Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
1 Primary versus secondary transport of STEMI patients – an impact on transport times and mortality. Abdulwasya Almawiri1, Jan F. Vojacek2, Josef Bis2, Josef Stasek2 , Ziad Albahri 2 Medical Service , Hradec Kralove, Czech Republic, 2 1 Emergency Department of Cardiovascular Medicine I, Charles University Prague, School of Medicine and University Hospital Hradec Kralove, Czech Republic Corresponding author: Ziad Albahri, Charles University Prague, Faculty of Medicine in Hradec Kralove, Department of Pediatrics and Cardiovascular Medicine, Hradec Kralove, Czech Republic, e-mail address: [email protected], [email protected]: tel 420 776266650 Keywords: STEMI – Primary PCI – Transport – Mortality Brief summary: Our study is first to show that direct transport from field to catheterization laboratory not only significantly shortens the transport times but also translates into significant decrease of not only one month but also one year mortality. Still significant proportion of patients are transported to regional hospitals or to the Coronary Care Unit of the Cardiac Center and only then to the catheterization laboratory. 2 Abstract: Aim: The door-balloon time (DBT) is linked to morbidity and mortality of patients with ST segment elevation myocardial infarction (STEMI). Despite preferable direct transport to catheterization laboratory (primary transport – PT), still significant proportion of STEMI patients is transported via non-PCI regional hospitals or Coronary Care Units (secondary transport – ST) prior to primary percutaneous coronary intervention (PPCI). This study assessed to what extent PT vs ST affects the DBT and mortality. Methods: Our region with 600,000 inhabitants uses 24 hours / 365 days system of immediate transport of patients with STEMI lasting less than 12 hours to referral catheterization laboratories in the tertiary University Hospital Cardiac Center for more than 15 years. We prospectively recorded DBT of consecutive patients with STEMI, treated by PCI in the years 2012-2013. Consequent follow-up was obtained in all patients. Results: Six hundred seventy-seven patients, age 37-96 years, mean 64 ± 16 years, 475 (70%) of them males and 202 (30%) females, were enrolled for the final analysis. From this number, 354 (52.3%) patients had PT and 323 (47.7%) ST. Median of DBT was 34±15.9 minutes for PT patients (n=354) and 100±28.8 minutes for patients with ST (n=323) (p<0.005). One-month mortality was 4% vs 9.5% (p=0.002) in the PT vs ST group, respectively. One-year mortality in the PT and ST groups was 7.3 vs 20.5% (p<0.005), respectively. Conclusion: The admission of patients with STEMI to regional hospitals or Coronary Care Units instead of direct transport to catheterization laboratory significantly prolongs the DBT and increases mortality. 3 Abstract: الهدف من الدراسة ):(Aim تقييم تآثير التاخير في الوقت )(The door-balloon time - DBT في نقل المرضى اللذين يعانون من الذبحه الصدريه الحادة )(STEMI الى قسم القثطرة و العناية القلبية الجرا ء عملية قثطرة مباشرة )(direct- PCI و تدوين الوفاة معدل خالل شهر و خالل سنة بعد عملية القثطرة بين المرضى اللذين نقلوا من مسشفيات صغيرة او عيادات خارجيه و المرضى الذين نقلوا من البيت مبا شرة الى قسم القثطرة و العناية القلبية. الطريقة Methods: يستقبل مركز القلب في المشفى الجامعي في هرادتس كرالوف الذي يعمل ٤٢ساعه /اليوم طوال العام المرضى اللذين يعانون من الذبحه الصدريه الحادة من المحافظه الذي نعيش فيها وماحولها من مدن صغيرة )عدد سكانها 600000نسمة (. قسمنا المرضى بالذبحة الصدرية )(STEMI) ( Acute Myocardial Infarction with ST elevation الى مجموعتين :المجموعه اآلولى تتضمن نقل مباشر الى قسم القثطرة و العناية القلبية بواسطه سيارات االسعاف . Primary Transport المجموعه ا لثانيه :نقل غير مباشر للمرضى من المسشفيات االخرى الى قسم القثطرة و العناية القلبية .Secondary Transport الدراسة تمت بين سنة .2013 – 2012سجلنا الوقت من بداية االلم الصدر ي )(Symptom-Onset-to Balloon Time عند مرضى الذبحة الصدرية )-Acute Myocardial Infarction with ST elevation (STEMI حتى فتح الشريان المغلق بالبالون او الشبكة )(by balloon or Stent وسجلنا الوقت من دخول المشفى الى توسيع الشريان خالل ٢٤ساعة من بدء االعراض, المغلق ).