Transfer for Primary Angioplasty Versus Immediate Thrombolysis in Acute Myocardial Infarction

Interfacility transfer of the critically ill: Transfer status does not influence survival

PURPOSE

To estimate differences in case-mix adjusted hospital mortality between adult ICU patients who are transferred during their ICU-stay and those who are not.

METHODS

19,260 visits to 12 ICUs in Nova Scotia (NS), Canada April 2018-September 2023 were analyzed. Data were obtained from the NS Provincial ICU database. Generalized additive models (GAMs) were used to estimate differences in case-mix adjusted hospital mortality between patients who underwent transfer and those who did not.

RESULTS

1040/19,260 (5%) ICU visits involved interfacility-transfer. No difference in hospital mortality was identified between transferred and non-transferred patients by GAM (OR, 0.99, 95% CI, 0.82 to 1.19; p = 0.91). No mortality difference was observed between patients undergoing a single transfer versus multiple (OR, 0.87; 95% CI, 0.45 to -1.69; p = 0.68). A GAM including the categories no transfer, one transfer, and multiple transfers identified a difference in hospital mortality for patients that underwent multiple transfers compared to non-transferred patients (OR, 0.68; 95% CI, 0.46 to 1.00, p = 0.05), but no difference was identified in a post-hoc matched cohort sensitivity analysis (OR, 0.68; 95% CI, 0.46 to 1.01, p = 0.05).

CONCLUSION

The transfer of critically ill patients between ICUs in Nova Scotia did not impact case-mix adjusted hospital mortality.

A Single Transradial Guiding Catheter in Patients With ST-Segment Elevation Myocardial Infarction Undergoing Percutaneous Coronary Intervention: A Door-to-Balloon Optimized Strategy

Background Acute coronary syndrome (ACS) is the leading cause of morbidity and mortality worldwide. The different reperfusion strategies have evolved over the years, and efforts have been directed to reduce its complications. Among these strategies, the one that has shown the best results is percutaneous coronary intervention, which has significantly improved the survival and prognosis of these patients; however, this procedure is not free of complications since multiple factors are involved. Among them is the time of patient care from the time of diagnosis until the coronary reperfusion therapy is performed. Methodology In this study, we describe the experience in our center with the 6-French Ikari Left guide catheter as a strategy of radial angiography-angioplasty with a single catheter to reduce the care times of patients with acute ST-elevation myocardial infarction (STEMI) in our center and compare it with the series reported by other international centers since. To establish an alternative to the usual approach that consists of the use of Judkins catheters, diagnosis, and guiding. Results Our study showed a success rate for diagnostic angiography and percutaneous coronary intervention (PCI) with the 6- French Ikari Left catheter comparable to those obtained in other centers, even with lower complication rates than the usual approach with Judkins' Catheters. Conclusions The use of the 6-French Ikari Left catheter demonstrated shorter needle-device time and compared to other international series, it was shown to be shorter and related to shorter fluoroscopy time. Our study has a small sample and only included a highly selected population, which represents a limitation. This study is vulnerable to the different practices of the operators, with involvement in procedure time and use of contrast volume.

Fractalkine Signalling (CX3CL1/CX3CR1 Axis) as an Emerging Target in Coronary Artery Disease

Acute myocardial infarction (MI) is the most common and dramatic complication of atherosclerosis, which, despite successful reperfusion therapy, can lead to incident heart failure (HF). HF occurs when the healing process is impaired due to adverse left ventricular remodelling, and can be the result of so-called ischaemia/reperfusion injury (IRI), visualised by the development of intramyocardial haemorrhage (IMH) or microvascular obstruction (MVO) in cardiac MRI. Thus far, translation of novel pharmacological strategies from preclinical studies to target either IRI or HF post MI have been largely unsuccessful. Anti-inflammatory therapies also carry the risk of affecting the immune system. Fractalkine (FKN, CX3CL1) is a unique chemokine, present as a transmembrane protein on the endothelium, or following cleavage as a soluble ligand, attracting leukocyte subsets expressing the corresponding receptor CX3CR1. We have shown previously that the fractalkine receptor CX3CR1 is associated with MVO in patients undergoing primary PCI. Moreover, inhibition of CX3CR1 with an allosteric small molecule antagonist (KAND567) in the rat MI model reduces acute infarct size, inflammation, and IMH. Here we review the cellular biology of fractalkine and its receptor, along with ongoing studies that introduce CX3CR1 as a future target in coronary artery disease, specifically in patients with myocardial infarction.

Impact of door in-door out time on total ischemia time and clinical outcomes in patients with ST-elevation myocardial infarction

INTRODUCTION

Patients with ST-elevation myocardial infarction (STEMI) requiring inter-hospital transfer for primary percutaneous coronary intervention (PCI) often have delays in reperfusion. The door in-door out (DIDO) time is recommended to be less than 30 min.

OBJECTIVES

To assess the DIDO time of hospitals that transfer patients with STEMI to a PCI center and to assess its impact on total ischemia time and clinical outcomes in patients with STEMI.

METHODS

We performed a retrospective study of 523 patients with STEMI transferred to a PCI center for primary PCI between January 1, 2013 and June 30, 2017.

RESULTS

Median DIDO time was 82 min (interquartile range, 61-132 min). Only seven patients (1.3%) were transferred in ≤30 min. Patients with DIDO times over 60 min had significantly longer system delays (207.3 min vs. 112.7 min; p<0.001) and total ischemia time (344.2 min vs. 222 min; p<0.001) than patients transferred in ≤60 min. Observed in-hospital mortality was significantly higher among patients with DIDO times >60 min vs. ≤60 min (5.1% vs. 0%; p=0.006; adjusted odds ratio for in-hospital mortality, 1.27 [95% CI 1.062-1.432]). By the end of follow-up, patients belonging to the >60 min group had a higher mortality (p=0.016), and survival time was significantly shorter (p=0.011).

CONCLUSION

A DIDO time ≤30 min was observed in only a small proportion of patients transferred for primary PCI. DIDO times of ≤60 min were associated with shorter delays in reperfusion, lower in-hospital mortality and longer survival times.

Using real world evidence to generate cost-effectiveness analysis of fibrinolytic therapy in patients with ST-segment elevation myocardial infarction in Thailand

BACKGROUND

Due to limited access to primary percutaneous coronary intervention for the management of ST-segment elevation myocardial infarction (STEMI) in low-to-middle-income countries (LMICs), fibrinolysis serves as a vital alternative reperfusion therapy. Among fibrinolytic agents, the cost-effectiveness of tenecteplase (TNK) in LMICs as compared to streptokinase (SK) for STEMI management remains unknown.

