Expansion of a regional ST-segment-elevation myocardial infarction system to an entire state.

BACKGROUND: Despite national guidelines calling for timely coronary artery reperfusion, treatment is often delayed, particularly for patients requiring interhospital transfer. METHODS AND RESULTS: One hundred nineteen North Carolina hospitals developed coordinated plans to rapidly treat patients with ST-segment-elevation myocardial infarction according to presentation: walk-in, ambulance, or hospital transfer. A total of 6841 patients with ST-segment-elevation myocardial infarction (3907 directly presenting to 21 percutaneous coronary intervention hospitals, 2933 transferred from 98 non-percutaneous coronary intervention hospitals) were treated between July 2008 and December 2009 (age, 59 years; 30% women; 19% uninsured; chest pain duration, 91 minutes; shock, 9.2%). The rate of patients not receiving reperfusion fell from 5.4% to 4.0% (P=0.04). Treatment times for hospital transfer patients substantially improved. First-hospital-door-to-device time for hospitals that adopted a "transfer for percutaneous coronary intervention" reperfusion strategy fell from 117 to 103 minutes (P=0.0008), whereas times at hospitals with a mixed strategy of transfer or fibrinolysis fell from 195 to 138 minutes (P=0.002). Median door-to-device times for patients presenting directly to PCI hospitals fell from 64 to 59 minutes (P<0.001). Emergency medical services-transported patients were most likely to reach door-to-device goals, with 91% treated within 90 minutes and 52% being treated with 60 minutes. Patients treated within guideline goals had a mortality of 2.2% compared with 5.7% for those exceeding guideline recommendations (P<0.001). CONCLUSION: Through extension of regional coordination to an entire state, rapid diagnosis and treatment of ST-segment-elevation myocardial infarction has become an established standard of care independently of healthcare setting or geographic location.

Duke Scholars

Author James Gerard Jollis Medicine, Cardiology

Author Hussein Rashid Al-Khalidi Biostatistics & Bioinformatics, Division of Biostatistics

Author Christopher Bull Granger Medicine, Cardiology