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type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/advagg_css\/css__ce2QY63WIanKyr8eSq7eavr1XQRRmFD6ZSmwpyJi8lM__zXwFqpqmxrZOXXcd_TpBQpjuELbmIP9wBR5UuTDWAO4__YJWWMMdfCJuAFm5cUEp88OsodhO3ZA-2lzRfoBsSlk4.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\n            \u003Cp id=\u0022p-1\u0022\u003ETiming has long been recognized as the most crucial aspect in the care of people with ST-segment elevation myocardial infarction (STEMI). A session on state-of-the-art STEMI care provided an opportunity to discuss the influence of ischemia time and explore ways to improve treatment quality with organized systems of care.\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003ECerebrovascular Disease\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EMyocardial Infarction\u003C\/li\u003E\u003C\/ul\u003E\u003Cp id=\u0022p-2\u0022\u003ETiming has long been recognized as the most crucial aspect in the care of people with ST-segment elevation myocardial infarction (STEMI). A session on state-of-the-art STEMI care provided an opportunity to discuss the influence of ischemia time and explore ways to improve treatment quality with organized systems of care.\u003C\/p\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-1\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EEffect of Time on Ischemia\u003C\/h2\u003E\n         \u003Cp id=\u0022p-3\u0022\u003EStudies suggest that delays to reperfusion increase infarct size and reduce myocardial salvage in patients with STEMI [Francone M. \u003Cem\u003EJ Am Coll Cardiol\u003C\/em\u003E 2009]. However, data are conflicting about the significance of onset-to-balloon time, with one study showing a significant association between the development of a transmural infarct but not infarct size [Hahn JY. \u003Cem\u003EAm J Cardiol\u003C\/em\u003E 2008] and another indicating that salvaged myocardium is markedly reduced when reperfusion occurs more than 90 minutes after coronary occlusion [Francone M. \u003Cem\u003EJ Am Coll Cardiol\u003C\/em\u003E 2009].\u003C\/p\u003E\n         \u003Cp id=\u0022p-4\u0022\u003EThe first 2 to 3 hours after symptom onset are most important, said Holger Thiele, MD, University of Leipzig Heart Center, Leipzig, Germany, who led a panel discussion on optimal cutoff time for treatment of ischemic events. All panelists agreed that assessing ischemia time is challenged by the subjectivity of patient recall and reporting.\u003C\/p\u003E\n         \u003Cp id=\u0022p-5\u0022\u003EChristopher Granger, MD, Duke Clinical Research Institute, Durham, North Carolina, USA, also discussed the timing of primary percutaneous coronary intervention (PCI). The American College of Cardiology\/American Heart Association (ACC\/AHA) guidelines recommend primary PCI as the preferred strategy only if it can be done within 90 minutes of first medical contact. If the time is expected to be longer than that, fibrinolytic therapy within 30 minutes of hospital presentation is the preferred perfusion method.\u003C\/p\u003E\n         \u003Cp id=\u0022p-6\u0022\u003EAccording to Dr. Granger, the most compelling data for life-saving reperfusion treatment comes from fibrinolytic therapy. \u201cHere, we know that regardless of the window of ischemia time, we can get survival benefit from reperfusion therapy within 12 hours of symptom onset,\u201d he said, adding that studies indicate a greater degree of benefit with earlier administration of fibrinolytic therapy. \u201cSurvival improves with earlier treatment, and it\u0027s not incremental\u2014the shorter the time, the better. We should be providing the fastest reperfusion therapy we can,\u201d he said, citing newer fibrinolytic agents that help improve outcomes.\u003C\/p\u003E\n         \u003Cp id=\u0022p-7\u0022\u003EIn discussing delay to PCI that is expected to be longer than the guideline-recommended time, the panel explored the question of whether it is better to give fibrinolytic therapy immediately or to transfer the patient, with some delay, to a PCI center. The panelists agreed that this continues to be an important question, with no well-defined answer. They also agreed that although the data support either a PCI-directed strategy when available in a timely fashion or a fibrinolytic strategy when PCI is not available instead of a routine facilitated PCI strategy, what the patient receives before PCI is a key unanswered question.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-2\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003ESystems of Care\u003C\/h2\u003E\n         \u003Cp id=\u0022p-8\u0022\u003EComprehensive systems of care are critical for improving the time-to-reperfusion therapy for patients with STEMI. Programs, such as the ACTION Registry-Get with the Guidelines (GWTG) and the AHA\u0027s Mission: Lifeline, have started to close the gap between ideal and actual time. Several studies have found significant improvements in door-to-balloon times when comprehensive systems of care are in place (\u003Ca id=\u0022xref-fig-1-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F1\u0022\u003EFigure 1\u003C\/a\u003E). Door-to-balloon times that are associated with transfers to PCI-capable facilities have also decreased, but the rates of ideal timing are far lower than in cases when no transfer is necessary. System delays have a definite influence on outcomes; long delays in transporting patients to a PCI-capable facility are associated with higher 7-year mortality.\u003C\/p\u003E\n         \u003Cdiv id=\u0022F1\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/11\/3\/30\/F1.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022STEMI DTB Times.\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-1369174835\u0022 data-figure-caption=\u0022STEMI DTB Times.