Transferring Clinicians, Not Patients, Can Improve STEMI Care

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Transferring patients with ST-segment elevation myocardial infarction (STEMI) to centers capable of performing primary percutaneous coronary intervention (PCI) is a widely used strategy. But in situations where hospitals have angiographic facilities that lack adequate staffing for primary PCI, an even better option may be to transfer interventionalists as needed, on an emergency basis, reports a paper published online April 26, 2011, ahead of print in Circulation: Cardiovascular Quality and Outcomes.

Results from the REVERSE-STEMI trial were previously presented in October 2008 at the annual Transcatheter Cardiovascular Therapeutics symposium in Washington, DC.

Moving Patients vs. Physicians

For the study, Wei Feng Shen, MD, PhD, of Shanghai Jiaotong University School of Medicine (Shanghai, China), and colleagues enrolled 334 patients with acute STEMI who presented to 5 referral hospitals. All centers possessed angiographic facilities yet had no specialists qualified to perform primary PCI. Subjects were randomized to 1 of 2 strategies: clinician transfer (n = 165) or patient transfer (n = 169).

Overall, approximately half of patients arrived at the hospital via ambulance. Baseline characteristics were similar between the 2 groups, including tirofiban use and angiographic features, with the exception of a higher prevalence of TIMI flow grade 2 of the infarct-related artery in interventionalist-transfer patients. Stent use also was equivalent for both groups.

Patients who remained at the referral hospital and were treated by cardiologists sent from a nearby tertiary hospital had shorter door-to-balloon (D2B) times, the study’s primary endpoint, than those who were transferred before undergoing primary PCI. LVEF and 1-year survival free of MACE (composite of death, nonfatal MI, and TVR) also were improved with the clinician transfer strategy (table 1).

Table 1. Outcomes According to Transfer Strategy

Multivariate proportional hazards modeling showed that patients who had D2B times exceeding 90 minutes were at greater risk of MACE at 1 year (HR 2.24; 95% CI 1.27-3.96; P = 0.02). Use of the interventionalist-transfer strategy independently predicted lower MACE risk in the cohort as a whole (HR 0.63; 95% CI 0.45-0.88; P = 0.003) as well as in particular subgroups: those with Killip class III to IV, multivessel disease, and anterior infarction; women; and those aged older than 65 years.

Some Caveats

Because of its ability to reduce D2B times and improve clinical outcomes, clinician transfer may improve the care of STEMI patients presenting to non-primary PCI capable hospitals, “particularly in a region where patient transfers could be prolonged by congestion,” the researchers conclude.

Despite their enthusiasm for the transfer strategy, Dr. Shen and colleagues nonetheless outline several limitations to their study. Among them is the lack of on-site surgical backup at 4 of the 5 referral hospitals, though they assert that “the safety and feasibility of [primary PCI] in hospitals without on-site cardiac surgical backup have been demonstrated by previous studies.” In addition, the proportion of patients with D2B times below 90 minutes was “still relatively low” in the interventionalist-transfer group, and glycoprotein IIb/IIIa inhibitors were not used during ambulance transportation in the patient-transfer group.

“Finally, the current interventionalist-transfer strategy may be a tentative option in shortening D2B time for patients with STEMI and in physician training in a single city with hospitals located close to one another. This model may not be applied to rural geographic settings with longer transfer distances,” they point out. “In the future an improved ambulance network with direct field triage of patients with STEMI and an automated system to transmit ECGs or detailed instructions to paramedic personnel may lead to a rapid transfer of patients with possible STEMI to hospitals with a 24-hours/day, 7-days/week [primary PCI] service, further shortening D2B time and improving the STEMI caring system in a cosmopolitan [area] like Shanghai.”

Not Quite Convinced

Sorin J. Brener, MD, of Weill Cornell Medical College (New York, NY), was less impressed by the clinician transfer strategy.

“It’s a unique approach obviously. I don’t think it’s been done before. But it’s hard to believe that it has real merit, because really the simplest way to solve this is to make the diagnosis [in the field] and then call in or transmit the ECG,” he told TCTMD in a telephone interview. “It’s the same distance to go to the tertiary center as it is the other way around. The distances here were very small.”

In New York, Dr. Brener related, patients bypass non-primary PCI capable hospitals entirely. During transport, “I get the ECG on my Blackberry long before the patient is at the hospital, so everybody has time to get there,” he said.

Moreover, Dr. Brener questioned why the D2B times for interventionalists, who traveled by car or taxi, would be so much shorter than those for patients sent by ambulance.

That being said, the scenario faced by the Chinese researchers—in which angiographic facilities exist but lack clinicians qualified to perform primary PCI—also exists in the United States, he pointed out.

Dr. Brener reported that approximately 20% of US hospitals are equipped for primary PCI around the clock. Another 50% of hospitals have functional cath labs but cannot do the procedure either because they are short staffed or are unable to provide surgical backup, cost being a key issue, he added.

Study Details

A single tertiary hospital served as a hub, providing all the experienced interventionalists needed to perform primary PCI, whether at a referral hospital or on-site. All referral hospitals had a coronary care unit and diagnostic catheterization lab.

For the clinician transfer strategy, the physician went directly to the local hospital via taxi or private automobile after each emergency call. Patients received loading doses of aspirin or clopidogrel, or intravenous tirofiban if necessary, and were prepared for treatment while waiting for the specialist to arrive. All medical supplies and other staff such as nurses and paramedics were supplied by the referral hospital.

For the patient-transfer strategy, ambulances equipped with paramedic personnel who could perform cardiopulmonary resuscitation first travelled from a regional service center to the local hospital then transferred patients to the tertiary hospital, where they underwent primary PCI.

 

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Source:
Zhang Q, Zhang RY, Qiu JP, et al. One-year clinical outcome of interventionalist- versus patient-transfer strategies for primary percutaneous coronary intervention in patients with acute ST-segment elevation myocardial infarction: Results from the REVERSE-STEMI study. Circ Cardiovasc Qual Outcomes. 2011;Epub ahead of print.

 

 

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