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Patients with ST-elevation myocardial infarction (STEMI) may get more timely treatment when state policies allow emergency medical services to steer patients to percutaneous coronary intervention (PCI)–capable hospitals, results of a registry study suggested.
Time to receipt of guideline-recommended therapy was significantly faster for states that had adopted STEMI hospital destination policies that permit bypassing closer facilities that are not PCI capable, according to results of the study, which was published in Circulation: Cardiovascular Interventions.
In addition, the mean door-to-balloon time was 48 minutes for patients in states with emergency medical services (EMS) destination policies, versus 52 minutes for patients in states with no destination policies.
These findings provide a compelling case for state-level policies to allow EMS to take patients directly to PCI-capable centers, according to lead study author Jacqueline Green, MD, MPH, a cardiologist at Piedmont Heart Institute in Fayetteville, Ga.
“A policy that improves access to timely care for even an additional 10% of patients could have a significant impact on a population level,” Dr. Green said in a statement.
The analysis by Dr. Green and her colleagues was based on 2013-2014 registry data for six states with bypass policies (Delaware, Iowa, Maryland, North Carolina, Pennsylvania, and Massachusetts) and six control states without bypass policies that were matched based on region, hospital density, and registry participation.
Time from first medical contact to treatment is a “critical determinant” of outcomes in patients with STEMI, Dr. Green and her colleagues wrote in their report.
“When a patient initially is taken to a non–PCI-capable hospital, considerable treatment delays are introduced as the patient must be evaluated, triaged, and wait for a second EMS transport to be called, arrive, and take the patient from the initial hospital to the PCI hospital,” they wrote.
However, whether reducing total ischemic time by “a few minutes” has clinical significance remains controversial, they acknowledged.
They noted that in one previous study, annual improvements in door-to-balloon times of about 16 minutes was not associated with significant reductions in mortality at the population level; however, a reanalysis of that data showed that effects at the individual lever were “important, even if modest at the population level,” they wrote.
In the present study, mean door-to-balloon times were “well within guideline-recommended time frames” for both the states with hospital destination policies and the states without them, Dr. Green and colleagues wrote.
“Many mitigating factors affecting STEMI mortality continue to exist when considering both population- and individual-level effects, and most cardiologists still agree that minimizing total ischemic time improves patient outcomes,” they said.
The project was funded by the American Heart Association’s Mission: Lifeline program, which aims to develop coordinated systems of care for time-sensitive, high-risk emergencies including heart attacks, stroke, and cardiac arrest.
One study coauthor reported serving as the Medical Director at ZOLL Medical. The others had no conflicts reported.
SOURCE: Green J et al. Circulation Cardiovasc Interven. 2018 May;11(5):e005706.
The important and comprehensive analysis by Jacqueline Green, MD, MPH, and her colleagues showed that care and outcomes of STEMI patients can be improved without increasing the number of PCI-capable facilities.
“The results indicate that simply living in a state which has a statewide prehospital plan for EMS [emergency medical services] transport is associated with improved treatment times for heart attack patients,” Daniel M. Kolansky, MD, and Paul N. Fiorilli, MD, wrote in an editorial.
Dr. Green and her colleagues did show that adopting statewide EMS policies which steer STEMI patients directly to PCI-capable hospitals was associated with significantly faster delivery of guideline-directed therapy.
However, the 4-minute improvement in mean door-to-balloon times for states with EMS destination policies versus those with no such policies is “modest,” according to the editorial authors.
“While it is difficult to be certain of the clinical significance of these findings, as the authors point out, it would seem that any action that shortens reperfusion time is an important step in the right direction,” they wrote.
Beyond prehospital EMS transport programs, there are many other aspects of care that could be improved to optimize timely delivery of care to STEMI patients.
Those aspects include routine use of prehospital ECG transmission, development of community outreach programs to help patients recognize symptoms, and more development of regionalized systems of care to reduce time from EMS activation to appropriate treatment.
“Although much work has already been accomplished to expedite the care of these patients, we need to continue to put together all the pieces of this puzzle to provide the best possible heart attack care for our patients,” Dr. Kolansky and Dr. Fiorilli concluded.
Dr. Kolansky and Dr. Fiorilli are with the cardiovascular medicine division at Hospital of the University of Pennsylvania in Philadelphia. These comments are derived from their editorial in Circulation: Cardiovascular Interventions . They had no disclosures.
The important and comprehensive analysis by Jacqueline Green, MD, MPH, and her colleagues showed that care and outcomes of STEMI patients can be improved without increasing the number of PCI-capable facilities.