METHODS

Cost-effectiveness was analyzed using a hybrid model consisting of short-term analysis (30-days decision tree model) and long-term analysis (Markov model). Both health care provider and societal perspectives over a lifetime horizon with 3% discount rate were considered. Input parameters were obtained from Thailand's national health database, a network meta-analysis and literature review. Outcome measure was an incremental cost-effectiveness ratio (ICER) determined by an incremental cost per quality-adjusted life years (QALY) gain. An ICER of less than $5,590 per QALY gain is considered cost-effective. Series of sensitivity analyses were also performed.

FINDINGS

From the societal perspective, TNK increases cost by $827 and increases QALY by 0·173. Thus, the ICER is $4,777 per QALY gained. Similarly, the ICER from health care provider perspective is $4,664 per QALY gained. In the probabilistic sensitivity analysis, using 5,590 USD per QALY as threshold, the probability of TNK being cost-effective was 83% from both perspectives. The most influential parameters were risk ratio of death for treatment with TNK compared to SK and drug cost of TNK.

INTERPRETATION

In a resource-limited country like Thailand, tenecteplase is a cost-effective fibrinolytic drug for treatment of STEMI compared to streptokinase.

FUNDING

None.

Morphological and Physiological Characteristics of Ruptured Plaques in Native Arteries and Neoatherosclerotic Segments: An OCT-Based and Computational Fluid Dynamics Study

Background

Intravascular imaging has been used to assess the morphology of lesions causing an acute coronary syndrome (ACS) in native vessels (NV) and identify differences between plaques that ruptured (PR) and caused an event and those that ruptured without clinical manifestations. However, there is no data about the morphological and physiological characteristics of neoatherosclerotic plaques that ruptured (PR-NA) which constitute a common cause of stent failure.

Methods

We retrospectively analyzed data from patients admitted with an acute myocardial infarction that had optical coherence tomography (OCT) imaging of the culprit vessel before balloon pre-dilation. OCT pullbacks showing PR were segmented at every 0.4 mm. The extent of the formed cavity, lipid and calcific tissue, thrombus, and macrophages were measured, and the fibrous cap thickness (FCT) and the incidence of micro-channels and cholesterol crystals were reported. These data were used to reconstruct a representative model of the native and neoatherosclerotic lesion geometry that was processed with computational fluid dynamics (CFD) techniques to estimate the distribution of the endothelial shear stress and plaque structural stress.

Result

Eighty patients were included in the present analysis: 56 had PR in NV (PR-NV group) and 24 in NA segments (PR-NA group). The PR-NV group had a larger minimum lumen area (2.93 ± 2.03 vs. 2.00 ± 1.26 mm², p = 0.015) but similar lesion length and area stenosis compared to PR-NA group. The mean FCT (186 ± 65 vs. 232 ± 80 μm, p = 0.009) and the lipid index was smaller (16.7 ± 13.8 vs. 25.9 ± 14.1, p = 0.008) while the of calcific index (8.3 ± 9.5 vs. 2.2 ± 1.6%, p = 0.002) and the incidence of micro-channels (41.4 vs. 12.5%, p = 0.013) was higher in the PR-NV group. Conversely, there was no difference in the incidence of cholesterol crystals, thrombus burden or the location of the rupture site between groups. CFD analysis revealed higher maximum endothelial shear stress (19.1 vs. 11.0 Pa) and lower maximum plaque structural stress (38.8 vs. 95.1 kPa) in the PR-NA compared to the PR-NV model.

Conclusion

We reported significant morphological and physiological differences between culprit ruptured plaques in native and stented segments. Further research is needed to better understand the causes of these differences and the mechanisms regulating neoatherosclerotic lesion destabilization.

The feasibility of Kimny guiding catheter for ST-segment elevation myocardial infarction

Objectives:

The Kimny guiding catheter is a single universal guiding catheter used for performing percutaneous coronary intervention (PCI) in both the right coronary artery (RCA) and the left coronary artery (LCA). Although this guiding catheter has been shown to yield high procedural success rates in nonemergent conditions, its feasibility for patients with ST-segment elevation myocardial infarction (STEMI) remains unknown and therefore needs to be further investigated.

Materials and Methods:

We retrospectively enrolled 62 consecutive STEMI patients who underwent primary PCI using the Kimny guiding catheter from January 2016 through December 2017. We then evaluated the rates of engagement and procedural success for PCI of the LCA and RCA with the Kimny guiding catheter.

Results:

Primary PCI of the infarct-related artery (IRA) by means of the Kimny guiding catheter proved to be successful in 61 of the STEMI patients (98.3%). Besides, the procedural success rate was found to be 100% (44/44) for the LCA and 94.4% (17/18) for the RCA (P = 0.293). With regard to contralateral (non-IRA) angiography, engagement rates of 97.4% (38/39) and 100% (18/18) were obtained for the RCA and LCA, respectively, (P = 1.0). No coronary artery ostial dissection was observed during the procedures. The mean number of total catheters used for each patient turned out to be only 1.035.

Conclusion:

Using the Kimny guiding catheter for primary PCI is feasible and results in high procedural success rates, particularly for the treatment of the LCA, with fewer catheters, and at a lower cost.

Association of Rural and Critical Access Hospital Status With Patient Outcomes After Emergency Department Visits Among Medicare Beneficiaries

IMPORTANCE

Rural US residents disproportionately rely on emergency departments (ED), yet little is known about patient outcomes after ED visits to rural hospitals or critical access hospitals (CAHs).

OBJECTIVE

To compare 30-day outcomes after rural vs urban ED visits and in CAHs, a subset of rural hospitals.

DESIGN, SETTING, AND PARTICIPANTS

This propensity-matched, retrospective cohort study used a 20% sample of national Medicare fee-for-service beneficiaries from January 1, 2011, to October 31, 2015. Rural and urban ED visits were matched on demographics, patient prior use of EDs, comorbidities, and diagnoses. Thirty-day outcomes overall and stratified by 25 common ED diagnoses were evaluated, with similar analysis of CAHs vs non-CAHs. Data were analyzed from February 15, 2020, to May 17, 2021.

