A Citywide Protocol for Primary PCI in ST-Segment Elevation Myocardial Infarction
Michel R. Le May, M.D., Derek Y. So, M.D., Richard Dionne, M.D., Chris A. Glover, M.D., Michael P.V. Froeschl, M.D., George A. Wells, Ph.D., Richard F. Davies, M.D., Heather L. Sherrard, R.N., Justin Maloney, M.D., Jean-François Marquis, M.D., Edward R. O'Brien, M.D., John Trickett, R.N., Pierre Poirier, A.C.P., Sheila C. Ryan, B.Sc., Andrew Ha, M.D., Phil G. Joseph, M.D., and Marino Labinaz, M.D.
Background If primary percutaneous coronary intervention (PCI)is performed promptly, the procedure is superior to fibrinolysisin restoring flow to the infarct-related artery in patientswith ST-segment elevation myocardial infarction. The benchmarkfor a timely PCI intervention has become a door-to-balloon timeof less than 90 minutes. Whether regional strategies can bedeveloped to achieve this goal is uncertain.
Methods We developed an integrated-metropolitan-area approachin which all patients with ST-segment elevation myocardial infarctionwere referred to a specialized center for primary PCI. We soughtto determine whether there was a difference in door-to-balloontimes between patients who were referred directly from the fieldby paramedics trained in the interpretation of electrocardiogramsand patients who were referred by emergency department physicians.
Results Between May 1, 2005, and April 30, 2006, a total of344 consecutive patients with ST-segment elevation myocardialinfarction were referred for primary PCI: 135 directly fromthe field and 209 from emergency departments. Primary PCI wasperformed in 93.6% of patients. The median door-to-balloon timewas shorter in patients referred from the field (69 minutes;interquartile range, 43 to 87) than in patients needing interhospitaltransfer (123 minutes; interquartile range, 101 to 153; P<0.001).Door-to-balloon times of less than 90 minutes were achievedin 79.7% of patients who were transferred from the field andin 11.9% of those transferred from emergency departments (P<0.001).
Conclusions Guideline door-to-balloon-times were more oftenachieved when trained paramedics independently triaged and transportedpatients directly to a designated primary PCI center than whenpatients were referred from emergency departments.
Source Information
From the University of Ottawa Heart Institute (M.R.L., D.Y.S., C.A.G., M.P.V.F., G.A.W., R.F.D., H.L.S., J.-F.M., E.R.O., S.C.R., A.H., P.G.J., M.L.) and the Ottawa Base Hospital Program (R.D., J.M., J.T.), University of Ottawa; and the Ottawa Paramedic Service (P.P.) — all in Ottawa, ON, Canada.
Address reprint requests to Dr. Le May at the Ottawa Heart Institute, 40 Ruskin St., Ottawa, ON K1Y 4W7, Canada, or at mlemay{at}ottawaheart.ca.
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