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JOURNAL ARTICLE

A citywide protocol for primary PCI in ST-segment elevation myocardial infarction

Michel R Le May, Derek Y So, Richard Dionne, Chris A Glover, Michael P V Froeschl, George A Wells, Richard F Davies, Heather L Sherrard, Justin Maloney, Jean-François Marquis, Edward R O'Brien, John Trickett, Pierre Poirier, Sheila C Ryan, Andrew Ha, Phil G Joseph, Marino Labinaz
New England Journal of Medicine 2008 January 17, 358 (3): 231-40
18199862

BACKGROUND: If primary percutaneous coronary intervention (PCI) is performed promptly, the procedure is superior to fibrinolysis in restoring flow to the infarct-related artery in patients with ST-segment elevation myocardial infarction. The benchmark for a timely PCI intervention has become a door-to-balloon time of less than 90 minutes. Whether regional strategies can be developed to achieve this goal is uncertain.

METHODS: We developed an integrated-metropolitan-area approach in which all patients with ST-segment elevation myocardial infarction were referred to a specialized center for primary PCI. We sought to determine whether there was a difference in door-to-balloon times between patients who were referred directly from the field by paramedics trained in the interpretation of electrocardiograms and patients who were referred by emergency department physicians.

RESULTS: Between May 1, 2005, and April 30, 2006, a total of 344 consecutive patients with ST-segment elevation myocardial infarction were referred for primary PCI: 135 directly from the field and 209 from emergency departments. Primary PCI was performed in 93.6% of patients. The median door-to-balloon time was shorter in patients referred from the field (69 minutes; interquartile range, 43 to 87) than in patients needing interhospital transfer (123 minutes; interquartile range, 101 to 153; P<0.001). Door-to-balloon times of less than 90 minutes were achieved in 79.7% of patients who were transferred from the field and in 11.9% of those transferred from emergency departments (P<0.001).

CONCLUSIONS: Guideline door-to-balloon-times were more often achieved when trained paramedics independently triaged and transported patients directly to a designated primary PCI center than when patients were referred from emergency departments.

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