MAIN OUTCOMES AND MEASURES

The primary outcome was 30-day all-cause mortality. Secondary outcomes were ED revisits with and without hospitalization.

RESULTS

The matched cohort included 473 152 rural and urban Medicare beneficiaries with a mean (SD) age of 75.1 (7.9) years (59.1% and 59.3% women, respectively; 86.9% and 87.1% White, respectively). Medicare beneficiaries at rural vs urban EDs experienced similar all-cause 30-day mortality (3.9% vs 4.1%; effect size, 0.01), ED revisits (18.1% vs 17.8%; effect size, 0.00), and ED revisits with hospitalization (6.0% vs 8.1%; effect size, 0.00). Rural ED visits were associated with more transfer (6.2% vs 2.0%; effect size, 0.22) and fewer hospitalizations (24.7% vs 39.2; effect size, 0.31). Stratified by diagnosis, patients in rural EDs with life-threatening illnesses experienced more transfer with 30-day mortality similar to that of patients in urban EDs. In contrast, mortality differed for patients in rural EDs with symptom-based diagnoses, including chest pain (odds ratio [OR], 1.54 [95% CI, 1.25-1.89]), nausea and vomiting (OR, 1.68 [95% CI, 1.26-2.24), and abdominal pain (OR, 1.73 [95% CI, 1.42-2.10]). All findings were similar for CAHs.

CONCLUSIONS AND RELEVANCE

The findings of this cohort study of rural ED care suggest that patient mortality for potentially life-threatening conditions is comparable to that in urban settings. Further research is needed to understand the sources of greater rural ED mortality for symptom-based conditions. These findings underscore the importance of ensuring access to treatment of life-threatening conditions at local EDs in rural communities, which are increasingly endangered by hospital closures.

Adherence to quality indicators for ST-elevation myocardial infarction and its relation to mortality: a hospital network analysis from the Belgian STEMI database

AIMS

To assess the adherence to established quality indicators (QIs) for ST-elevation myocardial infarction (STEMI) at the hospital-network level and its relation to outcome.

METHODS AND RESULTS

The data of 7774 STEMI patients admitted to 32 STEMI networks during the period 2014-18 were extracted from the Belgian STEMI database. Five QIs [primary percutaneous coronary intervention use, diagnosis-to-balloon time (DiaTB) <90 min, door-to-balloon time (DoTB) <60 min, P2Y12 inhibitor and statin prescription at discharge, and a composite QI score ranging from 0 to 10] were correlated with in-hospital mortality adjusted for differences in baseline risk profile (TIMI risk score). The median composite QI score was 6.5 [interquartile range (IQR) 6-8]. The most important gaps in quality adherence were related to time delays: the recommended DiaTB and DoTB times across the different networks were achieved in 68% (IQR 53-71) and 67% (IQR 50-78), respectively. Quality adherence was better in networks taking care of more high-risk STEMI patients. The median in-hospital mortality among the STEMI networks was 6.4% (IQR 4.1-7.9%). There was a significant independent inverse correlation between the composite QI score and in-hospital mortality (partial correlation coefficient: -0.45, P = 0.013). Stepwise regression analysis revealed that among the individual QIs, prolonged DiaTB was the most important independent outcome predictor.

CONCLUSION

Among established STEMI networks, the time delay between diagnosis and treatment was the most variable and the most relevant prognostic QI, underscoring the importance of assessing quality of care throughout the whole network.

Appropriate Air Medical Services Utilization and Recommendations for Integration of Air Medical Services Resources into the EMS System of Care: A Joint Position Statement and Resource Document of NAEMSP, ACEP, and AMPA

Air medical services involves providing medical care in transit while using either fixed wing (airplane) or rotor wing (helicopter) aircraft to move patients between locations. The modern use and availability of air medical services has expanded access to various health system resources, including specialty care. While this is generally beneficial, such expansion has also contributed to the complexity of health care delivery systems.(1, 2) Since the publication of the 2013 joint position statement Appropriate and Safe Utilization of Helicopter Emergency Medical Services,(3) research has shown that patient benefit is gained from the clinical care capabilities of air medical services independent of potential time saved when transporting patients.(4-6) Because the evidence basis for utilization of air medical services continues to evolve, NAEMSP, ACEP, and AMPA believe that an update regarding the appropriate utilization of air medical services is warranted, and that such guidance for utilization can be divided into three major categories: clinical considerations, safety considerations, and system integration and quality assurance considerations.

Predictors of hospital transfer and associated risks of mortality in acute pancreatitis

BACKGROUND

There is limited research in prognosticators of hospital transfer in acute pancreatitis (AP). Hence, we sought to determine the predictors of hospital transfer from small/medium-sized hospitals and outcomes following transfer to large acute-care hospitals.

METHODS

Using the 2010-2013 Nationwide Inpatient Sample (NIS), patients ≥18 years of age with a primary diagnosis of AP were identified. Hospital size was classified using standard NIS Definitions. Multivariable analyses were performed for predictors of "transfer-out" from small/medium-sized hospitals and mortality in large acute-care hospitals.

RESULTS

Among 381,818 patients admitted with AP to small/medium-sized hospitals, 13,947 (4%) were transferred out to another acute-care hospital. Multivariable analysis revealed that older patients (OR = 1.04; 95%CI 1.03-1.06), men (OR = 1.15; 95%CI 1.06-1.24), lower income quartiles (OR = 1.54; 95%CI 1.35-1.76), admission to a non-teaching hospital (OR = 3.38; 95%CI 3.00-3.80), gallstone pancreatitis (OR = 3.32; 95%CI 2.90-3.79), pancreatic surgery (OR = 3.14; 95%CI 1.76-5.58), and severe AP (OR = 3.07; 95%CI 2.78-3.38) were predictors of "transfer-out". ERCP (OR = 0.53; 95%CI 0.43-0.66) and cholecystectomy (OR = 0.14; 95%CI 0.12-0.18) were associated with decreased odds of "transfer-out". Among 507,619 patients admitted with AP to large hospitals, 31,058 (6.1%) were "transferred-in" from other hospitals. The mortality rate for patients "transferred-in" was higher than those directly admitted (2.54% vs. 0.91%, p < 0.001). Multivariable analysis revealed that being "transferred-in" from other hospitals was an independent predictor of mortality (OR = 1.47; 95% CI 1.22-1.77).

