Reduction of treatment delay in patients with ST-elevation myocardial infarction: impact of pre-hospital diagnosis and direct referral to primary percutaneous intervention

We were interested to read the paper by Terkelsen et al.1 describing pre-hospital identification, by physicians, of patients suitable for primary angioplasty. We would suggest, however, that physician involvement in the decision to transfer a patient for primary PCI might be unnecessary if appropriate training and protocols for ambulance personnel are in place. In the UK, where ambulances are not generally physician-manned, several strategies have been evaluated to assess whether paramedics can accurately identify patients with acute coronary syndromes and refer directly to an appropriate hospital facility. For example, paramedics were able, on clinical grounds alone, to identify high-risk patients for admission to CCU.2 When a 12-lead ECG was available alongside a facility to discuss patients with CCU nurses prior to admission, paramedics were able to expedite CCU admission with a high degree of accuracy.3 In London, paramedics' recognition of ST segment elevation was as good as that of emergency physicians, without the need to resort to telemetry.4 Moreover, a study of paramedics' identification of patients eligible for thrombolytic therapy demonstrated high accuracy.5 We would suggest that in emergency medical systems without physician-manned ambulances, suitably trained paramedics could accurately identify patients with ST elevation MI and refer directly to an interventional facility, reducing delays to reperfusion.