References

2008. www.ncbi.nlm.nih.gov/pmc/articles/PMC2525646/ (accessed 7 January 2012)

Maroko PR, Kjekshus JK, Sobel BE Factors influencing infarct size following experimental coronary artery occlusions. Circulation. 1971; 43:(1)67-82

Reimer K, Jennings R, Hall M Total Ischemia in Dog Hearts, in Vitro. Circulation. 1981; 49:901-11

Time Is Muscle. 2008. content.onlinejacc.org/cgi/content/full/52/15/1216 (accessed 7 January 2012)

Maroko PR, Kjekshus JK, Sobel BE Factors influencing infarct size following experimental coronary artery occlusions. Circulation. 1971; 43:(1)67-82

Transferring patients for primary angioplasty: a retrospective analysis of 104 selected high risk patients with acute myocardial infarction. 1996. doi:10.1136/hrt.78.4.333 (accessed 7 January 2012)

Time from symptom onset to treatment and outcomes after thrombolytic therapy. 1996. content.onlinejacc.org/cgi/content/abstract/27/7/1646

Early thrombolytic treatment in acute myocardial infarction: reappraisal of the golden hour. 1996. www.ncbi.nlm.nih.gov/pubmed/8813982.1 (accessed 7 January 2012)

Influence of treatment delay on infarct size and clinical outcome in patients with acute myocardial infarction treated with primary angioplasty. 1998. content.onlinejacc.org/cgi/content/full/32/3/629 (accessed 7 January 2012)

Impact of primary coronary angioplasty delay on myocardial salvage, infarct size, and microvascular damage in patients with ST-segment elevation myocardial infarction: insight from cardiovascular magnetic resonance. 2009. content.onlinejacc.org/cgi/content/abstract/54/23/2145 (accessed 7 January 2012)

Total Ischemic Time: The Correct Focus of Attention for Optimal ST-Segment Elevation Myocardial Infarction Care. 2011. interventions.onlinejacc.org/cgi/content/abstract/4/6/599 (accessed 7 January 2012)

ACC/AHA guidelines for the management of patients with ST-Elevation myocardial infarction—executive summary. 2004. content.onlinejacc.org/cgi/content/full/44/3/671 (accessed 7 January 2012)

Nallamothu BK, Bates ER, Herrin J Times to treatment in transfer patients undergoing primary percutaneous coronary intervention in the United States: National Registry of Myocardial Infarction (NRMI)-3/4 analysis. Circulation. 2005; 111:761-7

“St-elevation myocardial infarction: The first 24 hours.” Medscape News. 2011. www.medscape.com/viewarticle/567620

American Heart Association Mission Lifeline: Developing a STEMI Regional Care System”, American Heart Association Mission Lifeline. 2010. www.emcreg.org/publications/monographs/acep/2009/ACEP2009_dbd.pdf (accessed 7 January 2012)

The Pre-Hospital Electrocardiogram and Time to Reperfusion in Patients With Acute Myocardial Infarction 2000–2002. 2006. content.onlinejacc.org/cgi/content/abstract/47/8/1544 (accessed 7 January 2012)

Improvements in door-to-balloon time in the United States 2005 to 2010. 2011. circ.ahajournals.org (accessed 7 January 2012)

2008. www.ncbi.nlm.nih.gov/pmc/articles/PMC2525646/ (accessed 7 January 2012)

Swor R, Hegerberg S, McHugh-McNally A Prehospital 12-lead ECG: efficacy or effectiveness?. Prehosp Emerg Care. 2006; 10:(3)374-7

Ting HH, Rihal CS, Gersh BJ Regional systems of care to optimize timeliness of reperfusion therapy for ST-elevation myocardial infarction: the Mayo Clinic STEMI Protocol. Circulation. 2007; 116:(7)729-36

Henry TD, Unger BT, Sharkey SW Design of a standardized system for transfer of patients with ST-elevation myocardial infarction for percutaneous coronary intervention. Am Heart J. 2005; 150:(3)373-84

Vanderbilt Heart & Vascular Institute Publications. 2011. www.mc.vanderbilt.edu/documents/heart/files/STEMI%20Newsletter~Winter%202011_web.pdf (accessed 7 January 2012)

System Delay and Mortality Among Patients With STEMI Treated With Primary Percutaneous Coronary Intervention. 2010. jama.jamanetwork.com/article.aspx?articleid=186426 (accessed 7 January 2012)

management
clinical skills
patient care

Rural acute myocardial infarction survey (RAMIS)

01 January 2013
Features
02 January 2013
Volume 3 · Issue 1

Abstract

Objectives: The purpose of this study was to evaluate why current treatment goals for patients with Acute Myocardial Infarction are not being achieved despite a large body of evidence supporting regionalised ST Elevation Myocardial Infarction (STEMI) systems.

Background: Executing a STEMI system in a pre-hospital environment varies not only from state to state but also region to region. Statewide EMS treatment protocols serve to shield an ambulance service from litigation when following the published statewide protocols. Many critical access hospitals also have standardised protocols in place for the identification and treatment of STEMI patients. We sought to understand whether these plans are followed as many system providers believe they are. If deviations were found we sought to understand the reasons for those deviations.

Methods: Because all of these delay factors center around rural hospitals, the project team developed a simple online survey tool to poll the critical access hospitals of Nebraska.

Results: We found that the rural STEMI care system lacks a coordinated system that is considered to be essential for urban areas. When looking at why rural STEMI patients have a higher 30 day mortality compared to patients treated in an urban environment, several areas of potential failure have been identified.

Conclusion: We qualitatively demonstrated that STEMI patients in the rural setting of Nebraska are not receiving timely reperfusion even though data describing the number of persons and delays experienced are not widely tracked. Although currently lacking, individuals surveyed expressed a desire for a statewide coordinated STEMI care system.

Reperfusion is so central to the modern treatment of acute ST-elevation myocardial infarction (STEMI) that we are said to be in the reperfusion era. Many studies have shown a significant relationship between time-to-treatment resulting in reperfusion and mortality.

There are two main strategies to achieve reperfusion: thrombolytic therapy and percutaneous coronary intervention (PCI). Over the last 40 years the mantra ‘time is muscle’ has been popularised to describe the urgency of identifying and treating myocardial infarctions. In those early days of EMS it was thought that the treatment should happen within three hours of onset. Later treatment guidelines focused on treatment within two hours but suggested a ‘golden hour’ was even better. Although many historical studies have concluded with conflicting results, more recent data demonstrates that a shorter time-to-reperfusion will result in improved cardiac function.

In 2004, the American College of Cardiology (ACC)/American Heart Association (AHA) STEMI guidelines were updated to suggest the goal for stent or balloon angioplasty (also known as D2B or door-to-balloon time) of ≤ 90 minutes for at least 75 % of non-transfer PCI patients with STEMI in all participating hospitals performing primary PCI, while clot-busting medications should be given in 30 minutes (also known as D2N or door-to-needle time) to patients who do not have significant risk factors for bleeding issues. At the time, only 25 % of cardiac catheterisation labs were achieving D2B times of 92 minutes while less than 5 % of patients transferred from other hospitals were seeing D2B times of less than 90 minutes.

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Complications
Electrocardiography
Emergency medical services
Medical complications
Rural health Services