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STEMI networks

STEMI reperfusion – an unmet need in many regions

Current guidelines recommend primary percutaneous coronary intervention (PPCI) if PPCI can be performed within 120 minutes of STEMI diagnosis.1,2 If the time from diagnosis to PPCI is expected to exceed 120 minutes, a pharmaco-invasive approach is preferred.1,2

However, there are many barriers to achieving timely PPCI; including geographical barriers (i.e. remote/rural location)/lack of PCI-capable centres3, pre-hospital and system delays (patient-related, EMS-related time delays)4,5, and competition between hospitals / for-profit centres (also known as investor-owned centres).6

STEMI networks improve outcomes

The aim of a STEMI network is to ensure early recognition of STEMI, shorten time delays to treatment, and optimise outcomes.7

STEMI networks foster strong communication among medical professionals involved in the treatment of STEMI and facilitate pre-hospital diagnosis and thrombolysis or referral to a PCI-capable facility within guideline-specific timeframes.8

STEMI networks:

  • Lead to reduced time to reperfusion, increased reperfusion rates and decreased in-hospital mortality9
  • Facilitate pre-hospital diagnosis and thrombolysis or referral to a PCI-capable facility within guideline-specific timeframes10
  • Significantly improve clinical outcomes, improve care process and reduce healthcare disparities11

Network organisation recommendations from the ACC/AHA2 and ESC3

  1. Single emergency telephone number
  2. Protocols for standardised care (diagnosis, therapy, transfer)
  3. Optimal pre-hospital care (ambulances equipped with ECGs and defibrillators, correct/prompt diagnosis, pre-activation of the cath lab, early initiation of thrombolysis if timely PPCI is not possible)
  4. Bypass non-PPCI capable hospitals to increase proportion of patients receiving timely PPCI
  5. Cardiology/intensive care specialist as network leader
  6. Involve healthcare authorities
  7. Continual quality improvement with prospective registries and regular meetings of involved parties

STEMI network organisation

STEMI networks are diversely organised, and can be country-wide, regional, or city-based.

STEMI network components are as follows:12

  1. Emergency Medical services (EMS)
    a. Franco-German model where physicians are present both in ambulances and hospital
    b. Anglo-American model Ambulances staffed with paramedics/emergency medical technician, supported via telemedicine/remote physician
  2. Non-PCI-capable hospitals
  3. Hospitals with PCI facilities
STEMI network organisation

STEMI care is best performed within an organised network with a PCI-capable hospital (the hub) receiving referrals from surrounding hospitals (the spokes), and a defined catchment area from the field via emergency medical services.1

European STEMI networks: two models

Vienna STEMI network7,13

  • Central triage system started in 2003, organised by Vienna Ambulance System
  • 24/7 access to cath lab facilities with experienced interventionalists
  • Guaranteed through rotational system between tertiary centres: all centres available during the day and only two centres at night
  • Fibrinolysis is a part of reperfusion strategy when patient transfer is delayed >90 mins
  • Since initiation, the number of patients receiving timely PPCI has increased and the numbers receiving fibrinolysis have decreased (now only ∼3% of patients); marked decline in numbers receiving no reperfusion therapy

French Service d’Aide Médicale Urgente (SAMU) system13

  • Nationwide system implemented in 1995 and monitored by FAST-MI STEMI registry
  • One SAMU medical response centre for each department, responsible for mobile intensive care unit (MICU) dispatch (1 physician, 1 nurse and a driver, trained emergency medical technician) provide basic/advanced life support on-site and/or during transfer)
  • MICU alerts medical centre ahead of arrival about medical status of the patient to allow direct admission and avoid treatment delay
  • Implementation has improved outcomes, and increased reperfusion, mainly due to increased PPCI
  • When PPCI is not possible, a pharmaco-invasive strategy is implemented

STEMI networks around the world

India, China, Russia
Only few STEMI networks in accordance with International guidelines REVERSE-STEMI trial: in Shanghai physicians travel to outlying catheter laboratories instead of transporting patients
Australia
Well-organised STEMI networks in urban areas however long transfer times in rural areas
Middle East
Wide disparity in STEMI care owing to geographical diversity
Latin America
In Salvador, Bahia, Brazil, a regional STEMI alert team receives ECG from telemedicine centre and advises EMS to start pharmaco-invasive treatment or immediate transfer for PPCI
South Africa
Limited number of centres with PPCI facilities and long transfer times

 

Huber K et al. Eur Heat J 2014;35:1526-1532.

