As mentioned elsewhere in this scorecard, a myocardial infarction occurs when a part of the heart is not receiving adequate blood flow causing tissue damage. The definitive treatment for such an event is reperfusion, or returning blood flow to the area of damage. This can be accomplished through two principal methods, percutaneous coronary intervention (PCI) or thrombolysis. About 36% of hospitals are equipped for PCI, which is the ideal treatment¹.

In this procedure, the blood flow to your heart can be examined via an angiogram. With this information the treatment team can then decide whether to perform PCI, in which a special tube with an inflatable tip can be inserted into the affected vessel. This inflatable tip, or balloon, can be inflated which restores blood flow to the heart. In severe cases, a PCI may not be sufficient and coronary artery bypass grafting (CABG), a more invasive procedure, must be utilized².

Often a patient presents to one of the 64% of institutions that does not possess the ability or resources to perform a PCI. In this case, the providers can either immediately transfer to a capable hospital or perform thrombolysis. With thrombolysis, a medication is given which dissolves the clot of blood that may be preventing perfusion of the heart¹.

Initiation of proper medical care following a myocardial infarction (MI) is imperative for ensuring a positive outcome.  The metric of time to first medical contact to device is an effective way to measure the time from first contact with the patient, whether in or pre-hospital, to life saving device placement. In this metric, the device is most commonly a PCI balloon which allows reperfusion of the heart. Perfusion has repeatedly been shown to be the most important intervention to improve early survival in patients with a STEMI (S-T elevation myocardial infarction)³.

The AHA recommends that no more than 90 minutes should pass between EMS arrival and PCI if patient is brough to a PCI-capable center. Both the United States and Arkansas have median times below this benchmark. Arkansas most recently was shown to have a median time of 76.2 minutes, which unfortunately has trended up since 74.0 minutes in 2017. Nationally, the median time has stayed stable at 75.8 in 2017 and 2018. 

Source: ¹ Treatment of Heart Attack. Retrieved April 1,2018 from https://www.heart.org/en/health-topics/heart-attack/treatment-of-a-heart-attack

Source: ² Cardiac Procedures and Surgeries. Retrieved April 1,2018 fromhttps://www.heart.org/en/health-topics/heart-attack/treatment-of-a-heart-attack/cardiac-procedures-and-surgeries

Source: ³ Indications for fibrinolytic therapy in suspected acute myocardial infarction: collaborative overview of early mortality and major morbidity results from all randomised trials of more than 1000 patients Fibrinolytic Therapy Trialists' (FTT) Collaborative Group, The Lancet , Volume 343 , Issue 8893 , 311 - 322

The following groups and organizations have been pivotal in the efforts to improve STEMI outcomes:
• American College of Cardiology 
• Arkansas Department of Health Tobacco Cessation and Prevention Branch 
• Arkansas Department of Health Trauma Branch – Stroke and STEMI Section 
• Arkansas Department of Health Chronic Disease Branch 
• Heart Disease and Stroke Prevention Coalition 
• STEMI Advisory Council

A myocardial infarction occurs when a part of the heart is no longer receiving blood flow. Restoring blood flow to the affected area is the preferred treatment for patients experiencing an MI. Perfusion has repeatedly been shown to be the most important intervention to improve early survival in patients with a STEMI making this metric very important¹. The more quickly blood flow is restored, the better the outcome. The phrase "time is muscle" is often used to stress the importance of early reperfusion².  

Source: ¹ Indications for fibrinolytic therapy in suspected acute myocardial infarction: collaborative overview of early mortality and major morbidity results from all randomised trials of more than 1000 patients Fibrinolytic Therapy Trialists' (FTT) Collaborative Group, The Lancet , Volume 343 , Issue 8893 , 311 – 322

Source: ² Elliott M. Antman. Time is Muscle. Journal of the American College of Cardiology Oct 2008, 52 (15) 1216-1221; DOI: 10.1016/j.jacc.2008.07.011

The ADH has several quality improvement efforts that may positively impact the time from EMS contact to in-hospital PCI. The launching of the Arkansas Heart Attack Registry in 26 PCI centers will help monitor and improve this metric. Also, providing 12-lead EKG equipment for 6 providers serving 15 Arkansas counties to increase EMS capacity in assessing and managing STEMI patients will help reduce time to STEMI diagnosis. Additionally, there are general improvements that will improve this metric, as well as others. The first is creating a STEMI best practices operations toolkit to increase adherence to the latest evidence-based treatment guidelines.  Similarly, online STEMI education on evidence-based practice for all physicians, nurses and pre-hospital providers in the state will inform providers of these guidelines. Also, the ADH is developing a STEMI pilot program in the northeast and southwest regions aimed at improving care coordination between EMS and hospitals. Additionally, In the future the ADH STEMI Section plans to conduct hospital site visits to provide technical and quality improvement assistance registry data to help staff identify and close gaps in patient care.