(Door Balloon Time-DBT سجلنا الفرق في ارتفاع الوفاة معدل Mortalityوالمراضة Morbidityعند المجوعتين. النتائج Results: ستمئة وسبعة وسبعون مريضا ,ا لعمر من 96-37سنة ,متوسط ا لعمر 64 ±16سنة (70%) 475 ,من الرجال و (30%) 202من النساء شملوا في هذه الدراسة. من هذا الرقم (52.3%) 354 :نقلو مباشرة الى مركز القلب ) (Primary Transportو (47.7%) 323 نقل غير مباشر من المسشفيات االخرى ). (Secondary Transport متوسط الوقت ) (DBTللنقل المباشر كان 15.9±34دقيقة ) .P Valeu= (p<0.005وللنقل غير ا لمباشر . 28.8±100 معدل الوفيات خالل شهر ) (one-month mortalityكانت 4%للنقل المباشر و 9.5%للنقل غير ا لمباشر ).(P=0.002 معدل الوفيات خالل سنة ) (one-year mortalityكان 7.3 %للنقل المباشر و 20.5%للنقل غير المباشر ).(P<0.005 الخاتمة(Conclusion) : النقل الغير مباشر لمرضى الذبحة الصدرية الحادة الى قسم القثطرة و العناية القلبية يرفع لديهم معدل الوفيات الشهري و السنوي . 4 Introduction The importance of time aspects in the treatment of patients with ST segment elevation myocardial infarction (STEMI) is stressed both in the American College of Cardiology and the European Society of Cardiology guidelines [1, 2]. A primary transport (PT) of a patient with STEMI directly into the Cardiac Centers with feasibility of an immediate primary percutaneous coronary intervention (PPCI) and not to the nearest hospital is recommended [1, 2]. In the real situation, many delays in both prehospital and hospital phases of initial care for patients with STEMI may take place. The pre-hospital phase comprises "symptom onset – phone" time, which is affected mainly by public education, and "phone – admission to a Cardiac Center" time, which is mainly influenced by the organization network and the quality of given pre-hospital emergency medical care system. Hospital phase from admission to opening of the infarction-related artery, reflected in the door-to-balloon time (DBT), is mainly influenced by activities and organization of a Cardiac Center. Because of the proved link between the DBT and mortality of STEMI patients, an effort to minimize all in-hospital delays is of a great importance [3-7]. The aims of our study were to assess to what extent the primary admission of a STEMI patient to non-PCI centers or PCI Center Coronary Care Unit (CCU) (secondary transport – ST) prior to PCI, instead of direct transport to the catheterization laboratory (PT), influences the DBT and affects mortality of patients with STEMI. Patients and methods Our region with 600,000 inhabitants uses for more than 15 years a 24 hours / 365 days system of immediate transport of all patients with STEMI lasting less than 12 hours to referral catheterization laboratories in the tertiary University Hospital Cardiac Center with an option to send ECG and consult with board certified cardiologist. We have prospectively analyzed DBT and mortality of patients with STEMI admitted from January 1, 2012 through December 31, 2013 to the Cardiac Centre of the University Hospital in Hradec Kralove, Czech Republic, both primarily transported from the point of first medical contact (FMC) and secondarily from non-PCI centers. In addition to DBT, we have also recorded the mode of patient's initial transfer (i.e. direct transport to the catheterization laboratory, to non-PCI center first, or to PCI center CCU with a subsequent transfer to the catheterization laboratory) and the reasons for various delays in individual patients. The study was approved by the Ethical Committee of the University Hospital and the Faculty of Medicine Hradec Kralove, Charles University in Prague, Czech Republic. 5 Basic clinical data of all patients, including the mode and time intervals of initial transport as well as time of all intra-hospital procedures were routinely documented. The mortality data were obtained from the Institute of Health Information and Statistics of the Ministry of the Health, Czech Republic and from Czech National Registry of Cardiovascular Interventions, which updates regularly information about the death of any subject in the Registry. Normality of data was verified by the Kolmogorov-Smirnov test. Due to the non-normal distribution of the DBT, we used the median as a position descriptor and the interquartile range as a variability descriptor. Difference in medians was assessed by the Mann-Whitney test. DBT distributions were compared by Kolmogorov-Smirnov test. Statistical significance level was defined as p<0.05. Results: Basic clinical data Six hundred seventy-seven patients, age 37-96 years, mean 64 ± 16 years, 475 (70%) of them males and 