Letter by Elshazly Regarding Article "Primary Coronary Angioplasty for ST-Elevation Myocardial Infarction (STEMI) in Qatar: First Nationwide Program".

Dear Editor:

In their article “Primary Coronary Angioplasty for ST-Elevation Myocardial Infarction (STEMI) in Qatar: First Nationwide Program”, Gehani et al. developed an impressive plan to implement primary percutaneous coronary intervention (PCI) for the first time in Qatar. As a graduate of Weill Cornell Medical College in Qatar, I have witnessed immense improvement in the Qatari healthcare system over the past few years. From building the new state of the art Heart Hospital to developing the first unified nationwide primary PCI program in the world, there is no doubt that Qatar has made an immense leap towards implementing world-class cardiovascular healthcare in the Middle East.

The authors are applauded for their immense efforts to develop such a complicated protocol from scratch. Strategies such as 12-lead ECG transmission by EMS, a single easily reachable dedicated phone line, near campus accommodations for the primary PCI team and a nationwide awareness program are all crucial to sustaining a door to balloon (DTB) time of < 90 min, which is the essence of primary PCI . Given the importance of achieving DTB time < 90 min for the success of this program, it is important to outline some areas for improvement.

Accurate diagnosis of STEMI is the most important step of this program especially in the extremely busy ED and Primary Health Centers of Hamad General Hospital (HGH). Most patients with STEMI present to the ED and outpatient clinics, instead of calling EMS. Therefore, efficient standard protocols for the evaluation of patients presenting with chest pain should be developed. These protocols should outline specific time intervals from first contact with medical personnel to arrival at the catheterization lab such as the Mayo clinic protocol and should be printed and distributed to all healthcare providers in Qatar. An online training course about primary PCI should be offered to all medical personnel.

In the current high-tech era, an electronic medical record (EMR) system is imperative for faster diagnosis of equivocal cases of STEMI. For example, rapid access to baseline ECGs can help differentiate a new Left Bundle Branch Block from an old one. Therefore, developing an EMR for ECGs that is easily accessible to the on call interventional cardiologist is very crucial.

HGH is the biggest hospital in the country. It incorporates all specialties other than cardiology, which has relocated to the Heart Hospital. HGH patients who develop STEMI will require transfer to the Heart Hospital for primary PCI. This is a time consuming process that will waste 20–30 min of transport. Having a fully equipped catheterization lab at HGH as well as other large hospitals such as Al-Wakrah is an idea worth considering for maintaining a DTB < 90 min. Training specialized transport teams that understand the concept of “time is life” in STEMI is also crucial.

Finally, it is important to recognize that timely feedback starting at day one will help significantly improve this program at a faster pace. 24–48 h audits and feedback on each case will help identify flaws that can be fixed reliably and quickly.