The AHA Guidelines and Scientifi c Statements Handbook
Ongoing research efforts and
future directions
Regardless of the mode of reperfusion, the overarch-
ing concept is to minimize total ischemic time,
which is defi ned as the time from onset of symptoms
of STEMI to initiation of reperfusion therapy. It is
increasingly clear that two types of hospital system
provide reperfusion therapy: those with percutane-
ous coronary intervention (PCI) capability and
those without PCI capability. When PCI capability
is available, the best outcomes are achieved by offer-
ing this strategy 24 hours per day, 7 days per week.
The systems goal should be a fi rst medical contact-
to-balloon time within 90 minutes. There should be
an ongoing program of outcomes analysis and peri-
odic case review to identify process-of-care strate-
gies that will continually improve time to treatment
and facilitate rapid and appropriate treatment. A
comprehensive effort in this regard is the AHA
Mission: Lifeline program, a community-based
national initiative to improve the quality of care and
outcomes of patients with STEMI by improving
health care system readiness and response to STEMI
(Figure 3.13) [19]. The “Door-to-Balloon (D2B):
An Alliance for Quality” campaign (www.d2bal-
liance.org), launched by the ACC in collaboration
with many organizations, including the AHA, aims
to improve the timeliness of primary PCI. The
goal is to increase the percentage of patients who
receive timely primary PCI, with an emphasis on
having at least 75% of patients treated within 90
minutes of presentation at the hospital, with a rec-
ommendation for the use of evidence-based strate-
gies to reduce needless delays. The 75% goal was set
in recognition that some patients have clinically
relevant non-system-based delays that do not repre-
sent quality-of-care issues. In hospitals without
PCI capability, immediate transfer for primary PCI
is a treatment option when the expected door-
to-balloon time is within 90 minutes of fi rst medical
contact.
The STEMI Guidelines serve as the basis for perfor-
mance measures, many of which are common to both
STEMI and UA/NSTEMI patients (Table 3.7) [20].References available online at http://www.Wiley.com/go/
AHAGuidelineHandbook.During the production of this book these relevant
AHA statements and guidelines were published:
Hyperglycemia and Acute Coronary Syndrome,
http://circ.ahajournals.org/cgi/content/full/
117/12/1610; Management of Cocaine-Associated
Chest Pain and Myocardial Infarction, http://
circ.ahajournals.org/cgi/content/full/117/14/1897;
Implementation and Integration of Prehospital
ECGs into Systems of Care for Acute Coronary
Syndromes, http://circ.ahajournals.org/cgi/reprint/
CIRCULATIONAHA.108.190402.