Peter Bogaty and colleagues,1 in their review of the American College of Cardiology/American Heart Association STEMI guidelines from a Canadian perspective, recommend transfer of STEMI patients with Killip class 3/4 or other high-risk features of acute myocardial infarction for PCI, if such intervention is reliably available within 60 minutes. However, achieving a 60-minute transfer imposes significant challenges for emergency medical services (EMS) that the authors have not considered. Several studies examining interfacility transfer for primary PCI, operating under rigorous study protocols, were able to achieve randomization-to-balloon times of 80 to 122 minutes,2,3,4,5 which suggests that meeting a 60-minute target may be difficult in everyday practice.
The following recommendations would help to safely achieve this target:
The paramedics caring for the patient should be capable of advanced life support (ALS) interventions, as some of the patients may experience the complications of STEMI while in transit.4 Therefore, EMS dispatch should provide an ALS-crewed vehicle in the same time frame as would apply for a critical 9-1-1 call (in our system, this would be 8 minutes, 59 seconds). Alternatively, the same ambulance that brought the patient to the emergency department, if its crew is capable of providing ALS, should be used to transfer the patient.
A PCI “hot link” should exist between the referring and receiving institutions. The PCI centre should accept referrals without question and should reassess for PCI suitability on arrival.
Patients should be taken directly to the catheterization suite, without a stop in the receiving emergency department.
We feel that a 60-minute target for transfer is unlikely to be met without specific optimization of EMS and hospital systems. The absence of such optimization will inevitably lead to failure and abandonment of a strategy that has the potential to lessen morbidity and mortality.
Cathal O'Donnell Richard Verbeek Base Hospital Programme Sunnybrook and Women's College Health Sciences Centre Toronto, Ont.
Footnotes
Competing interests: None declared.
References
- 1.Bogaty P, Buller CE, Dorian P, O'Neill BJ, Armstrong PW. Applying the new STEMI guidelines: 1. Reperfusion in acute ST-segment elevation myocardial infarction. CMAJ 2004;171(9):1039-41. [DOI] [PMC free article] [PubMed]
- 2.Widimsky P, Groch L, Zelizko M, Aschermann M, Bednar F, Suryapranata H. Multicentre randomized trial comparing transport to primary angioplasty vs immediate thrombolysis vs combined strategy for patients with acute myocardial infarction presenting to a community hospital without a catheterization laboratory. The PRAGUE study. Eur Heart J 2000;21(10):823-31. [DOI] [PubMed]
- 3.Widimsky P, Budesinsky T, Vorac D, Groch L, Zelizko M, Aschermann M, et al; PRAGUE Study Group Investigators. Long distance transport for primary angioplasty vs immediate thrombolysis in acute myocardial infarction. Final results of the randomized national multicentre trial — PRAGUE-2. Eur Heart J 2003;24(1):94-104. [DOI] [PubMed]
- 4.Andersen HR, Nielsen TT, Rasmussen K, Thuesen L, Thayssen P, Abildgaard U, et al; DANAMI-2 Investigators. A comparison of coronary angioplasty with fibrinolytic therapy in acute myocardial infarction. N Engl J Med 2003;349(8):733-42. [DOI] [PubMed]
- 5.Grines CL, Westerhausen DR Jr, Grines LL, Hanlon JT, Logemann TL, Neimela M, et al; Air PAMI Study Group. A randomized trial of transfer for primary angioplasty versus on-site thrombolysis in patients with high-risk myocardial infarction: the Air Primary Angioplasty in Myocardial Infarction study. J Am Coll Cardiol 2002;39(11):1713-9. [DOI] [PubMed]