202 (30%) females, were enrolled for the final analysis. From this number, 354 (52.3%) patients were primarily transported directly to the catheterization laboratory (PT) and 323 (47.7%) patients were transported to regional hospitals or to the Coronary Care Unit of the Cardiac Center and only then to the catheterization laboratory (ST). Distribution of risk factors in both groups is shown in Table 1. Door-to-balloon time (DBT) DBT for PT was 34+15.9 minutes (interquartile range 20-115 minutes) and DBT for ST was 100+28.8 minutes ( interquartile range 35-160 minutes) (p<0005). Mortality Consequent follow-up was obtained in all patients. One-month mortality was 4.0% and 9.5% (p=0.002) in patients from PT and ST groups, respectively (Figure 1). One-year mortality in PT and ST groups were 7.3% and 20.5% (p<0005), respectively (Figure 2). 6 Patients not included in the study. The total of 869 patients (age 20-96 years, mean 64 ± 12.3 years, 618 i.e.71.1% were men and 251, i.e. 28.9% women) with the working diagnosis of STEMI were admitted to the Cardiac Center of the University Hospital in Hradec Kralove, Czech Republic from January 1, 2012 through December 31, 2013, both primarily transported from field and secondarily from non PCI centers. Localization of STEMI is shown in the Table 2. From this basic cohort a total of 192 patients were not enrolled for the final analysis, the reasons are shown in Table 3. 7 Fig 1. Comparison of one-month mortality in the patients from PT and ST groups. transport, ST=secondary transport PT=primary 8 Fig 2. Comparison of one-year mortality in the patients from PT and ST groups. transport, ST=secondary transport PT=primary 9 Table 1: Basic clinical data of patients in the study. DM=diabetes mellitus, AMI=Acute Myocardial Infarction, CABG=Coronary Artery Bypass Graft, PCI=Percutaneous Coronary Intervention, PT=primary transport, ST=secondary transport ST n = 323 PT n = 354 Risk factors n % n % DM 57 16.1 62 19.2 Hypertension 166 46.9 156 48.3 Dyslipidemia 68 19.2 79 24.5 Previous AMI 28 7.9 35 18.8 9 2.5 13 4.0 27 7.6 30 9.3 Previous Ischemic brain stroke 9 2.5 16 4.9 Chronic Lower Limb Ischemia 9 2.5 16 4.9 132 37.3 90 27.9 49 13.8 95 29.4 Previous CABG Previous PCI Active smoker Stop smoker Table 2. Localization of the STEMI in the original group of 869 patients referred to the tertiary center. LBBB=left bundle branch block Localization STEMI n % diaphragmatic wall 434 49.9 anterior wall 362 41.7 lateral wall 41 4.7 LBBB 32 3.7 Total 869 100 10 Table 3. Reasons for not including patients to the long-term follow-up from the original group of 869 patients referred to the tertiary center with the diagnosis of STEMI. PCI=Percutaneous Coronary Intervention Clinical condition n % acute bypass surgery 18 2.1 diffuse coronary artery disease, PCI not performed 66 7.6 coronary angiography without significant stenosis 25 2.9 3 0.3 54 6.2 death during PCI 5 0.6 unsuccessful PCI 14 1.6 pericarditis 4 0.5 no STEMI in final diagnosis hypertrophic cardiomyopathy 2 0.2 no STEMI in final diagnosis dissection of the thoracic aorta 1 0.1 192 22.1 coronary artery spontaneous dissection late reperfusion TOTAL >12 hours 11 Discussion: Reperfusion therapy by primary coronary angioplasty is accepted standard of treatment for patients with STEMI lasting less than 12 hours and under some circumstances also for patients with symptoms lasting more than 12 hours. Prerequisite for successful implementation of this strategy of treatment is – besides experienced operators in facilities performing primary PCIs on 24 hours / 365 days basis – well elaborated system of transfer of patients from field directly to catheterization laboratory. There is growing evidence that delay in myocardial reperfusion projects into increase of mortality [7]. These authors also showed that rather symptom onset-to-balloon time, but not DBT, is a main predictor of mortality, particularly in non-low-risk patients and in the absence of pre-procedural anterograde flow. Furthermore, a symptom onset-to-balloon time more than 4 hours was identified as independent predictor of one-year mortality [7]. According to ESC guidelines, there are four key points important for correct assessment of time intervals in patients with an acute phase of STEMI [1]. These are: (1) symptom onset (2) FMC (3) diagnosis of STEMI (4) reperfusion. If reperfusion therapy is PCI, the FMC-reperfusion interval should be less than 90 minutes and in large anterior myocardial infarctions and early presenters even less than 60 minutes [1]. In the PCI centers the DBT should be less than 60 minutes, the DBT being defined as the time between the patient’s presentation to the hospital and the passage of the wire to open the coronary artery. From the patient’s perspective the most important interval is total ischemic time from the onset of symptoms to the „provision of the reperfusion therapy“[1]. These guidelines also require bypassing non-PCI hospitals in the pre-hospital triage and the Emergency Department (ED) avoidance on arriving to PCI hospital [1]. Nevertheless, so far there are no direct hard mortality data to support this recommendation. Moreover, several studies, registries and analyses showed that compliance with these guidelines is still problematic and room for improvement remains. Patients with STEMI can access a PCI facility by several routes: (1) pre-hospital STEMI diagnosis is made by Emergency Medical Services (EMS) and the patients are transported to a PCI facility by EMS either directly to catheterization laboratory or (2) via Coronary Care Unit or ED of the PCI hospital; (3) the patients present to a hospital ED followed by referral to an on-site PCI facility; or (4) the patients are transferred from the non-PCI hospitals to a PCI facility in another hospital [8]. Our study compares DBT and short-term as well as one-year mortality of direct transport of patients 12 from the field to catheterization laboratory with other routes to primary PCI and shows that direct pattern not only significantly shortens DBT but also results in significant decrease of one-month and one-year mortality. We confirmed in our study low mortality in patients with STEMI and with the short DBT. Our analysis documented that the transfer of patients with STEMI to non-PCI centers or the PCIhospital CCU – as compared to the primary transport to the catheterization laboratory – results in a very significant time prolongation prior to opening the infarct-related artery, in median by more than 1 hour. The delay of opening the infarct-related artery significantly affected 1-month as well as 1-year mortality. One of the possible delays in hospital phase results from coronary care (or intensive care) unit stay prior to the PCI. The reason for admission of patients with STEMI to the PCI-hospital CCU was typically delay of the catheterization laboratory team activation by the pre-hospital emergency medical service or the inability to quickly release one of the catheterization laboratories at the time of STEMI patient arrival. The reason for transporting patients with STEMI to non-PCI hospitals is most frequently lack of experience to correctly evaluate ECG by attending physicians or paramedics. Direct transport of patients with STEMI and it’s influence on DBT was analyzed in several studies. Self-transportation without EMS and inter-hospital transportation are significant factors causing prolongation of the transport time. Fujii T with his coworkers [9] reported that approximately 35% of STEMI patients did not use EMS and 21% of patients were transported to non-PCI facilities even though they called EMS. Awareness in the community as well as among medical professionals to reduce total ischemic time of STEMI is necessary; this involves educating the general public and EMS crews [9]. Dorsch MF et al in another study found that directly admitted patients had significantly reduced DBT (58 vs 105 minutes, p< 0.001) and call-to-balloon time (105 vs 143 minutes, p <0 .001). The 90-minute target for DBT was achieved in 94% of direct admissions compared to only 29% of patients referred from the emergency room [10]. Their data correspond to our study with DBT 34+15.9 minutes for patients directly transferred to catheterization laboratory as compared to 100+28.8 minutes for secondary transport. Hagiwara MA et al [11] searched databases in English, Swedish, Danish and Norwegian language for a protocol-based pre-hospital pathways and main outcome measurements. For each hour of delay from FMC until reperfusion in ST-elevation myocardial infarction (STEMI) there was a 10% increase in risk of death and