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 1.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/11\/3\/30\/F1.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/11\/3\/30\/F1.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 1.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/11\/3\/30\/F1.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/12267\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption attrib\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 1.\u003C\/span\u003E \n               \u003Cp id=\u0022p-9\u0022 class=\u0022first-child\u0022\u003ESTEMI DTB Times.\u003C\/p\u003E\n            \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-1\u0022\u003EDTB=door-to-balloon time. Reproduced with permission from C. Granger, MD.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n         \u003Cp id=\u0022p-10\u0022\u003EDespite the success of better times to reperfusion, no study has yet to show improvements in mortality, said Alice K. Jacobs, MD, Boston University Medical Center, Boston, Massachusetts, USA. \u201cThis is the challenge,\u201d she noted.\u003C\/p\u003E\n         \u003Cp id=\u0022p-11\u0022\u003EIn addition to the need to improve the timing of transfers, prehospital diagnosis of STEMI also has to be better than it is. Studies in both urban and rural settings show that a prehospital diagnosis of STEMI with direct admission to a PCI center saves time and improves outcomes. A recent report from Denmark showed that prehospital electrocardiographic (ECG) diagnosis and direct referral for primary PCI enables STEMI patients who live far from a PCI center to achieve a system delay comparable with that of patients who live in close proximity to a PCI center [Sorenson JT et al. \u003Cem\u003EEur Heart J\u003C\/em\u003E 2011].\u003C\/p\u003E\n         \u003Cp id=\u0022p-12\u0022\u003EAlthough many studies have shown that transmitting ECG readings is not essential for improving timing, James McCarthy, MD, Memorial Hermann\u2013Texas Medical Center Hospital, Houston, Texas, USA, said that the prehospital ECG is an essential piece of the puzzle. Methods of transmitting ECG readings to hospitals are improving, and medical centers can enhance their systems of care by providing multiple means of communication, such as through cell phones and dedicated receivers. Dr. McCarthy noted that \u201cEmergency medical personnel need to know that the ECG is the first thing to do; the history can be taken later.\u201d Prehospital activation can save 15 minutes; yet, ECG is not done in the field in many parts of the country, and even when it is, there are tremendous disparities in who receives it, he said.\u003C\/p\u003E\n         \u003Cp id=\u0022p-13\u0022\u003EOther integral components of an efficient system of care include established medical and transport protocols and simplified handoff sheets for emergency medical personnel and transferring facilities. A recent study of air transfer found that the need for the transport team to initiate vasopressor therapy was the most frequently cited reason for delay in liftoff to the receiving facility (\u003Ca id=\u0022xref-fig-2-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F2\u0022\u003EFigure 2\u003C\/a\u003E) [McGrath CP et al. \u003Cem\u003EAir Med J\u003C\/em\u003E 2010]. \u201cDrips are the Achilles heel of transfers,\u201d Dr. McCarthy said, explaining that the types of pumps that are used to administer vasopressors differ between units, making it necessary to discontinue the drip and reload the drug. He said that the reported average time to do this is 18 minutes.\u003C\/p\u003E\n         \u003Cdiv id=\u0022F2\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/11\/3\/30\/F2.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Analysis of Transfer Delays.\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-1369174835\u0022 data-figure-caption=\u0022Analysis of Transfer Delays.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 2.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/11\/3\/30\/F2.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/11\/3\/30\/F2.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 2.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/11\/3\/30\/F2.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/12268\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption attrib\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 2.\u003C\/span\u003E \n               \u003Cp id=\u0022p-14\u0022 class=\u0022first-child\u0022\u003EAnalysis of Transfer Delays.\u003C\/p\u003E\n            \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-2\u0022\u003EReprinted from \u003Cem\u003EAir Med J.\u003C\/em\u003E McGrath CP et al. March-April 2010;29(2):84\u201387. With Permission from Elsevier.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n         \u003Cp id=\u0022p-15\u0022\u003EDr. Granger strongly encouraged attendees to use the ACTION Registry-GTWG and AHA tools to benchmark their performance. \u201cIf you don\u0027t measure it, you can\u0027t improve it,\u201d he said. He also said that hospitals should ensure that all staff members know the record of times and that these figures are reported to other hospitals and emergency medical services. Educating emergency medical personnel about why early diagnosis of STEMI is essential can help them become more engaged in identifying ways to improve timing.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2011 MD Conference Express\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/11\/3\/30.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_figures.js?nzn3mq\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzn3mq\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}