent or unique to our systems. A pitiful few of us raised our hands when asked if our EMS bypassed the emergency department on the way to the cath lab. We need less emergency-department mongering and more cath-lab mongering.

We need a little more technology like the costly SAMU that Dr Steg described and a centralized NASA-like approach to coordinated care. In this age of technology, even social media, what's the holdup on that?

At the end of the day, though, Dr Jacobs and her colleagues should be lauded for one of the greatest accomplishments in the history of acute-MI care. Because of Mission: Lifeline, we've come a long way, but the fact that we even recognize that we still have a long way to go is in and of itself a mission accomplished, if not yet fulfilled.


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