Thanks to Ivan Rokos, M.D. for pointing out an important change in the 2011 ACCF/AHA/SCAI Guidelines for Percutaneous Coronary Intervention.
Photo credit: Code STEMI Web Series at First Responders Network
For years now many have complained about the AHA's official recommendation that primary PCI for acute STEMI be accomplished within 90 minutes of first medical contact (which can be a Critical Access Hospital 1 or 2 hours away from a PCI hospital or a volunteer BLS EMS system in the rural setting).
There are two main reasons the 90-minute standard for rural patients is problematic.
- We hold PCI hospitals to a 90-minute standard for walk-in patients
- Not all STEMI patients are the same
You could argue that it's time to change the recommendation from 90-minutes to 60-minutes for walk-in patients at PCI hopsitals (which I agree with). But even so, for many patients the mortality benefit of primary PCI over fibrinolytic therapy persists well past 90-minutes.
It's also important to remember that many patients have contraindications to fibrinolytic therapy, meet high-risk criteria (pulmonary edema, hypotension, tachycardia) that make primary PCI necessary, and that up to 30% of patients who receive fibrinolytic therapy will have "failed fibrinolysis" (their symptoms and ST-elevation will not resolve after being given clot-busing drugs indicating that they have not been reperfused).
In other words, all hospitals need (in the words of Jodi Doering, R.N.) "a Plan A, a Plan B and a Plan C." This is far too important to leave to chance. There is mounting evidence that transfer PCI takes too long and that rural hospitals are not achieving door-in to door-out (DIDO) times of less than 30-minutes so there is plenty of room for improvement and my intent here is not to blame the guidelines for preventable delays.
Having said that it's simply not possible for some patients who would benefit from primary PCI to have their infarct-related artery opened up on the cath table within 90-minutes of first medical contact (which, let's face it, is not even being measured in the vast majority of STEMI "systems" — the word "systems" in scare quotes because if it's not measured it's not a system.)
Which brings me to the 2011 ACCF/AHA/SCAI Guidelines for Percutaneous Coronary Intervention (free full text).
18.104.22.168. Primary PCI of the Infarct Artery: Recommendations
The following statement accompanies the change in guidelines:
"Several reports have shown excellent outcomes for patients with STEMI undergoing interhospital transfer where first medical contact–to-door balloon time modestly exceeded the systematic goal of <90 minutes. In these reports, the referring hospital and the receiving hospital established a transfer protocol that minimized transfer delays, and outcomes were similar to those of direct-admission patients. On the basis of these results, the PCI and STEMI guideline writing committees have modified the first medical contact–to-device time goal from 90 minutes to 120 minutes for interhospital transfer patients, while emphasizing that systems should continue to strive for times ≤90 minutes. Hospitals that cannot meet these criteria should use fibrinolytic therapy as their primary reperfusion strategy."
This is an important change that every state, Critical Access Hopsital and rural EMS system should make note of and take steps to act upon.
The lives of our rural STEMI patients may depend upon it!