title: Rationale and strategies for implementing community-based transfer protocols for primary percutaneous coronary intervention for acute ST-segment elevation myocardial infarction.
abstract: 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.
authors.affiliation: Duke University Medical Center and Duke Clinical Research Institute, Durham, North Carolina, USA.
authors.forename: Richard E
authors.initials: RE
authors.lastname: Waters
authors.forename: Kanwar P
authors.initials: KP
authors.lastname: Singh
authors.forename: Matthew T
authors.initials: MT
authors.lastname: Roe
authors.forename: Mat
authors.initials: M
authors.lastname: Lotfi
authors.forename: Michael H
authors.initials: MH
authors.lastname: Sketch
authors.forename: Kenneth W
authors.initials: KW
authors.lastname: Mahaffey
authors.forename: L Kristin
authors.initials: LK
authors.lastname: Newby
authors.forename: John H
authors.initials: JH
authors.lastname: Alexander
authors.forename: Robert A
authors.initials: RA
authors.lastname: Harrington
authors.forename: Robert M
authors.initials: RM
authors.lastname: Califf
authors.forename: Christopher B
authors.initials: CB
authors.lastname: Granger
mesh_terms: D015906:Angioplasty, Balloon, Coronary; D002985:Clinical Protocols; D003695:Delivery of Health Care; D004562:Electrocardiography / Q000009:adverse effects; D006284:Health Plan Implementation; D006297:Health Services Accessibility; D006764:Hospitals, Community / Q000458:organization & administration; D006801:Humans; D009203:Myocardial Infarction / Q000209:etiology / Q000628:therapy*; D015425:Myocardial Reperfusion; D010360:Patient Transfer / Q000592:standards*; D011785:Quality Assurance, Health Care; D012041:Regional Medical Programs / Q000458:organization & administration*; D014481:United States