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Executive Summary

STEMI Networks and EMS

Recommendation

We recommend that the diagnosis and management of STEMI should be based on the implementation of “regional networks” between hospitals (‘hub’ and ‘spoke’ model) linked by an efficient ambulance service.

Recommendation

We recommend that each regional network (cluster of hub and spokes) should share a written protocol of referral and consultation.

Strong recommendation

Recommendation

We recommend that a national call center for the ambulance should be established and well publicized to make it easily remembered and used by patients.

Strong recommendation

Recommendation

We recommend that patients with chest pain and/or suspected STEMI should dial the EMS call center number without delays. We do not recommend self transfer (patients to use vehicles other than the EMS to reach hospitals in order to seek medical advice).

Strong recommendation

Recommendation

We recommend that all ambulance vehicles should be equipped with ECG machines and defibrillators.

Strong recommendation

Recommendation

We recommend that all ambulance personnel should be trained to recognize the symptoms of STEMI, administer aspirin, administer oxygen when appropriate, relieve pain and provide basic life support including using the defibrillator if indicated.

Strong recommendation

Recommendation

We recommend that all ambulance personnel should be trained to record an ECG and either interpret or transmit it, so that it can be reviewed by hospital-based cardiologist to establish or reject a STEMI diagnosis.

Strong recommendation

Recommendation

We recommend that once ECG diagnosis is confirmed, primary PCI team in the Cath lab of the Hub should be alerted of an imminent patient arrival.

Strong recommendation

Recommendation

We recommend that all patients with confirmed or suspected STEMI should receive 300 mg of chewable aspirin as soon as possible if patients were not receiving ASA before or if no contraindication.

Strong recommendation

Recommendation

We recommend that the ambulance should transfer the clinically stable patient from the field to the nearest PCI capable hospital, bypassing non-PCI capable hospitals.

Strong recommendation

Recommendation

We recommend that if the patient during transfer becomes unstable or deteriorate clinically, he should be redirected to the nearest hospital with ER.

Strong recommendation

Recommendation

We recommend that an ambulance transferring patients from the field to the hospital can be equipped with a trained paramedic while an ambulance transferring patient in-between hospitals should include an accompanying doctor on board.

Strong recommendation

Recommendation

We recommend that all EMS should have a written protocol stating the updated management protocols and should establish a formal relationship with a PCI center to enable prompt patient transfer.

Strong recommendation

Recommendation

We recommend that the time of EMS response, arrival to the patient, arrival to the designated hospital and the time of first ECG should be recorded and regularly audited aiming at improving performance quality metrics.

Strong recommendation

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Reperfusion Strategy

Recommendation

We recommend that reperfusion of the infarct related artery should be offered to all patients with STEMI presenting within the first 12 hours following chest pain onset.

Strong recommendation

Recommendation

We recommend that reperfusion of the infarct related artery should be offered to all patients with STEMI presenting within the 12–48 hours following chest pain onset.

Strong recommendation

Recommendation

We recommend that primary PCI should be used as a default reperfusion strategy for suspected STEMI patients provided that time delay would not exceed 120 minutes.

Strong recommendation

Recommendation

We recommend that patients should bypass non-PCI-capable centers and instead be transferred to the nearest Primary PCI Centre with the goal of achieving a maximum FMC-to-device time of ≤120 minutes (ideal FMC-to-device time ≤90 minutes in urban settings).

Strong recommendation

Recommendation

We recommend that in areas where the transfer of patients to the nearest hub will exceed 120 minutes, patients should be offered fibrinolytic therapy with immediate transfer afterwards to the hub for cardiac catheterization within 2–24 hours post fibrinolysis. This pathway is the Pharmacoinvasive pathway.

Strong recommendation

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Public Awareness

Recommendation

We recommend that public awareness campaigns should be organized to reduce “patient delay” and should include the following messages:

• Importance to know common symptoms of STEMI and to recognize it as early as possible.

• Importance to react rapidly by calling the emergency services (123: ambulance service or 16474: critical cases services).

Strong recommendation

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System Delay Reduction Measures

Recommendation

We recommend the following measures and policies to help minimize “system delays”:

• It is mandatory to do a pre-hospital ECG and diagnose a STEMI in less than 10 minutes from the patient presentation.

• EMS personnel should send the pre-hospital ECG to a hospital-based consultant to confirm or reject the diagnosis of STEMI.

• Once the diagnosis of STEMI is confirmed in the pre-hospital setting, immediate activation of the catheterization laboratory should be initiated.

• The patient should be directed to the nearest hub (Hospital with 24/7 primary PCI service).

• In the hub, the system should allow EMS personnel to bypass the emergency department and bring the patient straight to the catheterization laboratory.

• For patients presenting in a non-capable PCI center, door-in to door-out time should not exceed 30 minutes.

• Patients who will receive fibrinolytic therapy should receive it in less than 10 minutes from diagnosis and should be transferred to a primary PCI capable center routinely within 2–24 hours after thrombolytic therapy.

• A written protocol in PCI non-capable hospitals should determine the reperfusion strategy of this hospital.

• All hospitals and EMS taking care of patients presenting with STEMI should adopt the recommended time targets.

• Management delays should be recorded and audited regularly and policies should be established to regularly improve them.

Strong recommendation