Given the massive time, effort, and resources that went into the 18-month Mission: Lifeline research, W. Frank Peacock, IV, MD, is not so sure it is the right approach toward improving STEMI care. “They got a 5% average improvement in [time to] treatment. To me, that is a huge amount of effort for not much benefit,” he says. “You have to wonder if we have to do something differently than this.”
It should be noted that while the average improvement in the STEMI study was 5%, five of the 16 regions that participated improved by 12%, and the top performing region treated 76% of STEMI patients within guideline goals by the end of the project.
Nonetheless, Peacock argues that from a public health standpoint, it is symptom onset, not first medical contact, that should trigger STEMI care. However, the average STEMI patient typically arrives at the hospital two or three hours after their chest pain starts. “We are past the important window at this point,” he says. “We have tried to do huge patient education efforts, but that number hasn’t changed much.”
Peacock also notes that while the concept of beginning to measure time-to-treatment for STEMI patients at first medical contact has been around for a long time, hospitals simply do not want to adopt this measure because they cannot control the prehospital period. “They don’t control the ambulance. It is a separate company,” he says. “If EMS takes the patient to the wrong hospital, they can’t control that. And if a hospital takes too long to transfer a patient, the receiving hospital can’t control that.”
Peacock suggests a more cost-effective approach toward improving the care of STEMI patients would involve giving thrombolytic agents to appropriate patients who do not have quick access to catheterization labs. “If I have an MI [myocardial infarction] I want to be cathed, there is no question about it. But if I am back-packing in Montana and I have my MI, I am not going to get cathed [quickly]. It just isn’t going to happen, so I would like to have a thrombolytic,” he explains.
Patients who receive thrombolytic agents still need to be transferred to a hospital that can perform catheterization or percutaneous coronary intervention (PCI), but if they get reperfusion — or blood flow restored to the heart — from the thrombolytic agent, it is no longer an emergency, Peacock observes. “You can cath them in the morning,” he says. “You don’t need to go lights and sirens or get a helicopter. So the risks and benefits and costs and consequences change if you can get patients reperfused in some other fashion.”
Peacock acknowledges that not all patients with STEMIs are appropriate candidates for thrombolytic drugs. The age of the patient, the location of the MI, and other factors have to be considered before thrombolytics are prescribed, but Peacock maintains that this approach likely would boost outcomes for more patients and at far less cost and effort than the push for regionalization exemplified in the Mission: Lifeline program.
“What we are trying to do is get everyone catheterized, but at some point we have to say, ‘We have 1,253 EMS services, 484 hospitals, and thousands of doctors [involved in the Mission: Lifeline STEMI Systems Accelerator project] — and we are only making it 5% better,’” Peacock says. “We need to do something else in some patients.”
- W. Frank Peacock, IV, MD, FACEP, FACC, Professor of Emergency Medicine, Associate Chair and Research Director, Baylor College of Medicine, Houston. Email: firstname.lastname@example.org.