Two outstanding STEMI experiences are highlighted in the present issue of Cath Lab Digest. They have been submitted from hospitals in Ohio and California, and both demonstrate superb STEMI processes in action. Both institutions deserve praise for their robust efforts in mastering the process of STEMI intervention. As a result of their meticulous teamwork, the challenge of achieving consistent door-to-balloon (D2B) times of < 90 minutes, both on- and off-hours, was easily surpassed at both institutions. Readers can pick up valuable tips from their experience. Several of these have been previously highlighted in various STEMI sections of Cath Lab Digest — the publication that continues to lead the way in its mission to educate cardiovascular professionals about short D2B STEMI interventions.

In addition to referring the reader to the August issue of Cath Lab Digest that discusses both the STEMI process and the STEMI procedure in The Essence of STEMI Interventions, I would like to highlight numerous outstanding features from the two STEMI experiences reviewed in the present issue of Cath Lab Digest.1–3

1. Both institutions note the critical importance of “physician champions”, either the interventional cardiologist or the emergency department (ED) physician, often both acting in conjunction and leading the team on with establishing superb STEMI programs.

2. In the case of Northridge Hospital in California, the physician champion, Dr. Ivan Rokos, is a famed ED physician who is an internationally-recognized pioneer in the field of STEMI interventions.4,5

3. Readers will note that Dr. Rokos is an ED physician and that Dr. Zirafi is a cardiologist, hence, individual STEMI “physician champions” at their respective institutions. The emergence of physician champions from ED and interventional cardiology highlights the multidisciplinary teamwork that is critical for performing STEMI interventions.

4. Several physician champions (Dr. James Hoekstra from RACE, Dr. David Larson from Abbott Northwestern, and Dr. Fred Keroff from Memorial Hospital in Hollywood, Florida) are ED physicians who are world experts in STEMI interventions, and their prominence at national cardiology meetings is a testimony to the cohesion between emergency medical services (EMS), EDs and cardiovascular laboratories that leads to strong STEMI programs.

5. Northridge Hospital Medical Center has forged ahead in modeling its STEMI program after the National Trauma Center. In my Textbook of STEMI Interventions, I highlight the critical need for a national STEMI policy akin to the National Trauma Services that were established through an act of Congress. It is a national STEMI policy that will eliminate disparate treatment that STEMI patients receive at small hospitals that do not have STEMI availability or definite transfer policies versus the care at tertiary centers that provide 24/7 STEMI care. Legislation will also force the adoption of strict bypass policies by EMS and rapid triage to appropriate STEMI receiving centers. In this regard, it appears that the California Department of Health Services is paving the way for the adoption of a national STEMI policy.1,6,7

6. An outstanding achievement at Northridge Hospital Medical Center is the advocacy provided by the STEMI team to the EMS staff — to the technicians and to the students. Continuous education of the EMT is critical, as a skilled EMT can greatly contribute to the STEMI process. In various parts of Europe and in Canada, the EMTs perform numerous critical functions that greatly increase the STEMI process and enable the performance of short D2B interventions. One of the most remarkable population-based STEMI programs exists in Ottawa, Canada, where the “advanced paramedics” perform critical prehospital diagnoses of STEMI (electrocardiogram [ECG] interpretation concordant with cardiologists) and vital STEMI management en route to the PCI center.8

7. In this context, the limitations imposed on the STEMI intervention as a result of patient self-transport to the hospital, have been appropriately highlighted. The majority of patients suffering a heart attack self-transport to the ED in the United States. Compared to this, in Denmark, 99% of the patients are transported by EMS! Besides appropriate triage to a STEMI receiving center, the advanced paramedics sensibly incorporate telemedicine to correctly interpret the STEMI ECG, and activate the STEMI process.9

8. I attribute the excellent success at both institutions to the prehospital activation of the STEMI alert by EMS — this notable feature and its importance in achieving short D2B times is the single biggest lesson that other institutions could take from this superb work.

9. In permitting EMS to advise ED, and the ED in turn superseding the CVL, there is a perfect backward integration of the STEMI process. Through this efficient mechanism, autonomy is passed backward to the first responder. As discussed in the article, Essence of STEMI Intervention, the interventional cardiologist must accept this challenge to his autonomy in the larger interest of STEMI teamwork. Nevertheless, the interventional cardiologist remains the vital link, as he or she must perform the most critical, last-phase function of the STEMI procedure and perform a high-quality and timely STEMI intervention.1,2

10. The Touch-and-Go STEMI maneuver practiced by the STEMI team at Parma Community General Hospital is a smart and pragmatic strategy to shave off vital STEMI minutes from the D2B times.

11. Both institutions recognize the need to maintain low rates of “false alarms”. These occurrences can exhaust the entire STEMI system at any institution. Furthermore, they needlessly subject patients to unnecessary invasive procedures. Institutions should meticulously monitor their false-alarm rates, review them periodically and use them as a critical STEMI core measure of quality.1

12. Finally, great emphasis had been placed on the value of feedback to the EMS and ED – the value of real-time feedback of the STEMI intervention has been highlighted in numerous studies and its importance cannot be overstated.10,11

Dr. Sameer Mehta can be contacted at mehtas@bellsouth.net