title: Evolution and Impact of a Regional Reperfusion System for ST-Elevation Myocardial Infarction.
abstract: We describe the evolution of a regional system designed to provide primary percutaneous coronary intervention (pPCI) as the preferred method of revascularization for ST-elevation myocardial infarction (STEMI) and its impact on first medical contact (FMC)-to-device times and in-hospital outcomes.
  
  
  
  Patients with STEMI presenting to the Vancouver Coastal Health Authority between June 2007 and January 2015 (N = 2503) were categorized according to 3 sequential phases: phase 1 = standardization of reperfusion algorithms; phase 2 = use of prehospital electrocardiograms; phase 3 = expedited interfacility transfer for pPCI. In-hospital outcomes by phase and hospital type were analyzed using multivariable logistic regression techniques.
  
  
  
  Regional pPCI use increased across phases (55.0% vs 72.5% vs 86.7%; P < 0.001) and median FMC-to-device times shortened between phase 1 and later phases at both PCI-capable (117 minutes vs 92 minutes vs 97 minutes, respectively; P < 0.001) and non-PCI-capable hospitals (174 minutes vs 146 minutes vs 123 minutes, respectively; P < 0.001). Overall in-hospital mortality (9.4% vs 8.9% vs 10.3%, respectively; P = 0.54) and congestive heart failure (CHF) (15.8% vs 19.7% vs 22.0%, respectively; P = 0.056) were unchanged across phases. A trend toward increased mortality (9.0% vs 9.3% vs 12.9%, respectively; P = 0.079) and higher rates of CHF (15.7% vs 21.5% vs 25.9%, respectively; P = 0.014) were seen in PCI-capable hospitals.
  
  
  
  Our regional STEMI model increased access to pPCI and reduced median reperfusion times. However, FMC-to-device times remained prolonged in many patients and overall clinical outcomes were not improved-in particular at PCI-capable hospitals. A strategy of pPCI as the preferred method of reperfusion may not benefit all patients in a regional model of STEMI care.
authors.affiliation: Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada.
authors.forename: Christopher B
authors.initials: CB
authors.lastname: Fordyce
authors.affiliation: Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada.
authors.forename: John A
authors.initials: JA
authors.lastname: Cairns
authors.affiliation: School of Population and Public Health and the Centre for Health Evaluation and Outcome Sciences, Providence Health Care Research Institute, University of British Columbia, Vancouver, British Columbia, Canada.
authors.forename: Joel
authors.initials: J
authors.lastname: Singer
authors.affiliation: School of Population and Public Health and the Centre for Health Evaluation and Outcome Sciences, Providence Health Care Research Institute, University of British Columbia, Vancouver, British Columbia, Canada.
authors.forename: Terry
authors.initials: T
authors.lastname: Lee
authors.affiliation: BC Centre for Improved Cardiovascular Health, Vancouver, British Columbia, Canada.
authors.forename: Julie E
authors.initials: JE
authors.lastname: Park
authors.affiliation: Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada.
authors.forename: Richard A
authors.initials: RA
authors.lastname: Vandegriend
authors.affiliation: Vancouver Coastal Health Authority, Vancouver, British Columbia, Canada.
authors.forename: Michele
authors.initials: M
authors.lastname: Perry
authors.affiliation: Vancouver Coastal Health Authority, Vancouver, British Columbia, Canada.
authors.forename: Wendy
authors.initials: W
authors.lastname: Largy
authors.affiliation: BC Centre for Improved Cardiovascular Health, Vancouver, British Columbia, Canada.
authors.forename: Min
authors.initials: M
authors.lastname: Gao
authors.affiliation: Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada; Vancouver Coastal Health Authority, Vancouver, British Columbia, Canada.
authors.forename: Krishnan
authors.initials: K
authors.lastname: Ramanathan
authors.affiliation: Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada; Vancouver Coastal Health Authority, Vancouver, British Columbia, Canada. Electronic address: gcwong@mail.ubc.ca.
authors.forename: Graham C
authors.initials: GC
authors.lastname: Wong
mesh_terms: D000368:Aged; D000465:Algorithms; D002170:Canada / Q000453:epidemiology; D001026:Coronary Artery Bypass / Q000706:statistics & numerical data; D004562:Electrocardiography; D004632:Emergency Medical Services; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use; D006470:Hemorrhage / Q000453:epidemiology; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D010360:Patient Transfer; D062645:Percutaneous Coronary Intervention; D012041:Regional Medical Programs / Q000458:organization & administration*; D012189:Retrospective Studies; D000072657:ST Elevation Myocardial Infarction / Q000453:epidemiology / Q000628:therapy*; D012770:Shock, Cardiogenic / Q000453:epidemiology; D013686:Telemetry; D061665:Time-to-Treatment
chemical_list: D005343:Fibrinolytic Agents