Development of systems of care for ST-elevation myocardial infarction patients: current state of ST-elevation myocardial infarction care.

Advances in the treatment of ST-elevation myocardial infarction (STEMI) over the past 20 years have resulted in dramatic reductions in death attributable to STEMI. In large part, this reduction has been due to early reperfusion and advances in medical therapy.1 The American College of Cardiology (ACC)/American Heart Association (AHA) guidelines and the European Society of Cardiology guidelines for STEMI are in agreement that early and complete reperfusion is optimal, with the goal of door-to-balloon times within 90 minutes and door-to-needle times within 30 minutes.2,3 Most disturbing is that as many as one third of patients do not receive any reperfusion therapy in the absence of contraindications to its use.1,4 In the group of patients who do not receive any reperfusion, both shortand long-term outcomes are significantly worse. Advances in medical therapy, including use of aspirin, heparin, -blockers, and angiotensin-converting enzyme inhibitors, have also dramatically improved outcomes. Hospitals that are most compliant with the guideline recommendations have better outcomes than those that follow the guidelines less well.5–7 In addition, one of the major delays in patients receiving rapid reperfusion is the delay in the patient seeking care and arrival at the emergency department.8 The National Heart, Lung, and Blood Institute, the AHA, and others have initiated a number of programs to attempt to improve public awareness of this problem and to reduce the time between symptom onset and hospital arrival. Despite these programs, little progress has been made.9 The European Society of Cardiology has identified the need for the establishment of networks for reperfusion at regional and national levels with the ready availability of primary percutaneous coronary intervention (PCI) and adequate quality control.10 Although there are some differences in the delivery of STEMI care between the United States and Europe, both locations are characterized by wide variability in care that would be improved by a more effective and uniform system of care