Close, but not close enough

The most recent European Society of Cardiology (ESC) guidelines recommend primary percutaneous coronary intervention (PCI) as the preferred treatment for ST-segment elevation myocardial infarction (STEMI) whenever it is available within 90–120 min of the first medical contact [1]. However, timing of symptom onset appears to be hard to adjudicate precisely, and 'ischaemic time' thereby usually exceeds 3 h, the exact threshold after which infarct size starts to increase and long-term survival significantly starts to decline [2]. Fragmenting the different intervals of ischaemic time in the present study is therefore interesting when assessing how and where there is still room for improvement. Let us analyse the intervals in a time-dependent fashion. First, symptom onset to diagnosis. As mentioned, precise determination of symptom onset is challenging and Postma et al. demonstrate that the interquartile range suggests times varying between 30 min and 4 to 5 h, reflecting daily clinical practice in which patients do not always directly recognise alarm symptoms and call for medical contact [3]. What is more interesting, however, is the significant difference between time of symptom onset and diagnosis, which is roughly 30 min shorter in patients picked up by ambulances with field triage capabilities versus those referred first to hospitals without primary PCI facilities (spoke hospitals). Again it is precisely this 30-minute delay that proved to result in an 8 % relative increase in 1-year mortality in STEMI patients [4]. Second, diagnosis-to-door PCI, the item in which distance to, reachability and density of PCI facilities comes into play. In Europe, first medical contact-to-balloon time ranges between 60 and 177 min, irrespective of whether the patient underwent interhospital transfer or not (approximately 50 % in Europe). In the Netherlands there is at present, with 30 facilities , a relatively close density of primary PCI centres (roughly 1/560,000 inhabitants). In European countries offering primary PCI to the majority of their STEMI patients, this population varies between 0.3 and 1.1 million per centre [5]. The density of centres offering specific and in this case complex and high-risk procedures has been the topic of debate in both the medical literature and lay press. In general, a high-volume load for operators and institutions is associated with better outcomes [6]. More specifically for primary PCI, while patients treated in high-volume centres still tend to have shorter door-to-balloon times, there is conflicting evidence on the existence of better survival rates in patients treated in high-versus …