A citywide protocol for primary PCI in ST-segment elevation myocardial infarction

N Engl J Med. 2008 Jan 17;358(3):231-40. doi: 10.1056/NEJMoa073102.


Background: If primary percutaneous coronary intervention (PCI) is performed promptly, the procedure is superior to fibrinolysis in restoring flow to the infarct-related artery in patients with ST-segment elevation myocardial infarction. The benchmark for a timely PCI intervention has become a door-to-balloon time of less than 90 minutes. Whether regional strategies can be developed to achieve this goal is uncertain.

Methods: We developed an integrated-metropolitan-area approach in which all patients with ST-segment elevation myocardial infarction were referred to a specialized center for primary PCI. We sought to determine whether there was a difference in door-to-balloon times between patients who were referred directly from the field by paramedics trained in the interpretation of electrocardiograms and patients who were referred by emergency department physicians.

Results: Between May 1, 2005, and April 30, 2006, a total of 344 consecutive patients with ST-segment elevation myocardial infarction were referred for primary PCI: 135 directly from the field and 209 from emergency departments. Primary PCI was performed in 93.6% of patients. The median door-to-balloon time was shorter in patients referred from the field (69 minutes; interquartile range, 43 to 87) than in patients needing interhospital transfer (123 minutes; interquartile range, 101 to 153; P<0.001). Door-to-balloon times of less than 90 minutes were achieved in 79.7% of patients who were transferred from the field and in 11.9% of those transferred from emergency departments (P<0.001).

Conclusions: Guideline door-to-balloon-times were more often achieved when trained paramedics independently triaged and transported patients directly to a designated primary PCI center than when patients were referred from emergency departments.

Publication types

  • Evaluation Study

MeSH terms

  • Aged
  • Angioplasty, Balloon, Coronary / standards*
  • Cardiac Catheterization
  • Clinical Protocols / standards*
  • Coronary Angiography
  • Electrocardiography
  • Emergency Medical Services / standards*
  • Emergency Medical Technicians
  • Female
  • Hospital Mortality
  • Humans
  • Male
  • Middle Aged
  • Myocardial Infarction / mortality
  • Myocardial Infarction / therapy*
  • Patient Transfer / statistics & numerical data
  • Practice Guidelines as Topic / standards
  • Referral and Consultation* / standards
  • Time Factors
  • Treatment Outcome
  • Triage
  • Urban Health Services / standards