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EMS strategy change gets heart patients faster care

By Genevra Pittman

NEW YORK (Reuters Health) - People with a certain type of heart attack get better care when paramedics take them directly to a medical center that can perform stent procedures - even if it's not the closest hospital, according to new research from North Carolina.

In a so-called ST-segment elevation myocardial infarction, or STEMI, blood is blocked for an extended period of time and a patient needs artery-opening surgery as quickly as possible - ideally within two hours or less.

"Keeping the time from the onset of heart attack symptoms to getting the artery open as short as possible is vital for limiting heart muscle damage and improving survival," Dr. Gregg Fonarow, a cardiologist at the David Geffen School of Medicine at UCLA, wrote in an email to Reuters Health.

Since 2008, a North Carolina statewide program has encouraged paramedics to bring people with a STEMI directly to hospitals that can perform that procedure - rather than to another facility for evaluation and transfer. About one-quarter of U.S. hospitals are equipped to do stent procedures according to Fonarow, who wasn't involved in the new research.

Dr. Emil Fosbol from The Heart Centre, University Hospital of Copenhagen in Denmark and colleagues from North Carolina medical centers analyzed data on close to 1,300 STEMI patients treated in the state in 2008 through 2010.

Just under two-thirds of those people were transported directly to a stent-ready facility, and the rest to a closer hospital that didn't do the surgeries, the research team reported in Circulation.

Among people taken directly to a stent-ready hospital, 46 percent had artery-opening surgery within 90 minutes of first being seen by paramedics, as recommended by the American Heart Association.

In comparison, less than 22 percent of those transported to a non-stenting hospital - and then transferred - had surgery within two hours. (Goal ambulance-to-surgery time is slightly longer when patients get their initial treatment and their surgery at different facilities.)

After taking patient characteristics into account, there was no difference in how likely people were to die in the hospital, based on where they were initially taken. Fosbol and his colleagues said future studies should look into other medical outcomes as well as how often the patients die after they get released from the hospital.

For now, the research team said that when "logically feasible," emergency medical services (EMS) should take STEMI patients directly to the closest stent-ready hospital.

"A lot of regionalized programs, statewide programs are trying to implement systems so you're able to do that, but it's not possible to do that in all parts of all states in the U.S.," Fosbol told Reuters Health.

In some parts of rural North Carolina, he added, patients with a STEMI are taken by helicopter to the nearest hospital that does stenting.

"Increased efforts are needed in every community to ensure that systems of care are fully in place and STEMI patients can receive the most effective and lifesaving treatment in the most timely fashion," Fonarow said.

Most importantly for STEMI patients, Fosbol added, don't try to convince EMS to take you to your favorite hospital or one where you have family nearby.

"I've heard cases of some patients wanting to go to a certain hospital… which basically is a really bad idea if you have a STEMI," he said. "If the EMS person says, ‘We're going 50 minutes away from here to get to a (stent-ready) hospital,' the patient should say, ‘Okay.'"

SOURCE: http://bit.ly/10imdwi Circulation, online December 30, 2012.

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