heart failure. The aim of this review was to describe the impact of the direct admission of patients with STEMI to a catheterization laboratory as compared to transport via ED with regard to delays and outcome. Median delay in DBT was significantly shorter for the direct admission group in all 5 studies reported. Difference in median delay varied between 16 minutes and 47 minutes. In all 7 included studies the time from symptom onset or FMC-to-balloon time was significantly shorter in the direct admission group. The difference in median delay varied between 15 minutes and 1 hour and 35 minutes. Only two studies described hospital mortality. When combined the risk of death 13 was reduced by 37%. Time interval from symptom onset to balloon inflation, DBT and mortality in patients treated by primary PCI was analyzed already in 2000 [5]. The median DBT was 1hour 56 minutes and the mortality significantly increased by 41% to 62% for patients with DBT longer than 2 hours [5]. Although the data suggested important association, they already do not correspond to the current standards. Since that time, there has been a progressive decline in DBT among reperfusion-eligible STEMI patients [12]. Among others, appropriate activation of interventional cardiology emergency services reduced median DBT by 33.5 minutes [13]. These improvements have contributed to a progressive decline in mortality. Study of Krumholz HM and coworkers analyzed changes in DBT from 2005 through 2010 and showed that DBT declined from a median of 96 minutes in the year ending December 31, 2005, to a median of 64 minutes in the 3 quarters ending September 30, 2010. There were corresponding increases in the percentage of patients who had times <90 minutes (44.2% to 91.4%) and <75 minutes (27.3% to 70.4%) [14]. A new clinical performance measure parameter DIDO (door-in-door-out) was defined as the duration of time from arrival to discharge at the first or STEMI referral hospital [15]. Time of 30 minutes or less was observed in only a small proportion of patients transferred for primary PCI but was associated with shorter reperfusion delays and lower in-hospital mortality [15]. Hudson MP and coworkers [16] showed that both symptom onset-to-balloon time and hospital DBT are strongly associated with 90-day mortality following STEMI, longer DBT was significantly associated with worse 90-day mortality (3.2%, 4.0%, 4.6%, and 5.3% for delays <60 minutes, 60 to 90 minutes, 90 to 120 minutes, and ≥120 minutes, respectively, p<0.0001). The RESCA+31 multicentre, prospective, multidisciplinary French registry included 512 consecutive patients with STEMI managed by emergency physicians in the pre-hospital system or ED [17]. FMC was pre-hospital emergency care for 80% of patients, 97% received reperfusion treatment and 98% were admitted to a cardiology intensive care unit with a catheterization laboratory. The hospital mortality rate was 5%. Guidelines were complied with in 41% of patients for reperfusion strategies, in 47% for adjunctive treatments and in 23% for both. In 52% of cases, emergency physicians underestimated the delay between FMC and admission to a intensive care unit. Fosbol EL et al [18] assessed the adherence of emergency medical services to statewide strategy in North Carolina to bypass non-PCI centers. From 1288 patients 826 (64%) were transported directly to a PCI facility, thereby bypassing a closer non-PCI hospital, whereas 462 (36%) were first taken to a nonPCI hospital and later transferred to a PCI hospital. Their data are similar to our experience: 52.3% of our patients were primarily transported directly to the catheterization laboratory and 47.7% to regional hospitals or to the Coronary Care Unit of the Cardiac Center and only then to the catheterization 14 laboratory. In a multivariable analysis Fosbol EL et al [18] found that increase in differential driving time and cardiac arrest were associated with a lesser likelihood of being taken directly to a PCI center, whereas a history of PCI was associated with a higher likelihood of being taken directly to a PCI center. Patients sent directly to a PCI center were more likely to have times between FMC and PCI within guideline recommendations. Leleu H et al [8] used the results of the pilot testing of a national quality indicator program on