Elsevier

American Heart Journal

Volume 155, Issue 6, June 2008, Pages 1054-1058
American Heart Journal

Clinical Investigation
Interventional Cardiology
Direct ambulance admission to the cardiac catheterization laboratory significantly reduces door-to-balloon times in primary percutaneous coronary intervention

https://doi.org/10.1016/j.ahj.2008.01.014Get rights and content

Background

Primary percutaneous coronary intervention (PCI) is the preferred treatment for ST-segment elevation myocardial infarction (STEMI) provided it can be delivered within 90 minutes of hospital admission. In clinical practice this target is difficult to achieve. We aimed to determine the effect of direct ambulance admission to the cardiac catheterization laboratory on door-to-balloon and call-to-balloon times in primary PCI.

Methods

We performed a prospective evaluation of a new system of paramedic electrocardiogram diagnosis of STEMI and subsequent direct ambulance admission to the cardiac catheterization laboratory for primary PCI. Door-to-balloon and call-to-balloon times were recorded for all patients. Direct admissions were compared with admissions via the emergency room of the interventional center and of 2 referring hospitals. All times are quoted as medians.

Results

Five hundred and seventy-seven patients (70% male, age 63 ± 13 years) underwent primary PCI between April 2005 and May 2007. After February 2006, 172 (44%) of 387 patients were admitted directly from the ambulance to the catheterization laboratory. Directly admitted patients had significantly reduced door-to-balloon (58 vs 105 minutes, P < .001) and call-to-balloon times (105 vs 143 minutes, P < .001). The 90-minute target for door-to-balloon time was achieved in 94% of direct admissions compared to 29% of patients referred from the emergency room.

Conclusions

Direct admission of patients with suspected STEMI from the ambulance service to the catheterization laboratory significantly reduces time to treatment in primary PCI and allows the 90-minute door-to-balloon time target to be reliably achieved.

Section snippets

Setting

From April 2005, a 24/7 primary PCI service was established in a single large tertiary care interventional center with 6 catheterization laboratories and 7 interventional cardiologists, serving an urban population of 1.25 million across an established regional network including surrounding peripheral hospitals. Initially, all patients (ambulance admissions and self-presenters) were referred for primary PCI after presentation to the emergency room (ER) of either the PCI center or 2 referring

Results

Between April 1, 2005, and April 30, 2007, 622 cases of primary PCI were performed at our institution. Twenty-one cases were excluded from the analysis because their first ECG was nondiagnostic and ST-elevation occurred at a later stage making analysis of door-to-balloon and call-to balloon times inappropriate. Another 24 patients were excluded because they were referred from extrinsic sources (other referring hospital, STEMI as in-patient, peri-operative STEMI). The remaining 577 patients (63

Discussion

The principal finding of this study is that prehospital paramedic ECG diagnosis of STEMI and subsequent direct ambulance admission to the cardiac catheterization laboratory substantially reduce time to treatment in primary PCI, enabling almost all patients to be treated within the 90-minute target door-to-balloon time.

A number of investigators have demonstrated that prehospital ECG diagnosis reduces time-to-thrombolysis and as a result all-cause mortality in STEMI.12, 13, 14, 15, 16, 17

Conclusions

Prehospital paramedic ECG diagnosis of STEMI and subsequent direct ambulance admission to the cardiac catheterization laboratory dramatically reduces door-to-balloon times in primary PCI, enabling almost all patients to be treated within the 90-minute target. We believe this approach should be a key element of any contemporary primary PCI service.

Acknowledgements

The authors wish to thank Mandy Dudson, who helped with data input. We are also grateful to the database manager Peter Tooze, who provided excellent support throughout the project. Finally, we acknowledge the support of Chris Croden from the Yorkshire Ambulance Services.

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    This work was supported by a grant from the National Infarct Angioplasty Pilot project, Department of Health, UK.

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