CONCLUSIONS

Patients with AP transferred into large acute-care hospitals had a higher mortality than those directly admitted likely secondary to more severe disease. Early implementation of published clinical guidelines, triage, and prompt transfer of high-risk patients may potentially offset these negative outcomes.

Patterns of Care and Clinical Outcomes in Patients with Cerebral Sinus Venous Thrombosis

OBJECTIVES

To explore the association between rurality, transfer patterns and level of care with clinical outcomes of CVST patients in a rural Midwestern state.

MATERIALS AND METHODS

CVST patients admitted to the hospitals between 2005 and 2014 were identified by inpatient diagnosis codes from statewide administrative claims dataset. Records were linked across interhospital transfers using probabilistic linkage. Rurality was defined by Rural-Urban Commuting Areas using the 2-category approximation. Driving distances were estimated using GoogleMaps Application Programming Interface. Hospital stroke certification was defined by the Joint Commission. Severity of CVST was estimated by cost of care corrected for inflation and cost-to-charge ratios. Outcome was discharge disposition and total length of stay (LOS). Wilcoxon rank-sum, Chi-square, Fisher's exact tests and linear and logistic regressions were used.

RESULTS

168 CVST patients were identified (79.8% female; median age = 32, IQR = 24.0-45.5). Median LOS was four days (IQR = 2-7) and patients traveled a median of 8.1 miles (IQR = 2.5-28.5) to the first hospital; 42% of patients were transferred to a second hospital, 5% to a third. More than half (58.3%) bypassed the nearest hospital. 86% visit a primary or comprehensive stroke center (CSC) during their acute care. Rurality was not significantly associated with LOS or discharge disposition after adjusting for age, sex and cost of care. Patients in CSC demonstrated greater likelihood of being discharged home compared to at a primary stroke center after adjusting for age and disease severity (p = 0.008).

CONCLUSIONS

While rurality was not significantly associated with LOS or disposition outcome, care at a CSC increases likelihood of being discharge home.

Safety of returning patients immediately to their originating hospitals after primary percutaneous coronary intervention

Introduction

The objective of this study was to evaluate the safety and feasibility of the immediate return of patients with ST-elevation myocardial infarction (STEMI) to their originating hospitals after primary percutaneous coronary intervention (PPCI).

Methods

This was a prospective study, conducted between January 2014 and December 2017. All patients with STEMI who were transferred for PPCI and returned back to their referring hospitals (RB group) were included and compared to the onsite STEMI population (OS group). Patient’s demographics, PPCI data, bleeding and adverse cardiovascular events (ACEs) occurring during transfer, hospital stay, and at 1-month follow-up were recorded.

Results

A total of 156 patients in the OS group were compared against 350 patients in the RB group. We found that first medical contact to balloon time and onset of symptoms to balloon time were significantly longer in the RB group than in the OS group [110 ± 67 min vs. 46 ± 35 min (p < 0.0001) and 366 ± 300 min vs. 312 ± 120 min (p = 0.04)], respectively. There were no differences between the RB and OS groups in in-hospital ACEs: 0.3% versus 0% (p = 0.8) for death, 0.3% versus 0.6% (p = 0.79) for reinfarction, 0.6% versus 2% (p = 0.72) for bleeding, and no reported cases of repeat revascularization; and 30-day ACEs: 0.3% versus 0.6% (p = 0.82) for death, 0.3% versus 1.2% (p = 0.68) for reinfarction, 0.6% versus 2% (p = 0.74) for bleeding, and 1.1% versus 1.2% (p = 0.9) for repeat revascularization.

Conclusion

The immediate return of patients with noncomplicated STEMI after PPCI to their referring hospitals is safe and feasible, and can be used as part of an effective reperfusion strategy.

Step-down units are cost-effective alternatives to coronary care units with non-inferior outcomes in the management of ST-elevation myocardial infarction patients after successful primary percutaneous coronary intervention

Percutaneous coronary interventions (PCIs) within a door-to-balloon timing of 90 min have greatly decreased mortality and morbidity of ST-elevation myocardial infarction (STEMI) patients. Post-PCI, they are routinely transferred into the coronary care unit (CCU) regardless of the severity of their condition, resulting in frequent CCU overcrowding. This study assesses the feasibility of step-down units (SDUs) as an alternative to CCUs in the management of STEMI patients after successful PCI, to alleviate CCU overcrowding. Criteria of assessment include in-hospital complications, length of stay, cost-effectiveness, and patient outcomes up to a year after discharge from hospital. A retrospective case-control study was done using data of 294 adult STEMI patients admitted to the emergency departments of two training and research hospitals and successfully underwent primary PCI from 1 January 2014 to 31 December 2015. Patients were followed up for a year post-discharge. Student t test and χ² test were done as univariate analysis to check for statistical significance of p < 0.05. Further regression analysis was done with respect to primary outcomes to adjust for major confounders. Patients managed in the SDU incurred significantly lower inpatient costs (p = 0.0003). No significant differences were found between the CCU and SDU patients in terms of patient characteristics, PCI characteristics, in-hospital complications, length of stay, and patient outcomes up to a year after discharge. The SDU is a viable cost-effective option for managing STEMI patients after successful primary PCI to avoid CCU overcrowding, with non-inferior patient outcomes as compared to the CCU.

2019 Canadian Cardiovascular Society/Canadian Association of Interventional Cardiology Guidelines on the Acute Management of ST-Elevation Myocardial Infarction: Focused Update on Regionalization and Reperfusion

Rapid reperfusion of the infarct-related artery is the cornerstone of therapy for the management of acute ST-elevation myocardial infarction (STEMI). Canada's geography presents unique challenges for timely delivery of reperfusion therapy for STEMI patients. The Canadian Cardiovascular Society/Canadian Association of Interventional Cardiology STEMI guideline was developed to provide advice regarding the optimal acute management of STEMI patients irrespective of where they are initially identified: in the field, at a non-percutaneous coronary intervention-capable centre or at a percutaneous coronary intervention-capable centre. We had also planned to evaluate and incorporate sex and gender considerations in the development of our recommendations. Unfortunately, inadequate enrollment of women in randomized trials, lack of publication of main outcomes stratified according to sex, and lack of inclusion of gender as a study variable in the available literature limited the feasibility of such an approach. The Grading Recommendations, Assessment, Development, and Evaluation system was used to develop specific evidence-based recommendations for the early identification of STEMI patients, practical aspects of patient transport, regional reperfusion decision-making, adjunctive prehospital interventions (oxygen, opioids, antiplatelet therapy), and procedural aspects of mechanical reperfusion (access site, thrombectomy, antithrombotic therapy, extent of revascularization). Emphasis is placed on integrating these recommendations as part of an organized regional network of STEMI care and the development of appropriate reperfusion and transportation pathways for any given region. It is anticipated that these guidelines will serve as a practical template to develop systems of care capable of providing optimal treatment for a wide range of STEMI patients.

