title: Providing optimal regional care for ST-segment elevation myocardial infarction: a prospective cohort study of patients in the Hamilton Niagara Haldimand Brant Local Health Integration Network.
abstract: BACKGROUND
  Although considered the evidence-based best therapy for ST-segment elevation myocardial infarction (STEMI), many patients do not receive primary percutaneous coronary intervention (PCI) because of health care resource distribution and constraints. This study describes the clinical management and outcomes of all patients identified with STEMI within a region, including those who did not receive primary PCI.
  
  
  METHODS
  This study used a prospective cohort design. Patients presenting with STEMI to PCI- and non-PCI-capable hospitals in one integrated health region in Ontario were included in the study. The primary objective was to examine use of reperfusion strategies and timeliness of care. Secondary objectives included determining (through regression models) which variables were associated with mortality within 90 days, and describing patient uptake of risk-reducing therapies and activities post-STEMI.
  
  
  RESULTS
  Between Apr. 1, 2010, and Mar. 31, 2013, data were collected on 2247 consecutive patients presenting with STEMI. Patients presenting to the PCI-capable hospital were more likely to receive primary PCI (82.5% v. 65.2%, p < 0.001) and be treated within optimal treatment times. However, there was no appreciable difference in mortality at 90 days post-STEMI between patients presenting to PCI- and non-PCI-capable hospitals (7.8% v. 7.5%, p = 0.82), even after adjustment for acuity on presentation. Despite recognized risk factors, many patients were not taking evidence-based medications for risk factor modification before STEMI.
  
