AHA Policy Statement Focuses on Gaps in STEMI Systems of Care

Despite considerable successes in the treatment of STEMI, optimal delivery of care via standardized networks faces ongoing challenges in the United States, according to a new policy statement from the American Heart Association (AHA).

“We've made tremendous progress and [organizing] has definitely made a huge difference,” Timothy Henry, MD (The Christ Hospital, Cincinnati, OH), told TCTMD. “I don't think the details of the protocol are as important as that you actually have a protocol and that you are doing it in a standardized way and keeping track of it.”

Henry is a co-author of the policy statement chaired by Alice K. Jacobs, MD (Boston Medical Center, MA), and published last week in Circulation.

The AHA first introduced the concept of a national initiative to advance standardized systems of care for STEMI and other acute diseases in 2007 with its Mission: Lifeline program. In the statement, the committee says that after initial successes, including coverage of more than 85% of the US population by a STEMI system of care and declining morbidity and mortality rates, progress has slowed. The statement focuses on seven key areas where improvements can be made: public awareness and community education, entry into the healthcare system, direct to cardiac cath lab, transitions in care, post-MI care, telemedicine and rural health, and financial concerns.

Henry said the data thus far confirm the importance of STEMI systems and their ability to make a difference in outcomes. The growing importance of these networks, he added, should not only serve as an incentive to make them better but also encourage fuller participation.

“To the extent that there are places that are not involved in a system of care, hopefully this encourages them to be involved,” he said. “Non-PCI centers as well as PCI centers should standardize their protocols for all the sites that they work with.”

Barriers and Focus Areas for Change

An ongoing barrier in STEMI care involves the delays at multiple time points after the onset of symptoms, whether that’s in self transport to the hospital instead of calling 9-1-1, transportation delays, or failure to activate the cath lab prior to arrival. The policy statement notes that Texas and Mississippi are examples where successful public education campaigns increased emergency medical services (EMS) use and decreased mortality. Optimal messaging, they add, “should cross social media platforms and cultural, socioeconomic, and psychosocial barriers.” Importantly, the committee notes that public health messaging should emphasize that using EMS will result in timelier reperfusion and early prehospital notification that can save lives.

Continuous quality improvement and continuous feedback keep the system working well. Timothy Henry

The policy recommendation also states that basic EMS providers should be trained and given permission through certification and state protocols to obtain 12-lead ECGs on patients experiencing chest pain or other suspected ischemic symptoms. Furthermore, Jacobs and colleagues say EMS agencies “should have an internal quality improvement program in place to review 100% of identified STEMIs and to provide hospital feedback on transported patients later identified as having STEMI but not identified in the field.” EMS also should be represented at institutional and regional multidisciplinary quality-improvement meetings, they add.

To TCTMD, Henry noted that the policy statement also addresses the concept of Level I (comprehensive), Level II (primary), and Level III (acute ready) heart attack centers. Georgia, he noted, is one state that has recently adopted the three-level designation system for its emergency cardiac care centers. Levels I and II, for example, would be required to have access to intra-aortic balloon pumps, rapid response teams, and coronary ICUs. All heart attack centers would be required to have fibrinolytic administration capability, participate in the national acute MI data registry, have a transfer agreement in place, and engage in a regional system of care. The policy recommendation stresses that STEMI systems also should encourage cardiac rehabilitation referral, early enrollment, and adherence, as well as quality improvement and performance measures for post-MI patients.

In rural or remote areas, collaboration with regional STEMI receiving centers can help ensure best practice and access, including via telemedicine, Jacobs and colleagues say. They suggest that rural centers develop emergency department-based protocols for rapid assessment for fibrinolytics “and consideration of transfer for PCI based on mutually developed protocols with the PCI receiving center.”

From a financial standpoint, the policy recommendation advocates for “global reimbursement of the system of care” for STEMI.

Lastly, the document takes into account the added strain of the COVID-19 pandemic, which has been linked to huge declines in patients presenting with STEMI, as TCTMD first reported in 2020. Henry was senior author on a paper showing that at nine high-volume cath labs in the US, there was a nearly 40% drop in STEMI activations between 2019 and early 2020. Although much is still to be learned about the impact on care structures, he said, some lessons are already evident.

“Sites that had good, well-developed regional systems of care recovered their volume very quickly,” Henry observed. “At sites that didn’t have as well-developed systems, the recovery was more spotty. I think what it really shows you is that if you have a regional system in place, you can respond quickly to new information.

“That doesn’t apply just to COVID,” he continued. “Let's say you decide to change your anticoagulation, or the way you treat out-of-hospital cardiac arrest. Once you have a standardized protocol in place with a group of hospitals that you communicate with regularly, and you're giving them feedback every month or 2 months, you can adapt to changes in the environment much quicker. Continuous quality improvement and continuous feedback keep the system working well.”