Network models for large cities: the European experience

Abstract

Optimal treatment for ST segment elevation myocardial infarction (STEMI) has largely been defined and recently published in guidelines of the international societies of cardiology.1 2 Both reperfusion strategies—primary percutaneous coronary intervention (pPCI) and thrombolytic therapy (TT)—dramatically improve clinical outcome compared to conservative treatment strategies if offered with short time delay from symptom onset. Unfortunately, 25–30% of patients with acute STEMI are still not reperfused at all, even though they are seen by physicians within 12 h of symptom onset, due to lack of organised, around the clock, 24 h care. Even in existing but not optimised networks, reperfusion strategies are offered after unacceptably long time delays in real world settings as demonstrated by the Euro Heart acute coronary syndrome survey,3 the Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the ACC/AHA Guidelines (CRUSADE) initiative,4 and the Global Registry of Acute Coronary Events (GRACE),5 respectively. Very few patients receive all the guideline indicated treatments promptly.6 Reasons for this are: the long delay until patients call medical services for ongoing chest pain (patient delay); long transfer times of patients seen by emergency medical systems (EMS), especially the inter-hospital transfer (transportation delay); and the delay which occurs within PCI capable hospitals if the personnel is not sufficiently trained, if the annual caseload is low, or if the patient is not directly transferred to the catheter laboratory and time is lost in emergency rooms or coronary care units (in-hospital delay).7 This unfavourable situation can be improved by building up and optimising systems of care (STEMI networks), in which EMS, non-PCI capable hospitals, and hospitals with PCI facilities cooperate closely with the goal to reduce total ischaemic time, offer pPCI to the majority of patients within the recommended time, and use prehospital …