  
  CONCLUSIONS
  A systematic approach to regional STEMI care focusing on timely access to the best available therapies, rather than the type of reperfusion provided alone, can yield favourable outcomes.
authors.affiliation: Department of Medicine, Division of Cardiology, Columbia University, New York ; Department of Medicine, Division of Cardiology, McMaster University, Hamilton, Ont.
authors.forename: Mathew
authors.initials: M
authors.lastname: Mercuri
authors.affiliation: Department of Medicine, Division of Emergency Medicine, McMaster University, Hamilton, Ont. ; Hamilton Health Sciences, Hamilton Ontario, Hamilton, Ont.
authors.forename: Michelle
authors.initials: M
authors.lastname: Welsford
authors.affiliation: Department of Medicine, Division of Cardiology, McMaster University, Hamilton, Ont. ; Hamilton Health Sciences, Hamilton Ontario, Hamilton, Ont. ; Population Health Research Institute, Hamilton, Ont.
authors.forename: Jon-David
authors.initials: JD
authors.lastname: Schwalm
authors.affiliation: Department of Medicine, Division of Cardiology, McMaster University, Hamilton, Ont. ; Hamilton Health Sciences, Hamilton Ontario, Hamilton, Ont. ; Population Health Research Institute, Hamilton, Ont.
authors.forename: Shamir R
authors.initials: SR
authors.lastname: Mehta
authors.affiliation: Population Health Research Institute, Hamilton, Ont.
authors.forename: Purnima
authors.initials: P
authors.lastname: Rao-Melacini
authors.affiliation: Department of Medicine, Division of Cardiology, McMaster University, Hamilton, Ont. ; Hamilton Health Sciences, Hamilton Ontario, Hamilton, Ont. ; Population Health Research Institute, Hamilton, Ont.
authors.forename: Tej
authors.initials: T
authors.lastname: Sheth
authors.affiliation: Department of Medicine, Division of Cardiology, McMaster University, Hamilton, Ont. ; Hamilton Health Sciences, Hamilton Ontario, Hamilton, Ont.
authors.forename: Michael
authors.initials: M
authors.lastname: Rokoss
authors.affiliation: Department of Medicine, Division of Cardiology, McMaster University, Hamilton, Ont. ; Hamilton Health Sciences, Hamilton Ontario, Hamilton, Ont. ; Population Health Research Institute, Hamilton, Ont.
authors.forename: Sanjit S
authors.initials: SS
authors.lastname: Jolly
authors.affiliation: Department of Medicine, Division of Cardiology, McMaster University, Hamilton, Ont. ; Hamilton Health Sciences, Hamilton Ontario, Hamilton, Ont.
authors.forename: James L
authors.initials: JL
authors.lastname: Velianou
authors.affiliation: Department of Medicine, Division of Cardiology, McMaster University, Hamilton, Ont. ; Hamilton Health Sciences, Hamilton Ontario, Hamilton, Ont. ; Population Health Research Institute, Hamilton, Ont.
authors.forename: Madhu K
authors.initials: MK
authors.lastname: Natarajan
references.citation: Circulation. 2007 Aug 14;116(7):729-36
references.pmid: 17673456
references.citation: Implement Sci. 2012 Jun 09;7:54
references.pmid: 22682691
references.citation: Circulation. 2011 Jul 12;124(2):154-63
references.pmid: 21690494
references.citation: JACC Cardiovasc Interv. 2012 Dec;5(12):1239-46
references.pmid: 23257372
references.citation: JAMA. 2013 Sep 4;310(9):959-68
references.pmid: 24002282
references.citation: Can J Cardiol. 2013 Feb;29(2):151-67
references.pmid: 23351925
references.citation: JAMA. 2000 Jul 5;284(1):60-7
references.pmid: 10872014
references.citation: Healthc Q. 2010;13(1):105-9
references.pmid: 20104046
references.citation: Intern Med J. 2010 Feb;40(2):112-6
references.pmid: 19383057
references.citation: Circulation. 2006 Feb 14;113(6):e85-151
references.pmid: 16407573
references.citation: Crit Pathw Cardiol. 2007 Sep;6(3):91-7
references.pmid: 17804968
references.citation: J Am Coll Cardiol. 2009 Jan 13;53(2):161-6
references.pmid: 19130984
references.citation: JAMA. 2007 Nov 28;298(20):2371-80
references.pmid: 17982184
references.citation: Open Med. 2010;4(1):e13-21
references.pmid: 21686287
references.citation: Am Heart J. 2013 Feb;165(2):123-32
references.pmid: 23351814
references.citation: J Am Coll Cardiol. 2012 Oct 2;60(14):1223-30
references.pmid: 23017532
references.citation: Am J Cardiol. 2006 Feb 15;97(4):458-61
references.pmid: 16461036
references.citation: Circulation. 2006 Feb 28;113(8):1079-85
references.pmid: 16490818
references.citation: Am Heart J. 2010 Jul;160(1):30-35.e1
references.pmid: 20598969
references.citation: EuroIntervention. 2009 Aug;5(3):299, 301-309
references.pmid: 19736153
references.citation: N Engl J Med. 2003 Aug 21;349(8):733-42
references.pmid: 12930925
references.citation: N Engl J Med. 2008 Jan 17;358(3):231-40
references.pmid: 18199862
references.citation: N Engl J Med. 2013 Apr 11;368(15):1379-87
references.pmid: 23473396
references.citation: Circulation. 1995 Apr 1;91(7):1923-8
references.pmid: 7895348
references.citation: J Am Coll Cardiol. 2013 Jan 29;61(4):e78-140
references.pmid: 23256914
references.citation: Am Heart J. 2010 Jan;159(1):117.e1-6
references.pmid: 20102876
references.citation: Health Policy. 2009 Aug;91(3):314-20
references.pmid: 19223088
references.citation: CMAJ. 2007 Jun 19;176(13):1833-8
references.pmid: 17576980
references.citation: Can J Cardiol. 2013 Aug;29(8):951-9
references.pmid: 23332092
references.citation: N Engl J Med. 2009 Jun 25;360(26):2705-18
references.pmid: 19553646
references.citation: J Gen Intern Med. 2008 Aug;23(8):1246-56
references.pmid: 18459014
references.citation: J Am Coll Cardiol. 2005 Aug 2;46(3):417-24
references.pmid: 16053952