The need for regional integrated care for ST-segment elevation myocardial infarction.

Case 1 presentation: A 57-year-old man suffered a sudden cardiac arrest at home, witnessed by his son, who called 911 and began cardiopulmonary resuscitation immediately. Emergency medical services (EMS) were activated and arrived on the scene within 10 minutes. The patient was found to be in ventricular fibrillation and was defibrillated 5 times by EMS. He was intubated in the field, and an ECG revealed inferior STsegment elevation. The Reperfusion of Acute Myocardial Infarction in North Carolina Emergency Departments protocol was initiated. He was transported across county lines, past a non–percutaneous coronary intervention (PCI) hospital, directly to a PCI facility, where the preactivated catheterization laboratory was awaiting arrival (Figure 1). On presentation, he was comatose with a pulse of 90/min, blood pressure of 90/ 70 mm Hg, and had pulmonary edema with distant heart tones. Case 2 presentation: A 76-year-old man was driven by his family to his local emergency department after having 1 day of worsening shortness of breath and 2 hours of substernal chest pain. On arrival to this non-PCI facility, he was found to be in respiratory failure, requiring mechanical ventilation, and developed cardiogenic shock. An ECG revealed anterior ST-segment elevation, and laboratory analysis revealed an initial hematocrit of 24%. Because of the distance from the closest PCI facility, he was given fibrinolytic therapy. Despite fibrinolytic therapy, there was failure of resolution of the ST-segment elevation. Approximately 6 hours later, the patient was transferred via helicopter to a PCI center for immediate coronary angiography and rescue PCI.