Gaps in myocardial infarction care: how might we best EFFECT change?

Despite medical advances, coronary artery disease continues to burden us. Millions worldwide have a myocardial infarction each year, and millions suffer the ravages of atherosclerosis: stable and unstable angina, congestive heart failure, and sudden cardiac death. Combating this plague has always required attention to research—biology of atherosclerosis, drug development, clinical trials—and attention to implementation—access to care, guideline dissemination, and treatment standardization. The story of ST-elevation myocardial infarction (STEMI) illustrates the difficulty of doing this. The science has been, in relative terms, easy. Investigators have steadily progressed from using aspirin to administering thrombolytics and to employing primary percutaneous intervention; these advances, along with adjunctive therapy such as beta-blockers and ACE-inhibitors, have decreased 30-day mortality in clinical trials to an impressive 5–6%. Unfortunately, translating these findings into practice has not been so easy. For example, trials have consistently shown importance of time from symptom onset to time to treatment in reducing STEMI mortality, yet numerous obstacles persist. Despite public education campaigns to activate the emergency medical system when symptoms of a heart attack arise, up to 50% of patients with STEMI do not call 9-1-1, but instead transport themselves.1 The medical system fares no better; despite guidelines for a door-to-balloon time of 90 min with primary percutaneous intervention, the majority of STEMI patients do not reach these targets.2 Most disturbingly, an important percentage of STEMI patients eligible for reperfusion therapy (either thrombolysis or percutaneous intervention) do not receive it.3