“The results indicate that simply living in a state which has a statewide prehospital plan for EMS [emergency medical services] transport is associated with improved treatment times for heart attack patients,” Daniel M. Kolansky, MD, and Paul N. Fiorilli, MD, wrote in an editorial.
Dr. Green and her colleagues did show that adopting statewide EMS policies which steer STEMI patients directly to PCI-capable hospitals was associated with significantly faster delivery of guideline-directed therapy.
However, the 4-minute improvement in mean door-to-balloon times for states with EMS destination policies versus those with no such policies is “modest,” according to the editorial authors.
“While it is difficult to be certain of the clinical significance of these findings, as the authors point out, it would seem that any action that shortens reperfusion time is an important step in the right direction,” they wrote.
Beyond prehospital EMS transport programs, there are many other aspects of care that could be improved to optimize timely delivery of care to STEMI patients.
Those aspects include routine use of prehospital ECG transmission, development of community outreach programs to help patients recognize symptoms, and more development of regionalized systems of care to reduce time from EMS activation to appropriate treatment.
“Although much work has already been accomplished to expedite the care of these patients, we need to continue to put together all the pieces of this puzzle to provide the best possible heart attack care for our patients,” Dr. Kolansky and Dr. Fiorilli concluded.
Dr. Kolansky and Dr. Fiorilli are with the cardiovascular medicine division at Hospital of the University of Pennsylvania in Philadelphia. These comments are derived from their editorial in Circulation: Cardiovascular Interventions . They had no disclosures.
The important and comprehensive analysis by Jacqueline Green, MD, MPH, and her colleagues showed that care and outcomes of STEMI patients can be improved without increasing the number of PCI-capable facilities.
“The results indicate that simply living in a state which has a statewide prehospital plan for EMS [emergency medical services] transport is associated with improved treatment times for heart attack patients,” Daniel M. Kolansky, MD, and Paul N. Fiorilli, MD, wrote in an editorial.
Dr. Green and her colleagues did show that adopting statewide EMS policies which steer STEMI patients directly to PCI-capable hospitals was associated with significantly faster delivery of guideline-directed therapy.
However, the 4-minute improvement in mean door-to-balloon times for states with EMS destination policies versus those with no such policies is “modest,” according to the editorial authors.
“While it is difficult to be certain of the clinical significance of these findings, as the authors point out, it would seem that any action that shortens reperfusion time is an important step in the right direction,” they wrote.
Beyond prehospital EMS transport programs, there are many other aspects of care that could be improved to optimize timely delivery of care to STEMI patients.
Those aspects include routine use of prehospital ECG transmission, development of community outreach programs to help patients recognize symptoms, and more development of regionalized systems of care to reduce time from EMS activation to appropriate treatment.
“Although much work has already been accomplished to expedite the care of these patients, we need to continue to put together all the pieces of this puzzle to provide the best possible heart attack care for our patients,” Dr. Kolansky and Dr. Fiorilli concluded.
Dr. Kolansky and Dr. Fiorilli are with the cardiovascular medicine division at Hospital of the University of Pennsylvania in Philadelphia. These comments are derived from their editorial in Circulation: Cardiovascular Interventions . They had no disclosures.
Patients with ST-elevation myocardial infarction (STEMI) may get more timely treatment when state policies allow emergency medical services to steer patients to percutaneous coronary intervention (PCI)–capable hospitals, results of a registry study suggested.
Time to receipt of guideline-recommended therapy was significantly faster for states that had adopted STEMI hospital destination policies that permit bypassing closer facilities that are not PCI capable, according to results of the study, which was published in Circulation: Cardiovascular Interventions.
In addition, the mean door-to-balloon time was 48 minutes for patients in states with emergency medical services (EMS) destination policies, versus 52 minutes for patients in states with no destination policies.
These findings provide a compelling case for state-level policies to allow EMS to take patients directly to PCI-capable centers, according to lead study author Jacqueline Green, MD, MPH, a cardiologist at Piedmont Heart Institute in Fayetteville, Ga.
“A policy that improves access to timely care for even an additional 10% of patients could have a significant impact on a population level,” Dr. Green said in a statement.
The analysis by Dr. Green and her colleagues was based on 2013-2014 registry data for six states with bypass policies (Delaware, Iowa, Maryland, North Carolina, Pennsylvania, and Massachusetts) and six control states without bypass policies that were matched based on region, hospital density, and registry participation.
Time from first medical contact to treatment is a “critical determinant” of outcomes in patients with STEMI, Dr. Green and her colleagues wrote in their report.
“When a patient initially is taken to a non–PCI-capable hospital, considerable treatment delays are introduced as the patient must be evaluated, triaged, and wait for a second EMS transport to be called, arrive, and take the patient from the initial hospital to the PCI hospital,” they wrote.
