ABSTRACT
Tremendous progress has been made over the past decade in the field of primary percutaneous coronary intervention (PPCI). It is estimated from data derived from clinical trials that compared to fibrinolytics, mechanical reperfusion with PPCI reduces mortality by 25%, as well markedly decreasing the rate of recurrent infarction, intracranial hemorrhage, and stroke (1). The superior outcomes are to a large extent attributable to the advances in adjunctive interventional techniques and pharmacological therapy that have made it possible to achieve normal epicardial flow in as many as 90% to 95% of patients with ST elevation myocardial infarction (STEMI) as compared to 40% to 60% after fibrinolytics (2). These benefits have resulted in PPCI becoming the preferred strategy for reperfusion in the United States and many countries in Europe (3). Despite these advances, a significant proportion of patients still experience adverse outcomes highlighting the need for further improvements in treatment strategies (1). An important step in this direction is to maximize the delivery of evidence-based practice to as many, if not all patients with STEMI, recognizing that approximately one-third of patients around the world do not receive any form of reperfusion therapy (4,5). Second, there remains the need to develop novel adjunctive cardioprotective treatment in order to improve myocardial salvage (6). Third, it is essential to reduce treatment delays by adhering to the national guidelines that in the United States recommend a first medical contact-to-balloon time of ≤90 minutes (3), and in Europe a first medical contact-to-balloon time of ≤120 minutes (7). It is recognized that the benefits of PPCI over fibrinolytics are lost if there is excessive incremental delay in getting a patient to a cardiac catheterization laboratory compared to the time when fibrinolytics could have been administered. A widely quoted estimate for this incremental delay is >60 minutes (8), however, another analysis reported that the mortality benefit of PPCI may persist with incremental delays of up to 120 minutes (9). Given the importance of time to treatment and the shift toward PPCI as the preferred reperfusion strategy, it has become important for health care organizations to restructure with the goal of developing integrated systems of care for STEMI that provide greater access to timely, high-quality catheterbased reperfusion and other evidence-based therapy (10).
