A European perspective on improving acute systems of care in STEMI: we know what to do, but how can we do it?

Abstract

For the management of ST-segment elevation acute myocardial infarction (STEMI), international guidelines recommend primary percutaneous coronary intervention with adjunctive antithrombotic therapy, the management of complications, and secondary prevention measures. Delivery of care has, however, lagged behind establishing the evidence for effectiveness. Approximately a quarter of all patients with STEMI still fail to receive reperfusion therapy. Additionally, for most patients delays substantially exceed guideline recommendations and secondary prevention is incomplete. What can be done? First, cardiologists need to take the lead in improving systems of care, with the integration of prehospital care within 'heart attack networks' involving intervention centers, nonintervention hospitals, primary care, and paramedic ambulance care. Several examples show that such systems are feasible. 'Door-to-balloon' initiatives can improve care in the final interventional hospital, but only make a modest contribution to total patient delay. Second, high-risk patients, including the elderly and those with cardiac complications like heart failure, should be targeted for more-aggressive interventional and pharmacologic therapy; the opposite situation currently exists in clinical practice (the treatment–risk paradox). Third, greater emphasis on quality improvement, collaboration among health professionals, and achieving high-quality care for all is required from funding bodies, regulatory agencies and professional societies.

Key Points

• Data from registries and European surveys demonstrate that there is a substantial gap between evidence-based recommendations for the management of acute ST-segment elevation myocardial infarction (STEMI) and clinical practice

• Although a considerable proportion of patients now receive primary percutaneous coronary intervention (PCI), about a quarter of all patients with STEMI fail to receive reperfusion therapy

• Only a minority of patients currently achieve reperfusion within the first 2–3 h of symptom onset

• Substantial heterogeneity exists across Europe in the provision of reperfusion therapy, time delays, and the extent to which integrated 'heart attack networks' have been developed

• The goal of providing rapid and comprehensive reperfusion to all patients is achievable, and has been shown to be feasible, but requires a focus on improving systems of acute care and integrating prehospital emergency systems, primary care and PCI centers, and non-PCI hospitals ('heart attack networks')

• The diversity of health-care systems, and the differences in geography and population distribution across Europe, mean that the principles of providing an integrated and expedited system of care for acute STEMI will need to be adapted regionally; nevertheless, the same principles apply to all health-care systems and few currently meet the guideline recommendations