Intravenous Tissue Plasminogen Activator for Large Vessel Ischemic Stroke - Is There Still a Role?

While the efficacy of Intravenous tissue plasminogen activator (tPA) is well established, its impact on large vessel occlusion (LVO) is controversial. Whether IV tPA should be bypassed in favor of endovascular thrombectomy (MT) will be addressed. Compelling evidence exists to suggest tPA administration might be bypassed in tPA eligible patients in favor of MT for LVO. A trial of MT with patients randomized for IV tPA within the 4.5-h time window should conducted at comprehensive stroke centers demonstrating equipoise between time to tPA or MT with time to treatment from ED arrival of 45 min. We may do well to consider the systems pathway taken by interventional cardiologists 15 years ago.

Clinical Outcomes of Transferred Versus Onsite Primary Percutaneous Coronary Intervention for Patients With STEMI: Time to Look Beyond Door to Balloon Time

BACKGROUND

It is currently unknown if the delay due to practical aspects associated with transfer of patients from a non-percutaneous coronary intervention (PCI) facility to a primary PCI facility is associated with adverse outcomes.

METHODS

We conducted a retrospective cohort study of all patients who presented with ST-segment elevation myocardial infarction (STEMI) and underwent primary PCI in 2 large regional STEMI centers in Massachusetts between January 2005 and June 2009. The cohort was divided into onsite patients who presented directly to the primary PCI center and transferred patients referred from another facility. The primary outcome was a composite of in-hospital major cardiovascular events (death, myocardial infarction, and stroke). Secondary outcomes were the individual components of the composite endpoint and bleeding complications.

RESULTS

The cohort included a total of 1236 patients. Among them, 426 (34%) patients were transferred patients and 810 (66%) were onsite patients. The median door to balloon time was significantly higher at for transferred patients (124 vs. 71 minutes). There was no significant difference in primary composite endpoint between the 2 groups (onsite 3.8% vs. transfer 5.3%, odds ratio 1.50, 95% confidence interval 0.79-2.84; P = 0.21). Adjusted risk estimates did not show a statistical difference in all-cause bleeding rates between the groups (onsite 10.1% vs. transfer 7.3%, odds ratio 0.68, 95% confidence interval 0.41-1.14; P = 0.14).

CONCLUSIONS

This study confirms that well-established and integrated regional STEMI programs provide equivalent care to transferred patients and onsite patients. Parameters beyond door to balloon times should be investigated for their contributions to improve patient outcomes.

Implementing myocardial infarction systems of care in low/middle-income countries

Ischaemic heart disease is the leading cause of death worldwide, with an increasing trend from 6.1 million deaths in 1990 to 9.5 million in 2016, markedly driven by rates observed in low/middle-income countries (LMIC). Improvements in myocardial infarction (MI) care are crucial for reducing premature mortality. We aimed to evaluate the main challenges for adequate MI care in LMIC, and possible strategies to overcome these existing barriers.

Reperfusion is the cornerstone of MI treatment, but worldwide around 30% of patients are not reperfused, with even lower rates in LMIC. The main challenges are related to delays associated with patient education, late diagnosis and inadequate referral strategies, health infrastructure and insufficient funding. The implementation of regional MI systems of care in LMIC, systematising timely reperfusion strategies, access to intensive care, risk stratification and use of adjunctive medications have shown some successful strategies. Telemedicine support for remote ECG, diagnosis and organisation of referrals has proven to be useful, improving access to reperfusion even in prehospital settings. Organisation of transport and referral hubs based on anticipated delays and development of MI excellence centres have also resulted in better equality of care. Also, education of healthcare staff and task shifting may potentially widen access to optimal therapy.

In conclusion, efforts have been made for the implementation of MI systems of care in LMIC, aiming to address particularities of the health systems. However, the increasing impact of MI in these countries urges the development of further strategies to improve reperfusion and reduce system delays.

Another important time target in ST-elevation myocardial infarction management—door-in door-out time: Do we meet door-in door-out time targets?

Background:

In non-PCI capable hospitals, another important time to be noticed in patients who have been referred for PCI-capable centers; is the time of doo-in door-out (DIDO), defined as the duration of time from patient discharge from the transferrring hospital. In our country, there is no clear information about the duration of DIDO time and transfer time. Consequently, very little is known about how frequently these targets can be met nationally.

Objectives:

This study aimed to measure door-in door-out time for ST-elevation myocardial infarction diagnosed patients who admitted to emergency department of a hospital capable of non-percutaneous coronary intervention and to measure whether door-in door-out time meets the guidelines.

Methods:

This single-center, prospective study was conducted in emergency department (non-percutaneous coronary intervention capable) between 1 August 2015 and 1 August 2016 with patients who presented to the emergency department and were diagnosed with ST-segment elevation myocardial infarction. All the times including door-in time, door to electrocardiogram time, door to emergency medical services activation time, door to defined percutaneous coronary intervention hospital, and finally door-in door-out time were measured and recorded.

Results:

During the study period, 135 of patients met the inclusion criteria and diagnosed with ST-elevation myocardial infarction and referred to another hospital for percutaneous coronary intervention. When the median values (interquartile range of 25%–75%) of the time periods are examined, it is found door-in door-out time was 55 (43–74) min. It was found that the number of patients meeting the recommended duration of door-in door-out (30 min or less) was 12 (8.9%). Of the remaining 123 patients (91.1%), door-in door-out times were found to be over 30 min.

Conclusion:

In conclusion, our study showed that compliance with door-in door-out time is very poor and is far behind to met the criteria which is recommended by current guidelines.

Implementation of Regional ST-Segment Elevation Myocardial Infarction Systems of Care: Successes and Challenges

Current guidelines recommend that communities create and maintain a regional system of ST-segment elevation myocardial infarction (STEMI) care that includes assessment and continuous quality improvement of emergency medical services and hospital-based activities. Availability and timely access is a challenge in many areas of the United States. This article reviews clinical trial data supporting the use of primary percutaneous coronary intervention as the optimal reperfusion strategy, and fibrinolysis as an option when this is not possible. It then describes the outcomes and benefits of implementing regional systems of STEMI care, and discusses ongoing challenges for STEMI system implementation, including inadequate data collection and feedback, and hospital and physician competition.