However, whether reducing total ischemic time by “a few minutes” has clinical significance remains controversial, they acknowledged.
They noted that in one previous study, annual improvements in door-to-balloon times of about 16 minutes was not associated with significant reductions in mortality at the population level; however, a reanalysis of that data showed that effects at the individual lever were “important, even if modest at the population level,” they wrote.
In the present study, mean door-to-balloon times were “well within guideline-recommended time frames” for both the states with hospital destination policies and the states without them, Dr. Green and colleagues wrote.
“Many mitigating factors affecting STEMI mortality continue to exist when considering both population- and individual-level effects, and most cardiologists still agree that minimizing total ischemic time improves patient outcomes,” they said.
The project was funded by the American Heart Association’s Mission: Lifeline program, which aims to develop coordinated systems of care for time-sensitive, high-risk emergencies including heart attacks, stroke, and cardiac arrest.
One study coauthor reported serving as the Medical Director at ZOLL Medical. The others had no conflicts reported.
SOURCE: Green J et al. Circulation Cardiovasc Interven. 2018 May;11(5):e005706.
Patients with ST-elevation myocardial infarction (STEMI) may get more timely treatment when state policies allow emergency medical services to steer patients to percutaneous coronary intervention (PCI)–capable hospitals, results of a registry study suggested.
Time to receipt of guideline-recommended therapy was significantly faster for states that had adopted STEMI hospital destination policies that permit bypassing closer facilities that are not PCI capable, according to results of the study, which was published in Circulation: Cardiovascular Interventions.
In addition, the mean door-to-balloon time was 48 minutes for patients in states with emergency medical services (EMS) destination policies, versus 52 minutes for patients in states with no destination policies.
These findings provide a compelling case for state-level policies to allow EMS to take patients directly to PCI-capable centers, according to lead study author Jacqueline Green, MD, MPH, a cardiologist at Piedmont Heart Institute in Fayetteville, Ga.
“A policy that improves access to timely care for even an additional 10% of patients could have a significant impact on a population level,” Dr. Green said in a statement.
The analysis by Dr. Green and her colleagues was based on 2013-2014 registry data for six states with bypass policies (Delaware, Iowa, Maryland, North Carolina, Pennsylvania, and Massachusetts) and six control states without bypass policies that were matched based on region, hospital density, and registry participation.
Time from first medical contact to treatment is a “critical determinant” of outcomes in patients with STEMI, Dr. Green and her colleagues wrote in their report.
“When a patient initially is taken to a non–PCI-capable hospital, considerable treatment delays are introduced as the patient must be evaluated, triaged, and wait for a second EMS transport to be called, arrive, and take the patient from the initial hospital to the PCI hospital,” they wrote.
However, whether reducing total ischemic time by “a few minutes” has clinical significance remains controversial, they acknowledged.
They noted that in one previous study, annual improvements in door-to-balloon times of about 16 minutes was not associated with significant reductions in mortality at the population level; however, a reanalysis of that data showed that effects at the individual lever were “important, even if modest at the population level,” they wrote.
In the present study, mean door-to-balloon times were “well within guideline-recommended time frames” for both the states with hospital destination policies and the states without them, Dr. Green and colleagues wrote.
“Many mitigating factors affecting STEMI mortality continue to exist when considering both population- and individual-level effects, and most cardiologists still agree that minimizing total ischemic time improves patient outcomes,” they said.
The project was funded by the American Heart Association’s Mission: Lifeline program, which aims to develop coordinated systems of care for time-sensitive, high-risk emergencies including heart attacks, stroke, and cardiac arrest.
One study coauthor reported serving as the Medical Director at ZOLL Medical. The others had no conflicts reported.
SOURCE: Green J et al. Circulation Cardiovasc Interven. 2018 May;11(5):e005706.
FROM CIRCULATION: CARDIOVASCULAR INTERVENTIONS
Key clinical point: Significantly faster time to guideline-recommended treatment was seen in states that adopted STEMI hospital destination policies that allow EMS to bypass facilities that are not PCI capable.
Major finding: Primary PCI was delivered within the guideline-recommended time from first contact for 58% of patients living in states with hospital destination policies, compared with 48% of patients in states with no such policies.
Study details: A report from the American Heart Association’s Mission: Lifeline program that was based on analysis of 2013-2014 registry data for six states with bypass policies and six matched control states without bypass policies.
Disclosures: The AHA Mission: Lifeline program funded the project. One study coauthor reported serving as the medical director at ZOLL Medical. The others had no conflicts reported.
Source: Green J et al. Circ Cardiovasc Interv. 2018 May;11(5):e005706.