Chapter 19
Creating Efficient STEMI Systems
Ivan Rokos, MD, FACEP, (FACC), Sameer Mehta, MD, FACC, Estefania Oliveros, MD, Zarna Dahya, MD, William J. French, MD, FACC

Across much of the world, acute ST-elevation myocardial infarction (STEMI) remains a major cause of mortality and morbidity. The most common cause of acute STEMI is sudden plaque rupture within a coronary vessel, resulting in thrombus formation and acute occlusion of the infarct-related artery. Without therapy, an acute coronary occlusion can quickly lead to myocardial necrosis, long-term cardiac complications, and even sudden death. Because “time is muscle” has remained a fundamental principle in cardiology for more than 30 years, the primary goal of therapy for acute STEMI is timely reperfusion
with either fibrinolytics or primary percutaneous coronary intervention (PCI). The current American College of Cardiology (ACC)/American Heart Association (AHA) and European guidelines prioritize primary PCI as the preferred strategy for reperfusion if performed in a timely manner by expert interventionalists.

This chapter describes the creation of efficient STEMI systems, with a focus on primary PCI as the “Plan A” reperfusion strategy. Fibrinolytic therapy is considered the “Plan B” option in most situations, but this option is upgraded to “Plan A” status for those patients who cannot receive timely primary PCI due to distance from a cath lab, local geography, weather-related issues, or natural disaster. The chapter begins with a review of the evidence base for rapid reperfusion, followed by a discussion of the many driving forces behind the creation of STEMI systems and regional networks. Next, issues surrounding five points of entry into the STEMI process are evaluated, followed by a detailed description of two types of
STEMI receiving center networks (pre-hospital cardiac triage and inter-hospital transfer). Additionally, topics such as false-positive cath lab activation, pharmaco-invasive strategies, and cost-effectiveness
are briefly reviewed.