The effects of fibrinolytic before referring STEMI patients: A systematic review and meta-analysis

BACKGROUND

Accessibility of primary percutaneous coronary intervention (PCI) in patients with ST-segment elevation myocardial infarction (STEMI) in primary care settings is limited. Referring patients to PCI-capable hospitals might increase cardiac events. Hence, fibrinolytic injection before referring patients to PCI-capable settings decreases cardiac events, however, the effect of fibrinolytic injection before the referral has not been systematically evaluated. This study aimed to systematically review the effect of fibrinolytic injection before referring patients with STEMI to PCI-capable settings.

METHODS

A systematic search with Embase, Cochrane CENTRAL, Google scholar, and PubMed was conducted. Studies conducted in patients with STEMI presented to non PCI-capable settings and compared fibrinolytic injection with no injection before referring patients to PCI-capable settings were included. The primary outcome was the composite outcomes of major adverse cardiac events (MACEs) at 30 days. Meta-analyses were performed using random-effect model.

RESULTS

Of 912 articles, three RCTs and three non-RCTs were included. Based on RCTs, fibrinolytic injection before the referral has failed to decrease MACEs compared to non-fibrinolytic injection [relative risk (RR) 1.18; 95% confidence interval (CI), 0.89-1.57, p = 0.237]. Fibrinolytic injection has also failed to decrease mortality, re-infarction, and ischemic stroke. On the other hand, fibrinolytic injection was associated with a higher risk of major bleeding.

CONCLUSIONS

In non PCI-capable settings, fibrinolytic injection before referring patients with STEMI to PCI-capable settings has no clinical benefit but could increase risk of major bleeding. Clinicians might more carefully consider whether fibrinolytic injection should be used in patients with STEMI before the referral.

Comparing mortality between fibrinolysis and primary percutaneous coronary intervention in patients with acute myocardial infarction: a systematic review and meta-analysis of 27 randomized-controlled trials including 11 429 patients

OBJECTIVES

We aimed to improve the limitations encountered in previously published studies and then compare mortality in patients with acute myocardial infarction (AMI) who were treated with either fibrinolysis or a primary percutaneous coronary intervention (PPCI).

METHODS

EMBASE, MEDLINE, and the Cochrane databases were searched for trials comparing fibrinolysis with PPCI in patients with AMI. The only endpoint that was assessed in this analysis was all-cause mortality. Therefore, in-hospital, short-term, mid-term, and long-term mortality were analyzed, whereby odds ratios (OR) with 95% confidence intervals (CIs) were calculated using the RevMan 5.3.

RESULTS

A total of 11 429 patients obtained from 37 studies (involving 27 trials) were included. The results of this analysis showed that fibrinolytic therapy was associated with significantly higher in-hospital and mid-term mortality (OR: 0.61; 95% CI: 0.46-0.82, P=0.001 and OR: 0.73; 95% CI: 0.54-0.99, P=0.04, respectively). Short-term and long-term mortality were also significantly higher in the fibrinolytic group (OR: 0.76; 95% CI: 0.65-0.90, P=0.001, and OR: 0.82; 95% CI: 0.71-0.96, P=0.01, respectively) compared with PPCI.

CONCLUSION

This analysis of 11 429 patients showed a significantly higher mortality rate to be associated with fibrinolysis compared with PPCI in these patients with AMI. Hence, compared with fibrinolysis, PPCI is expected to be the preferred method of revascularization in patients with AMI, especially in PCI-capable centers.

Outcomes of Physician-Staffed Versus Non-Physician-Staffed Helicopter Transport for ST-Elevation Myocardial Infarction

Background

The effect of physician‐staffed helicopter emergency medical service (HEMS) on ST‐elevation myocardial infarction (STEMI) patient transfer is unknown. The purpose of this study was to evaluate the characteristics and outcomes of physician‐staffed HEMS (Physician‐HEMS) versus non‐physician‐staffed (Standard‐HEMS) in patients with STEMI.

Methods and Results

We studied 398 STEMI patients transferred by either Physician‐HEMS (n=327) or Standard‐HEMS (n=71) for primary or rescue percutaneous coronary intervention at 2 hospitals between 2006 and 2014. Data were collected from electronic medical records and each institution's contribution to the National Cardiovascular Data Registry. Baseline characteristics were similar between groups. Median electrocardiogram‐to‐balloon time was longer for the Standard‐HEMS group than for the Physician‐HEMS group (118 vs 107 minutes; P=0.002). The Standard‐HEMS group was more likely than the Physician‐HEMS group to receive nitroglycerin (37% vs 15%; P<0.001) and opioid analgesics (42.3% vs 21.7%; P<0.001) during transport. In‐hospital adverse outcomes, including cardiac arrest, cardiogenic shock, and serious arrhythmias, were more common in the Standard‐HEMS group (25.4% vs 11.3%; P=0.002). After adjusting for age, sex, Killip class, and transport time, patients transferred by Standard‐HEMS had increased risk of any serious in‐hospital adverse event (odds ratio=2.91; 95% CI=1.39–6.06; P=0.004). In‐hospital mortality was not statistically different between the 2 groups (9.9% in the Standard‐HEMS group vs 4.9% in the Physician‐HEMS group; P=0.104).

Conclusions

Patients with STEMI transported by Standard‐HEMS had longer transport times, higher rates of nitroglycerin and opioid administration, and higher rates of adjusted in‐hospital events. Efforts to better understand optimal transport strategies in STEMI patients are needed.

New or presumed new left bundle branch block in patients with suspected ST-elevation myocardial infarction

AIMS

Using a comprehensive large prospective regional ST-elevation myocardial infarction (STEMI) system database, we evaluated the prevalence, clinical and angiographic characteristics, and outcomes in patients with ischemic symptoms and new or presumed new left bundle branch block (LBBB). We then tested a new hierarchical diagnosis and triage algorithm to identify more accurately new LBBB patients with an acute culprit lesion.

