Bypassing the emergency department to improve the process of care for ST-elevation myocardial infarction: necessary but not sufficient.

T he past several decades have been marked by dramatic advances in the management of patients with an acute decompensation of ischemic heart disease. A now common phrase in our clinical lexicon is acute coronary syndrome, which is further subdivided into presentations with and without ST-segment elevation on the ECG, thus dividing acute coronary syndrome presentations into ST-segment elevation myocardial infarction (STEMI) and unstable angina/ non–ST-segment myocardial infarction (MI). 1 Given the time urgency of restoring antegrade flow in the culprit coronary artery in STEMI, it is understandable that a major focus of clinical research has been defining the optimal reperfusion regimen, first with fibrinolysis and later with catheter-based interventions. In 2006, an American Heart Association (AHA) Consensus Statement was published outlining the fact that, at the time, only a minority of patients with STEMI in the United States received primary percutaneous coronary intervention (PCI) and, in those who did, <40% were treated within 90 minutes after hospital arrival. 2 The AHA convened an acute MI Advisory Working Group that agreed that the next step in the process after the initial consensus statement was to develop an implementation plan to establish a system of care to increase the number of patients with STEMI who received timely access to primary PCI. Within a year, a conference was held with representation from all the key stakeholders, the success of early model STEMI systems was reviewed, and the AHA launched Mission:Lifeline, an initiative to improve the quality of care and outcomes for patients with STEMI and to improve the healthcare system readiness and response to STEMI. 3 Several remarkable achievements of Mission:Lifeline over the past 6 years are worth noting. A robust Website exists that is the central clearing house to learn more about Mission:Lifeline, get the latest news on hot topics, access tools and resources, and register/locate a system of care for STEMI. 4 As of June 2013, a total of 680 STEMI systems were registered across the United States, covering 67% of our nation's population. In an earlier report published in 2012, when 381 unique systems involving 899 PCI hospitals from 47 states responded to a survey via the Mission:Lifeline Website, the organizational characteristics of the collaborative efforts to provide timely reperfusion for STEMI in the United States were summarized. 5 Of note, at the time, 55% of systems reported the availability of 12-lead ECGs in their emergency medical system (EMS) …