STEMI – taking the acute cardiac care to the patient

The Working Group on Acute Cardiac Care (WGACC) of the European Society of Cardiology (ESC) published in 2011 a scientific statement on the pre-hospital treatment of ST-segment elevation myocardial infarction (STEMI).1 This statement was developed following a focused meeting in Versailles during the Acute Cardiac Care Congress held in October 2008, followed by extensive deliberations and drafting to incorporate the most recent, relevant, and high-quality evidence and guidance. This new publication is important for a number of reasons. Previous ESC strategies2 and policy statements3 on pre-hospital care have highlighted the role of nurses and emergency medical service (EMS) staff in ambulances. This most recent statement, however, has an increased – and timely – emphasis on the importance of collaboration between physicians, nurses, and ambulance staff. The unique collaboration of the WGACC, Council on Cardiovascular Nursing and Allied Professions (CCNAP), and European Society of Emergency Medicine (EuSEM) has resulted in a statement aimed at maximizing the likelihood of patients with STEMI receiving the best evidence-based care available in the (heterogenous) geographical and logistical context of pre-hospital care across the ESC countries. Half a century ago, Julian4 established one of the world’s first coronary care units (CCU) in Edinburgh. While the focus of community-based resuscitation by lay responders today remains on the application of basic life-support techniques, the use of defibrillation has moved over time from the CCU4 to the ambulance5 and finally into the community by trained lay responders6 and to ‘public access’ schemes.7 This demonstrates the journey of a treatment originally conceived in and for the CCU, out to its application in shops, airports, and other community settings, even including people’s homes. In 1980, de Wood and colleagues8 demonstrated the role of occlusive coronary artery thrombus in acute myocardial infarction. The use of thrombolytic drugs to restore coronary artery patency in STEMI was then widely adopted following the major clinical trials of the 1980s.9,10 Like defibrillation, the use of thrombolytic therapy has moved from the CCU11 to the emergency department12 then finally to the community.13,14 If available in timely fashion in an experienced centre, primary percutaneous intervention has become the ‘gold standard’ reperfusion strategy. But it is important to remember that the majority of ‘STEMI time’ takes place outside of the cath-lab, and indeed outside of the hospital. While there is some evidence that community-based initiatives aimed at reducing the time between symptom onset and the patient’s call for help can be useful,15,16 this is dependent on high-quality and continuous effort.17 STEMI patients account for a small minority (perhaps <1%) EMS activity. Development of STEMI networks shows promise, but the approach differs across countries.18,19 There are two main models of EMS provision: the ‘Franco-German’ model with physicians in ambulances and control rooms, and the ‘Anglo-American’ model of ambulances staffed by paramedics, nurses, or emergency medical technicians. While the presence of a physician on the ambulance may be beneficial and possibly increase survival, there is little high-quality evidence to recommend a physician on every ambulance. There are conflicting conclusions from pooled analyses, randomized trials, observational studies, expert opinion, and clinical guidelines regarding the optimal mode of treatment in STEMI. In an effort to describe the application of these data and guidelines in a contemporary European context, Widimsky et al.19 published data from the national STEMI registries of 30 countries. The study gave a valuable insight into the logistics of care and use of EMS in STEMI. For example, despite ranking 27th of 30 countries for primary percutaneous coronary intervention (PPCI) provision per 100,000 population (in 2008–9), the UK ranked 2nd of 30 in having the shortest time delays in patients treated by PPCI and has the highest rate of EMS use by STEMI patients.19 In proposing how countries may overcome ‘system delays’, the authors state that some of the problems may be overcome by ‘organizing cooperating networks of PPCI hospitals in close vicinity’,19 organized by the local EMS, citing the Vienna STEMI network18 as one such model. Minimizing treatment delay in STEMI may, however, be less reliant on the organization of PPCI hospital networks than ensuring that as many patients as possible arrive at the first hospital by ambulance. Thus a well-organized system of pre-hospital care is paramount, not least because such a system is likely to provide earlier access to resuscitation should it be required. Uptake of guidelines amongst emergency department physicians and cardiologists is suboptimal.20 While not all guideline-recommended interventions in the pre-hospital setting are within either the competence or regulatory framework of nursing or paramedic practice, these groups may wish to consider adding to the existing evidence base describing the benefits of direct EMS paramedic activation of the cath-lab,21 and combined intensive CCU nurse/EMS paramedic activation of the cath-lab22 in STEMI. The statement highlights the need for more high-quality research in the pre-hospital setting to help inform future guidelines, practice, and models of delivery. The ongoing STREAM, EUROMAX, and ATLANTIC trials are good examples of cardiologists, nurses, and EMS staff working closely together to achieve this goal. Educational preparation for safe and effective pre-hospital STEMI care is the key and it is suggested that this could draw on relevant sections of the ESC Core Curriculum for the general cardiologist as a platform for all professionals engaged in pre-hospital STEMI care. The heterogeneity of EMS educational preparation is an important and challenging factor which requires discussion. The statement highlights the differences between countries such as the Netherlands, where EMS staff are highly trained critical care nurses who undergo an additional 12 months of pre-hospital care training, and countries such as the UK, where paramedics undertake only 10–12 weeks of training (although this is changing). The Education Committee of CCNAP is currently engaged in describing the demographic of post-graduate nurse education across the ESC countries with the aim of establishing a core curriculum in cardiovascular nursing. There may be an argument for extending this work to other allied health professions (such as paramedics) in the future. The creation of emergency medicine as an independent specialty, and the development of intensive and acute cardiac care as a subspecialty in cardiology,23 will increase the quality of medical training and quality of care, with nurses and other professionals working in these (sub)specialty areas harnessing potential for collaboration across interdisciplinary barriers: acute cardiac care, like the rest of health care, is a multidisciplinary undertaking. As the emphasis of the first-point of STEMI care continues to be devolved from the traditional intensive CCU model to the emergency department, to even (for PPCI) avoiding community hospitals and emergency departments with preferential ambulance transportation to a high-volume PPCI centre,24 it is apparent that educational needs of ‘acute cardiac care’ nurses and other professionals have changed. Cardiovascular nurses must seize the opportunity to define our role alongside physician and paramedic colleagues in this exciting enterprise.