Pre-hospital diagnosis, triage and treatment in patients with ST elevation myocardial infarction

The treatment of acute ST elevation myocardial infarction (STEMI) has greatly improved in the last three decades, especially after the introduction of primary percutaneous coronary intervention (PCI). However, primary PCI is available in selected centres only, thus necessitating transportation of the STEMI patient. Improvement in the logistics of care for these patients is associated with significant improvement of patient outcome. Both the American Heart Association (AHA) and the European Society of Cardiology (ESC) STEMI guidelines recommend pre-hospital infarct diagnosis as a class I recommendation.w1 w2 Despite this, the large majority of STEMI patients are only diagnosed after arrival in the hospital.1 Therefore, great care should be taken in the initial diagnosis, risk assessment and triage, subsequent transfer and the distance of transportation as well as pre- and in-hospital time delays in these patients. STEMI patients can be diagnosed in the pre-hospital phase in two ways. The first option is diagnosis in the ambulance via an emergency medical services (EMS) call (118 or 911) by the patient or by a general practitioner. The second option is diagnosis at a referral non-PCI centre after self-referral of the patient or when no pre-hospital ECG is performed by EMS in the ambulance. Pre-hospital diagnosis in the ambulance gives the best outcomes for STEMI patients, since pre-hospital treatment can be started directly in the ambulance after diagnosis and triage.2 ,3 Subsequently, these patients are directly transferred in an ambulance from the pick-up place to the nearest PCI centre with 24/7 service, bypassing the emergency departments of the nearby referral non-PCI centres. The second option, diagnosis at a non-PCI centre, also occurs often, especially in rural areas. These patients are transported to a PCI centre, following diagnosis and triage of STEMI, preferably …