STEMI Interventions: A New Section in Cath Lab Digest

Sameer Mehta, MD, FACC, MBA, is studying ST-elevation myocardial infarction interventions in his work with the Primary PCI and the Single INdividual Community Experience REgistry for Primary PCI (SINCERE) Database at 5 community hospitals in Miami, Florida. A past chief of interventional cardiology and director of the cardiovascular laboratory at Cedars Medical Center in Miami, Dr. Mehta is also president of the Indo-American Society of Interventional Cardiologists (ISIC) and a course director for the Lumen-Vascular Interventions Symposium. Dr. Mehta will be commenting on the important work going on around the world as societies and their hospitals struggle to educate patients about the importance of timely intervention in ST-elevation myocardial infarction, and work collaboratively to decrease the time from patient arrival to intervention. In this issue of Cath Lab Digest, Larry H. Brown, RN, BSN, CNOR provides a compelling portrayal of the state-of-the-art ST-elevation myocardial infarction (STEMI) interventions at St. Luke’s Episcopal Hospital in Houston, Texas. The article is succinct and the attached tables are well-constructed. St. Luke’s deserves accolades for this exemplary achievement of 100% door-to-balloon (D2B) STEMI interventions success with a mean D2B time of 75 minutes. This outstanding experience is a testimony to the scientific superiority of PCI and the immense gains that can accrue from very urgent and prudent STEMI interventions. These translate into scientific, economic, social and health benefits to individual patients and to the community. The massive prevalence of coronary artery disease makes it easy for society to palpate the dramatic results of STEMI interventions. As the experience from St. Luke’s Episcopal Hospital demonstrates, it does not take long before anecdotes of STEMI interventions translate into predictable and common pathways for effective management of acute myocardial infarction (AMI). As they work to develop their STEMI interventions programs, institutions can gain from the invaluable lessons that have been learned at St. Luke’s Episcopal Hospital. I found the following instructions particularly meaningful: 1) Early activation of the entire team by a single page initiated by the ED staff/physician; 2) Cross-training of CVL staff; 3) Standardized, written protocols; 4) STEMI committee represented by cardiology and ED personnel for peer review and CQI; 5) Strategies for rapid retrieval of PCI hardware during the procedure. In addition to the above recommendations, St. Luke’s Episcopal Hospital provides valuable insights into the role that fellows in training can play in STEMI interventions at academic institutions. Predictable success with short D2B interventions is both a matter of streamlining system and hospital processes, and the skills and availability of the interventional cardiologist. Coordinated teamwork between the three constituents of a successful STEMI program EMS, ED and CVL will determine the success of a program. The program at St. Luke’s amply demonstrates the critical need to get all these components in place and steer them with committees that are represented from these areas and that work in a spirit of collaboration, without assigning blame. The very strong emphasis on training of staff at St. Luke’s is meritorious. From my experience with the SINCERE* database, I would like to make the following additional recommendations: 1) Since STEMI interventions are determined by effective management of thrombus, it is critical for all CVL that perform STEMI interventions to be equipped with at least two choices of Aspiration Catheters; with the ThromCat device and most critically, with the Possis AngioJet device (no conflict of interest to report regarding any and all recommendations). Even more importantly, the CVL staff must be trained in these devices and be able to set up the AngioJet very rapidly. 2) Use of early activation systems that transmit EKG to the ED and to individual interventionalists. Beyond applauding the work of the STEMI committee at St Luke’s Episcopal Hospital, I want to offer a few words of caution. Although the author correctly points out the enormous differences between academic and community hospitals, I can categorically state that challenges at community hospitals are no less than those that are cited at academic institutions. I would also like to caution against any complacency regarding false alarms ACC/AHA Guidelines recommend these numbers to be below 15% and every effort should be made to maintain these numbers as exceedingly low. Beyond D2B success, few false alarms are effective measures of a successful STEMI interventions program. Finally, institutions will realize that the hallmark of success for STEMI interventions is comparable results for on and off hours. Dr. Mehta can be contacted at mehtas@bellsouth.net *The SINCERE Database currently holds 257 (enrollment is ongoing) short D2B STEMI interventions at 5 community hospitals in Miami (for more information, see the August 2007 issue of Cath Lab Digest). The STEMI Intervention section showcases best practices and pathways to improvement, whether dramatic or incremental. Cath Lab Digest encourages outstanding facilities to submit their work. For author guidelines, email Rebecca Kapur at rkapur@hmpcommunications.com.

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