Future directions to improve STEMI management

  • Education campaign7
  • Community organisation7
  • Unique European-wide emergency telephone number1,7
  • Automated external defibrillators (AEDs) in public places7
  • Standardised written STEMI management protocols7
  • Ambulances (vehicles, helicopters, planes) equipped with defibrillators, 17-lead ECG, trained professionals capable of basic and advanced life support or initiation of FT in case of delays1,7
  • ECG transmission/teleconsultation1,7,13
  • Single number to activate catheterisation laboratory7,13
  • Experienced cardiologist or intensive care specialist to lead the network7
  • 24/7 accessible tertiary care centres1,7
  • Increased use of radial access in STEMI patients referred for PPCI to reduce bleeding complications1,7

Additional resources: ESC symposia videos on STEMI networks

Welsh, Robert
Robert Welsh

Virtual symposium from ESC 2017

Clinical importance of a STEMI network and integrated pharmacoinvasive reperfusion strategy
Goldstein, Patrick and team
Patrick Goldstein

Virtual symposium from ESC 2017

STEMI and stroke networks: Experiences from the North of France
Surya Dharma
Surya Dharma

Virtual symposium from ESC 2019

STEMI networks in practice: Comparison of real-life regional systems of care
Optimising STEMI networks in countries with limited timely access to PCI:
Miodrag Ostojic

Virtual symposium from ESC 2018

STEMI guideline update: The situation in Serbia
Optimising STEMI networks in countries with limited timely access to PCI:
Antonio Carvalho

Virtual symposium from ESC 2018

Optimising STEMI networks in countries with limited timely access to PCI: The situation in Brazil
Optimising STEMI networks in countries with limited timely access to PCI:
John French

Virtual symposium from ESC 2018

STEMI guideline updates: Where are we now? The situation in Australia

Additional resources: STEMI networks slide kit

The STEMI networks slide kit aims to establish an evidence-based, streamlined guidance on the purpose and practicality of establishing and running a STEMI network. It empowers HCPs with international guideline-based information to assist them in the process of setting up, organising, and participating in a regional STEMI network, in order to achieve optimal patient outcomes, and provides evidence from existing STEMI networks on protocols, challenges, solutions and outcomes.

References: 

  1. Ibanez B, James S, Agewall S, et al. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J. 2018;39(2):119-177. doi:10.1093/eurheartj/ehx393

  2. O’Gara, O’Gara PT, Kushner FG, et al. 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2013;127(4). doi:10.1161/CIR.0b013e3182742cf6

  3. Kamona A, Cunningham S, Addison B, et al. Comparing ST-segment elevation myocardial infarction care between patients residing in central and remote locations: a retrospective case series. Rural Remote Health. Published online October 27, 2018. doi:10.22605/RRH4618

  4. Armstrong PW, Boden WE. Reperfusion Paradox in ST-Segment Elevation Myocardial Infarction. Ann Intern Med. 2011;155(6):389. doi:10.7326/0003-4819-155-6-201109200-00008

  5. Stassen W, Wallis L, Vincent-Lambert C, Castren M, Kurland L. The proportion of South Africans living within 60 and 120 minutes of a percutaneous coronary intervention facility. Cardiovasc J Afr. 2018;29(1):6-11. doi:10.5830/CVJA-2018-004

  6. Jollis JG, Al-Khalidi HR, Roettig ML, et al. Regional Systems of Care Demonstration Project: American Heart Association Mission: Lifeline STEMI Systems Accelerator. Circulation. 2016;134(5):365-374. doi:10.1161/CIRCULATIONAHA.115.019474

  7. Huber K, Gersh BJ, Goldstein P, Granger CB, Armstrong PW. The organization, function, and outcomes of ST-elevation myocardial infarction networks worldwide: current state, unmet needs and future directions. Eur Heart J. 2014;35(23):1526-1532. doi:10.1093/eurheartj/ehu125

  8. Sørensen JT, Mæng M. Regional systems-of-care for primary percutaneous coronary intervention in ST-elevation myocardial infarction: Coron Artery Dis. 2015;26(8):713-722. doi:10.1097/MCA.0000000000000290

  9. Filgueiras Filho NM, Feitosa Filho GS, Solla DJF, et al. Implementation of a Regional Network for ST‐Segment–Elevation Myocardial Infarction (STEMI) Care and 30‐Day Mortality in a Low‐ to Middle‐Income City in Brazil: Findings From Salvador’s STEMI Registry (RESISST). J Am Heart Assoc. 2018;7(14). doi:10.1161/JAHA.118.008624

  10. Kalla K, Christ G, Karnik R, et al. Implementation of Guidelines Improves the Standard of Care: The Viennese Registry on Reperfusion Strategies in ST-Elevation Myocardial Infarction (Vienna STEMI Registry). Circulation. 2006;113(20):2398-2405. doi:10.1161/CIRCULATIONAHA.105.586198

  11. Granger CB, Bates ER, Jollis JG, et al. Improving Care of STEMI in the United States 2008 to 2012: A Report From the American Heart Association Mission: Lifeline Program. J Am Heart Assoc. 2019;8(1). doi:10.1161/JAHA.118.008096

  12. Tubaro M, Danchin N, Goldstein P, et al. Pre-hospital treatment of STEMI patients. A scientific statement of the Working Group Acute Cardiac Care of the European Society of Cardiology: Acute Coronary Syndromes. Acute Card Care. 2011;13(2):56-67. doi:10.3109/17482941.2011.581292

  13. Danchin N. Systems of Care for ST-Segment Elevation Myocardial Infarction. JACC Cardiovasc Interv. 2009;2(10):901-908. doi:10.1016/j.jcin.2009.05.025