The American Heart Association is leading a major national effort to improve and expedite treatment for ST-segment elevation myocardial infarction. With the logo Mission: Lifeline, reminiscent of TV's “Mission: Impossible,” the AHA, in collaboration with other organizations, is developing criteria and certification for members of the STEMI “treatment train,” from emergency medical services through referring hospitals to the hospital that can perform emergency percutaneous coronary intervention 24/7.
To reach the goals of fibrinolytic therapy in less than 30 minutes and PCI therapy within 90 minutes for STEMI, the nation's EMS and hospital referral system must improve. There are excellent community systems that can serve as models, but creating a uniform system is a challenge, given the wide variety of players.
Unlike the European systems, uniform in their configuration and, for the most part, federally funded and very successful at expediting care for STEMI, the U.S. system is a helter-skelter of private and voluntary players, bent on preserving their own priorities. Only 6% of American EMS systems are hospital based. The rest are provided by fire departments, volunteers, and private operators. State governments control EMS operations, which are certified for different levels of care and are variably equipped to deal with cardiac emergencies. Americans use EMS systems in less than 25% of instances to obtain emergency care for STEMI. In spite of extensive public education, Americans do not understand the need for rapid response to chest pain symptoms.
“Although the performance of primary PCI has increased from 18% to 53%” nearly 30% of patients with STEMI fail to receive either fibrinolytic therapy or PCI, said Dr. Alice Jacobs, former president of the AHA, who is leading the Mission: Lifeline effort (Circulation 2007;116:689–92). Most STEMI patients seek medical help at hospitals that are not equipped to perform primary PCI. To expand the number of PCI-approved hospitals, the requirement to have on-site cardiac surgery in such hospitals will have to be dropped. Rapid transfer to PCI hospitals can be achieved if systems are in place to expedite patient transfer or to initiate fibrinolytic therapy when primary PCI is neither feasible nor appropriate. Non-PCI hospitals within the Mission: Lifeline network would be certified as “STEMI referral hospitals” and would create pathways that expedite transfer to “STEMI receiving hospitals.” Most importantly, competency and numerical criteria have been developed for certification as a “STEMI receiving hospital.”
Mission: Lifeline registration of EMS and referring and receiving hospitals is underway. Certification of sites that meet the published criteria is soon to start. Many communities and hospital systems have the infrastructure in place, but urban and rural systems are up against major logistical and political barriers. The AHA is to be applauded for rising to the challenge of the improvement of emergency cardiac care for STEMI. But achieving the goals of Mission: Lifeline nationwide might actually be a “Mission: Impossible.”
For more information, visit www.americanheart.org/missionlifeline