METHODS AND RESULTS

From March 2003 to June 2013, 3903 consecutive STEMI patients were treated using the Minneapolis Heart Institute regional STEMI protocol including 131 patients (3.3%) with new LBBB. These patients had fewer culprit arteries (54.2% vs. 86.4%; P<0.001), were older, more commonly women, with a lower ejection fraction, and more frequently presented with cardiac arrest or heart failure than those without new LBBB. At 1 year follow-up, all-cause mortality accounting for baseline differences was higher in patients with new LBBB (hazard ratio 1.73, 95% confidence interval 1.17-2.58; P=0.007). The new algorithm yielded high sensitivity (97%) and negative predictive value (94%) for identification of a culprit lesion. Using the definition of new LBBB with either hemodynamically unstable features or Sgarbossa concordance criteria on electrocardiogram (ECG), 45% of new LBBB patients would have been treated as 'STEMI equivalent'.

CONCLUSION

Patients with acute ischemic symptoms and new LBBB represent a high-risk population with unique clinical challenges. If validated in an independent dataset, the new algorithm may improve the diagnostic accuracy regarding reperfusion therapy for new LBBB patients.

Ten Years of Advancements in Interventional Cardiology

The past decade has seen the evolution of an exciting technology that has changed forever the treatment of aortic aneurysmal disease. From rather crude homemade stent-grafts constructed in the surgical suite to elegant commercially manufactured devices in a variety of configurations and sizes, the aortic endograft has experienced a meteoric rise in popularity to become a beneficial, minimally invasive therapy that can obviate the risk of rupture and death. There are now 3 approved endovascular devices on the market for infrarenal abdominal aortic aneurysm repair, and it is likely that additional and improved devices will become available in the future. This review revisits the developmental history of the aortic endograft, noting the ongoing refinements that have arisen from our experiences with the growing population of stent-graft patients. Although research continues to search for solutions to the problems of endoleak and migration, long-term results even with the earlier second and third-generation devices are better than has been achieved with open surgical repair.

The impact of recommended percutaneous coronary intervention care on hospital outcomes for interhospital-transferred STEMI patients

BACKGROUND

Timely transfer and percutaneous coronary intervention (PCI) with or without thrombolysis are recommended by the American Heart Association (AHA) to care for ST-segment elevation myocardial infarction (STEMI) patients who present first to a non-PCI-capable hospital. This study was to evaluate the impact on in-hospital mortality of the compliance with guidelines regarding to the time of PCI for patients with STEMI who were transferred to a capable PCI hospital.

METHODS

We used the CArdioVAscular disease Surveillance data from November 2007 to December 2012 for this study. Adult patients who were diagnosed with STEMI and transferred from a primary hospital for PCI were included. Patients who underwent PCI or coronary artery bypass graft surgery in the primary hospital and patients with an unknown emergency department disposition were excluded. The main exposure was the AHA recommendation for reperfusion therapy. We tested the association between compliance with AHA and hospital mortality.

RESULTS

A total of 2078 patients were analyzed, 30.0% of whom were treated in compliance with the guidelines, whereas the remaining 70.0% were not. Thrombolysis was performed in 7.9% and 0.8% (P value < .01) and hospital mortality was 5.0% and 6.8% (P value = .11) in the compliant and violence groups, respectively. The adjusted odds ratios (95% confidence intervals) of the compliant group for hospital mortality were 0.75 (0.46-1.21), respectively. A sensitivity analysis of symptom onset to arrival time was a trend for a beneficial effect in the compliant group.

CONCLUSIONS

Among the patients who were transferred for STEMI care, undergoing PCI as recommended by the AHA was not associated with a mortality benefit, but the patients whose symptom onset to hospital arrival time was within 30 minutes showed an association between compliance and lower mortality.

Reperfusion Options for ST Elevation Myocardial Infarction Patients with Expected Delays to Percutaneous Coronary Intervention

Primary percutaneous coronary intervention (PCI) is the preferred reperfusion strategy for ST elevation myocardial infarction (STEMI). However, only one-third of hospitals in the US have PCI availability 24/7. For non-PCI hospitals, transfer remains the optimal strategy. For expected delays of greater than 120 minutes, a pharmacoinvasive strategy is recommended. In patients with evidence of failed reperfusion or hemodynamic instability, immediate rescue PCI should be performed. All other patients should undergo routine cardiac catheterization and PCI within 24 hours after fibrinolysis. A pharmacoinvasive strategy is best implemented within an organized regional STEMI system with prospective standardized transfer protocols.

Inter-hospital transfer is associated with increased mortality and costs in severe sepsis and septic shock: An instrumental variables approach

PURPOSE

The objective of this study was to evaluate the impact of regionalization on sepsis survival, to describe the role of inter-hospital transfer in rural sepsis care, and to measure the cost of inter-hospital transfer in a predominantly rural state.

MATERIALS AND METHODS

Observational case-control study using statewide administrative claims data from 2005 to 2014 in a predominantly rural Midwestern state. Mortality and marginal costs were estimated with multivariable generalized estimating equations models and with instrumental variables models.

RESULTS

A total of 18 246 patients were included, of which 59% were transferred between hospitals. Transferred patients had higher mortality and longer hospital length-of-stay than non-transferred patients. Using a multivariable generalized estimating equations (GEE) model to adjust for potentially confounding factors, inter-hospital transfer was associated with increased mortality (aOR 1.7, 95% CI 1.5-1.9). Using an instrumental variables model, transfer was associated with a 9.2% increased risk of death. Transfer was associated with additional costs of $6897 (95% CI $5769-8024). Even when limiting to only those patients who received care in the largest hospitals, transfer was still associated with $5167 (95% CI $3696-6638) in additional cost.

CONCLUSIONS

The majority of rural sepsis patients are transferred, and these transferred patients have higher mortality and significantly increased cost of care.

Myocardial perfusion grade predicts final infarct size and left ventricular function in patients with ST-elevation myocardial infarction treated with a pharmaco-invasive strategy (thrombolysis and early angioplasty)

AIMS

Primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI) usually restores TIMI 3 flow in the occluded artery, but microvascular impairment may persist in >30% of patients. Less is known about microvascular reperfusion in STEMI patients treated with thrombolysis followed by early PCI. We aimed to assess the association between TIMI myocardial perfusion (TMP) at the end of the PCI procedure and left ventricular function (LVEF) and infarct size after three months in such patients.

