Primary percutaneous coronary intervention for every patient with ST-segment elevation myocardial infarction: what stands in the way?

According to data from randomized, controlled trials, primary percutaneous coronary intervention (PCI) is the treatment of choice for ST-segment elevation myocardial infarction (MI). In these trials, 1 life was saved and 2 other life-threatening complications, including stroke and reinfarction, were prevented for every 50 patients with ST-segment elevation MI treated with primary PCI rather than thrombolytic therapy. Only 1 major bleeding episode occurred. How can these superior results be realized outside the context of randomized trials? We anticipate 4 obstacles to instituting primary PCI as the universal treatment of ST-segment elevation MI: 1) lack of timely availability, 2) technical expertise of center and operator, 3) the need to address patient subgroups that are not studied in randomized trials, and 4) comparisons of primary PCI to newer pharmacologic regimens. We propose 3 strategies to increase the availability of this procedure: 1) perform primary PCI in qualified community hospitals without surgical back-up; 2) transfer patients from community hospitals without primary PCI capability to hospitals with primary PCI capability; and 3) develop a universal system in which ambulances directly transfer patients to a regional primary PCI center, not necessarily to the closest hospital, similar to the system used for trauma patients. We contend that, in light of the superior clinical outcomes seen with primary PCI for treating ST-segment elevation MI, this procedure should be available to all patients with ST-segment elevation MI and efforts should be made to institute these measures.