A new policy statement on ST-segment-elevation myocardial infarction (STEMI) care from the American Heart Association acknowledges declining morbidity and mortality rates.1 Still, room for improvement remains. “The ED plays a central role in the STEMI system of care,” notes Alice Jacobs, MD, FACC, lead statement author and vice chair for clinical affairs in the department of medicine at Boston University Medical Center.

Jacobs and colleagues offered recommendations on how the ideal system of care for STEMI patients should be designed and implemented. “The overall goal is to ensure that patients with STEMI receive the best evidence-based care at each stage in their illness,” Jacobs says.

Although the policy focuses on STEMI patients, similar concepts “could and should” be applied to those with other time-sensitive cardiovascular disorders, Jacobs says. EDs must be ready to facilitate direct transport to the cardiac catheterization lab. “Importantly, the ED should be represented at institutional and regional multidisciplinary quality improvement meetings,” Jacobs urges.

ED providers could contribute in specific ways, including prehospital cath lab activation, knowing when it is appropriate to bypass the ED, understanding the sequence of events for patients presenting to the ED, knowing what to do to shorten ED dwell time, and knowing what is best to do if awaiting cath lab arrival.

For EDs seeking to improve STEMI care, Jacobs offers important considerations. Specifically, at STEMI referral hospitals, ED providers should diagnose STEMI, provide guideline-directed medical therapy, and offer the planned reperfusion strategy according to guideline recommendations for time-to-reperfusion. “The ED strives to shorten door-in-to-door-out time, which has been shown to be associated with in-hospital mortality,” Jacobs says.

For STEMI receiving centers, the ED should be prepared to accept patients who are walk-ins, arrive via EMS, or arrive via interhospital transfer, always with the goal of limiting ED dwell time. “ED dwell time has been shown to be associated with in-hospital mortality,” Jacobs warns.


  1. Jacobs AK, Ali MJ, Best PJ, et al. Systems of care for ST-segment-elevation myocardial infarction: A policy statement from the American Heart Association. Circulation 2021;144:e310-e327.