Hospital networks for the treatment of acute myocardial infarction

Patients with ST-elevation myocardial infarction (STEMI) may have a survival benefit, as well as a reduced occurrence of reinfarction and stroke, if treated with primary percutaneous coronary intervention (PCI) instead of fibrinolysis. Furthermore, there are no other reperfusion options for patients with absolute contraindications to fibrinolysis or after failed fibrinolysis or in shock. Unfortunately, primary PCI programs require a relatively high number of experienced interventional cardiologists as well as other specialized personnel to guarantee a 24-hour call schedule together with a high level of skill. Since these conditions may be achieved only in a minority of hospitals with high volumes of interventional procedures, most of the patients with STEMI will be admitted to hospitals without a primary PCI program. The implementation of hospital networks based on a Hub-and-Spoke model is the only way to allow the choice of a reperfusion treatment on the basis of clinical needs and not only on the basis of the hospital characteristics. In Italy this process should be driven by regional authorities that have to establish the distribution of Hub centers, in close cooperation with cardiologists and physicians involved in emergency departments and 118 Service. Several key points, such as the collaboration between cardiologists and emergency physicians, common diagnostic and therapeutic protocols, prehospital diagnosis and treatment, transportation difficulties, overflow of the patients in the Hub centers, public campaigns for the use of the 118 Service and registries for all patients with STEMI, should be adequately addressed and implemented. In hospitals with well established primary PCI programs, all patients with STEMI should receive a mechanical reperfusion. The selection of patients with STEMI who might benefit most from mechanical reperfusion even after transfer, should be made considering the patient's risk profile, the time interval from symptom onset and the time interval to a primary PCI: in late comers (> 3 hours of symptom onset) and in the elderly, primary PCI should be the treatment of choice, but in early comers and younger patients, if an excessive time delay is necessary to perform a primary PCI, fibrinolysis might be a good initial option. In the latter, a systematic immediate transfer of high-risk patients to a primary PCI center for facilitated or rescue PCI should be considered.