STEMI in 64 hospitals in France, providing data on patient characteristics, referral route and symptom-onset-toneedle time. They compared delays for three different routes in a population of 1217 patients. Median symptom-onset-to-needle time was186 minutes for the EMS-PCI route, 237 minutes for the ED-PCI route and 305 minutes for the ED-transfer-PCI route. A total of 70.8% of patients were transported by EMS as recommended. STEMI patients receive prompter care after pre-hospital diagnosis and direct transport to a PCI facility by EMS than by visiting a hospital ED. Le May MR and his coworkers [19] in a similar analysis assessed 1,389 consecutive patients with STEMI referred for primary PCI: 822 (59.2%) were referred directly from the field to a PCI center, and 567 (40.8%) were transported to a non–PCI-capable hospital first. Death at 180 days in their study occurred in 5.0% of patients transferred directly from the field, and in 11.5% of patients transported from the field to a non–PCI-capable hospital (p <0.0001). Our study further elaborated on these findings and documented that also the stop at the PCI-center CCU influences the short-term as well as one-year mortality. Limitations of our study Our study alike all other studies on this topic is not a randomized clinical trial, so the risk of selection bias is obvious. However, randomized study on the mode of STEMI patients transport is not feasible. DBT may be questioned as the main parameter to evaluate the outcome of patients with acute STEMI. We did not perform multivariate analysis to evaluate whether other factors like age, gender, a history of prior myocardial infarction, smoking, diabetes, hypertension, heart failure, renal dysfunction and possibly also other factors may have a negative role apart from the mode of transport, as this was not originally planned as one of the primary goal of our study. Conclusions: Our study is first to show that direct transport from field to catheterization laboratory not only significantly shortens the transport times but also translates into significant decrease of not only one month but also one year mortality. Still significant proportion of patients are transported to regional hospitals or to the Coronary Care Unit of the Cardiac Center and only then to the catheterization laboratory. Secondary transport of STEMI patients from field via non-PCI centers or via PCI-centers 15 CCU to catheterization laboratory not only prolongs the DBT but also increases short-term as well as oneyear mortality. Every effort should be made to implement the network with direct transfers of STEMI patients to a catheterization laboratory for primary PCI, bypassing the non-PCI hospitals and EDs. Supported by the PRVOUK Project P 37/03 Charles University Prague, Czech Republic Conflict of interest statement The authors state that there are no conflicts of interest regarding the publication of this article. 16 References: 1. Steg PG, James SK, Atar D, Badano LP, Blömstrom-Lundqvist C, Borger MA, Di Mario C, Dickstein K, Ducrocq G, Fernandez-Aviles F, Gershlick AH, Giannuzzi P, Halvorsen S, Huber K,Juni P, Kastrati A, Knuuti J, Lenzen MJ, Mahaffey KW, Valgimigli M, van 't Hof A, Widimsky P, Zahger D. ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J. 33 (2012) 2569-619. doi: 10.1093/eurheartj/ehs215. 2. O'Gara PT, Kushner FG, Ascheim DD, Casey DE Jr, Chung MK, de Lemos JA, Ettinger SM, Fang JC, Fesmire FM, Franklin BA, Granger CB, Krumholz HM, Linderbaum JA, Morrow DA, Newby LK, Ornato JP, Ou N, Radford MJ, TamisHolland JE, Tommaso CL, Tracy CM, Woo YJ, Zhao DX, Anderson JL, Jacobs AK, Halperin JL, Albert NM, Brindis RG, Creager MA, DeMets D, Guyton RA, Hochman JS, Kovacs RJ, Kushner FG, Ohman EM, Stevenson WG, Yancy CW. 2013 ACCF/AHA guideline for the management of ST elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 61 (2013) e78-140. doi: 10.1016/j.jacc.2012.11.019. 3. Brodie BR, Stuckey TD, Wall TC, Kissling G, Hansen CJ, Muncy DB, Weintraub RA, Kelly TA . Importance of time to reperfusion for 30-day and late survival and recovery of left ventricular function after primary angioplasty for acute myocardial infarction. J Am Coll Cardiol. 32 (1998) 1312-9. 