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VIEWPOINT

Rationale and strategies for implementing community-based transfer protocols for primary percutaneous coronary intervention for acute ST-segment elevation myocardial infarction

^* Duke University Medical Center and Duke Clinical Research Institute, Durham, North Carolina, USA

Manuscript received October 27, 2003; revised manuscript received December 19, 2003, accepted December 23, 2003.

^* Reprint requests and correspondence: Dr. Matthew T. Roe, 2400 Pratt Street, Durham, North Carolina 27705, USA.
roe00001{at}mc.duke.edu

The focus for the initial approach to the treatment of acute ST-segment elevation myocardial infarction (STEMI) has shifted toward extending the benefits of mechanical reperfusion with primary percutaneous coronary intervention (PCI) to patients who present to community hospitals that have no interventional capabilities. Several randomized clinical trials have shown that transferring STEMI patients to tertiary centers for primary PCI leads to better outcomes than when fibrinolytic therapy is administered at community hospitals. Furthermore, potent pharmacologic reperfusion regimens that enhance early reperfusion of the infarct vessel before primary PCI may enhance the positive result of the transfer approach. Despite these promising findings, several obstacles have hindered the adoption of patient-transfer strategies in the U.S., including greater distances between community and tertiary hospitals, a lack of integrated emergency medical services, and the medical community's limited experience with centralized acute myocardial infarction (AMI) care networks. Nonetheless, the implementation of system-wide changes in the care of STEMI patients analogous to the creation of trauma networks could facilitate the creation and ongoing evaluation of dedicated patient transfer strategies and better early invasive care in the U.S. Within this context, a systematic, stepwise approach to the creation of AMI care networks and to the development of standard nomenclature and performance indicators is necessary to guide quality assurance monitoring and future research efforts as the care of STEMI patients is redefined. Consequently, this current evolution of reperfusion strategies has the potential to further reduce morbidity and mortality for patients presenting with STEMI.

Abbreviations and Acronyms   AMI = acute myocardial infarction   AIR-PAMI = Air Primary Angioplasty in Myocardial Infarction   DANAMI = Danish Multicenter Randomized Trial on Thrombolytic Therapy Versus Acute Coronary Angioplasty in Acute Myocardial Infarction   MI = myocardial infarction   PCI = percutaneous coronary intervention   PRAGUE = Primary Angioplasty After Transport of Patients from General Community Hospitals to Catheterization Units With/Without Emergency Thrombolysis Infusion   SK = streptokinase   STEMI = ST-segment elevation myocardial infarction

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