Management of acute coronary syndromes in the community hospital without cardiac surgical capability: how can access to interventional therapy be improved?

Early coronary artery intervention is emerging as the treatment of choice for patients with high risk acute coronary syndromes (ACS). However, most patients with ACS are admitted to hospitals which do not have ready access to interventional therapy. Extending the benefits of early intervention to this population is problematic at such community hospitals, since this approach would require either emergency transfer to a tertiary center or the performance of angioplasty on-site at hospitals without cardiac surgical capability. A third solution, pre-hospital ambulance triage to interventional centers, is not currently practised in most countries. A growing body of evidence indicates that hospitals without cardiac surgical capability can establish safe and effective primary angioplasty programs. Patients with acute myocardial infarction (AMI) who are randomized to transfer for primary angioplasty without fibrinolytic treatment have fewer major adverse cardiac events than those treated with fibrinolytics alone or fibrinolytics and transfer. In patients with unstable angina (UA) or non-ST-elevation AMI, an early aggressive approach led to a significant reduction in the composite end-point of death, AMI, or rehospitalization for recurrent UA at 6 months with no increase in cost, compared with conservative management. Ongoing trials in Europe indicate that pre-hospital ambulance triage of patients with large AMI to interventional centers can be remarkably rapid, safe, and effective. In order to improve the access of such patients to early intervention, 3 interdependent solutions are proposed:The development of more interventional programs at those hospitals without cardiac surgical facilities that can meet rigorous standards. The development of protocols to insure the early and more frequent transfer of patients with high-risk ACS to interventional centers for coronary angiography and revascularization. The pre-hospital triage of patients with AMI to established heart attack centers with 24-hour, 365-day emergency interventional capability for immediate primary angioplasty (after the model of trauma centers). Universal triage/transfer of all such patients to interventional centers could, however, quickly flood the capability of all tertiary surgical hospitals. With the aging of the 'baby boomers' in the near future, the need for interventional facilities will increase even further. Thus the second and third solutions above will ultimately depend on the first solution. Improving the delivery of interventional therapy to patients with ACS can provide a substantial healthcare benefit to society.