METHODS AND RESULTS

Patients with STEMI treated with thrombolysis and early PCI were included. TMP grade was assessed at the end of the PCI procedure, and MRI was performed after three months. Of the 89 patients included, 92% (n=82) had TIMI 3 flow at the end of the PCI procedure, while only 62% (n=55) had TMP grade 2 or 3. Patients with TMP grade 2-3 had significantly higher LVEF (59% [53-67] vs. 50% [41-56], p<0.0001) and smaller infarct size (8.3 ml [2.7-15.5] vs. 20.7 ml [13.0-36.0], p<0,0001) after three months.

CONCLUSIONS

In STEMI patients treated with thrombolysis and early PCI, the TMP grade at the end of the PCI procedure was significantly associated with LVEF and infarct size after three months.

Prognostic factors of in-hospital mortality in all comers with ST elevation myocardial infarction undergoing primary percutaneous coronary intervention

BACKGROUND

The prognostic factors of in-hospital mortality in all comers and unselected patients with ST elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI) have not been well established.

OBJECTIVE

To identify the predictive factors of in-hospital mortality in patients with STEMI undergoing primary PCI in a tertiary heart centre.

METHODS

Between January 2008 and December 2011, all patients with STEMI undergoing primary PCI were retrospectively included in this study. Baseline characteristics and angiographic data were reviewed and recorded. The study endpoint was all-cause in-hospital mortality.

RESULTS

Of the 541 patients included in the study, 63 (11.6%) died during hospitalisation. Cardiogenic shock at admission was recorded in 301 patients (55.6%) and 424 patients (78%) had multivessel disease. Median door-to-device time was 65 min. After adjustment for baseline variables, the factors associated with in-hospital mortality included age >60 years (OR 2.98, 95% CI 1.17 to 7.05; p=0.01), left ventricular ejection fraction <40% (OR 2.53, 95% CI 1.20 to 5.36; p=0.02), and final TIMI flow grade 0/1 (OR 20.55, 95% CI 3.49 to 120.94; p=0.001).

CONCLUSIONS

Age, left ventricular function and final TIMI flow are significant predictors of adverse outcomes in unselected patients with STEMI undergoing primary PCI.

[Outcomes evaluation after the implementation of a pre-hospital thrombolysis protocol in rural areas]

INTRODUCTION

The aim is to evaluate the outcomes obtained from the implementation of a pre-hospital thrombolysis protocol in 3 rural emergency care teams, as well as delays and strategies of reperfusion applied in the treatment of the ST-segment elevation myocardial infarction.

MATERIAL AND METHODS

Retrospective cohort study (n=52) with historical control (n=20) of the patients assisted for ST-segment elevation myocardial infarction. Medical emergency care teams, hospital, computerized medical history and ARIAM register reports were revised, obtaining epidemiological and clinical features, off-hospital management, reperfusion, time intervals and mortality.

RESULTS

The baseline features in both groups were not significantly different. There was a non-significant improvement of emergency care teams-hospital diagnostic concordance (85.3 versus 76.9%). We found a similar use of nitroglycerin, morphine and aspirin; significant increase (P<0.0001) of clopidogrel/prasugrel (55 versus 90.4%) and enoxaparin/fondaparinux (35 versus 76.9%), as well as pre-hospital thrombolysis (5 versus 30,8%, P<0.03), that was applied within the first 2h to 71.4%, with a median door-needle of 40min, whereas in-hospital thrombolysis and primary angioplasty were performed after 3h from the symptoms onset (P<0.01). Delays are associated with the patient's own lateness (P<0.02). Pharmaco-invasive strategy increases (62.5 versus 84.6%) more than primary angioplasty (15 versus 17.3%), reducing in-hospital thrombolysis (35 versus 19.2%), all of them non-significant. Complications are similar and one-year mortality is reduced (P<0.67).

CONCLUSIONS

The protocol is effective, safe, and reliable. It reduces delays and improves pre-hospital attention. The pharmaco-invasive strategy is a valid option.

Field triage in the ambulance versus referral via non-percutaneous coronary intervention centre in ST-elevation myocardial infarction patients undergoing primary percutaneous coronary intervention: A systematic review

AIMS

The purpose of this study was to determine whether direct ambulance transport of ST-elevation myocardial infarction (STEMI) patients to a percutaneous coronary intervention (PCI) hospital (field triage) leads to a lower 30-day mortality compared to transport via a referral non-PCI hospital (referral via a spoke centre) in STEMI patients.

METHODS AND RESULTS

We performed a systematic review of interventions. An experienced librarian searched in PubMed, EMBASE.com and The Cochrane Library (via Wiley) from January 1980-February 2013. Studies that examined field triage and/or referral via a spoke centre in STEMI patients treated with primary or facilitated PCI were included. Two authors independently conducted the study selection and data extraction. Multivariable frequency weighted logistic regression analysis was performed to assess the effect of the type of transfer on the outcome measures. We identified 14 randomised clinical trials (RCTs), including 20 transfer groups and 4474 participants. Thirty-day mortality was lower in patients who underwent field triage (3.0%; 95% confidence interval (CI) 2.2-4.2) compared to patients who were referred via a spoke centre (4.7%; 95% CI 4.0-5.5). In multivariable frequency weighted logistic regression analysis, field triage was independently associated with a lower incidence of 30-day mortality (odds ratio (OR): 0.58; 95% CI 0.37-0.89).

CONCLUSION

Field triage compared to referral via a spoke centre leads to a lower 30-day mortality in STEMI patients. Therefore, direct ambulance transport to a PCI hospital should become the transfer type for STEMI patients.

Achieving regionalization through rural interhospital transfer

Regionalization of emergency medical care aims to provide consistent and efficient high-quality care leading to optimal clinical outcomes by matching patient needs with appropriate resources at a network of hospitals. Regionalized care has been shown to improve outcomes in trauma, myocardial infarction, stroke, cardiac arrest, and acute respiratory distress syndrome. In rural areas, effective regionalization often requires interhospital transfer. The decision to transfer is complex and includes such factors as capabilities of the presenting hospital; capacity at the receiving hospital; and financial, geographic, and patient-preference considerations. Although transfer to a comprehensive center has proven benefits for some conditions, the transfer process is not without risk. These risks include clinical deterioration, limited resource availability during transport, vehicular crashes, time delays for time-sensitive care, poor communication between providers, and neglect of patient preferences. This article reviews the transfer decision, financial implications, risks, and considerations for patients undergoing rural interhospital transfer. We identify several strategies that should be considered for development of the regionalized emergency health care system of the future and identify areas where further research is necessary.