4. Brodie BR, Stone GW, Morice MC, Cox DA, Garcia E, Mattos LA, Boura J, O'Neill WW, Stuckey TD, Milks S, Lansky AJ, Grines CL . Importance of time to reperfusion on outcomes with primary coronary angioplasty for acute myocardial infarction (results from the Stent Primary Angioplasty in Myocardial Infarction Trial). Am J Cardiol. 88 (2001) 1085-90. 5. Cannon CP, Gibson CM, Lambrew CT, Shoultz DA, Levy D, French WJ, Gore JM, Weaver WD, Rogers WJ, Tiefenbrunn AJ. Relationship of symptom-onset-to-balloon time and door-to-balloon time with mortality in patients undergoing angioplasty for acute myocardial infarction. JAMA. ;283(2000):2941-7. 6. De Luca G, Suryapranata H, Zijlstra F, van 't Hof AW, Hoorntje JC, Gosselink AT, Dambrink JH, de Boer MJ; ZWOLLE Myocardial Infarction Study. Symptom-onsetto-balloon time and mortality in patients with acute myocardial infarction treated by primary angioplasty. J Am Coll Cardiol. 42 (2003) 991-7. 17 7. De Luca G, Suryapranata H, Ottervanger JP, Antman EM. Time delay to treatment and mortality in primary angioplasty for acute myocardial infarction: every minute of delay counts. Circulation. 109 (2004) 1223-5. 8. Leleu H, Capuano F, Ferrua M, Nitenberg G, Minvielle E, Schiele F. Symptom-toneedle times in ST-segment elevation myocardial infarction: shortest route to a primary coronary intervention facility.Arch Cardiovasc Dis. 106 (2013) 162-8. doi:10.1016/j.acvd.2012.12.003. 9. Fujii T, Naoki MN, Suzuki T, Trii S, Murakami T, Nakano M, Nakazawa G, Shinozaki N, Matsukage T, Ogata N, Yoshimachi F, Ikari Y. Impact of transport pathways on the time from symptom onset of ST- Segment elevation myocardial infarction to door of coronary intervention facility. J Cardiol. 64 (2014) 11-8. doi: 10.1016/j.jjcc.2013.11.008. 10. Dorsch MF, Greenwood JP, Priestley C, Somers K, Hague C, Blaxill JM, Wheatcroft SB, Mackintosh AF, McLenachan JM, Blackman DJ. Direct ambulance admission to the cardiac catheterization laboratory significantly reduces door-to-balloon times in primary percutaneous coronary intervention. Am Heart J. 155 (2008) 1054-8. doi: 10.1016/j.ahj.2008.01.014. 11. Hagiwara MA, Bremer A, Claesson A, Axelsson C, Norberg G, HerlitzJ. The impact of direct admission to a catheterisation lab/CCU in patients with ST-elevation myocardial infarction on the delay to reperfusion and early risk of death: results of a systematic review including meta-analysis. Scand J Trauma Resusc Emerg Med. 22 (2014) 67. doi: 10.1186/s13049-014-0067-x. 12. Gibson CM, Pride YB, Frederick PD, Pollack CV Jr, Canto JG, Tiefenbrunn AJ, Weaver WD, Lambrew CT, French WJ, Peterson ED, Rogers WJ. Trends in reperfusion strategies, door-to-needle and door-to-balloon times, and in hospital mortality among patients with ST-segment elevation myocardial infarction enrolled in the National Registry of Myocardial Infarction from 1990 to 2006. Am Heart J. 156 (2008) 1035-44. doi: 10.1016/j.ahj.2008.07.029 13. Singer AJ, Shembekar A, Visram F, Schiller J, Russo V, Lawson W, Gomes CA, Santora C, Maliszewski M, Wilbert L, Dowdy E, Viccellio P, Henry MC. Emergency department activation of an interventional cardiology team reduces door-to-balloon times in ST-segment-elevation. Ann Emerg Med. 50 (2007) 538-44. 14. Krumholz HM, Herrin J, Miller LE, Drye EE, Ling SM, Han LF, Rapp MT, Bradley EH, Nallamothu BK, Nsa W, Bratzler DW, Curtis JP. Improvements in door-toballoon time in the United States, 2005 to 2010.Circulation. 124 (2011) 1038-45. doi: 10.1161/CIRCULATIONAHA.111.044107. 18 15. Wang TY, Nallamothu BK, Krumholz HM, Li S, Roe MT, Jollis JG, Jacobs AK,Holmes DR, Peterson ED, Ting HH. Association of Door-In to Door-Out Time With Reperfusion Delays and Outcomes Among Patients Transferred for Primary Percutaneous Coronary Intervention FREE. JAMA. 305 (2011) 2540-2547. doi:10.1001/jama.2011.862. 16. Hudson MP, Armstrong PW, O'Neil WW, Stebbins AL, Weaver WD, Widimsky P, Aylward PE, Ruzyllo W, Holmes D, Mahaffey KW, Granger CB. Implications of primary percutaneous coronary intervention treatment delays: insights from the Assessment of Pexelizumab in Acute Myocardial Infarction trial. Circ Cardiovasc Qual Outcomes. 4 (2011) 183-92. doi: 10.1161/CIRCOUTCOMES.110.945311. 17. Sandouk A, Ducassé JL, Grolleaua S, Azéma O , Elbazc M , Farahd B, Tidjanec A, Irving MK, Charpentier S. Compliance with Guidelines in patients with ST-segment elevation myocardial infarction after implementation of specific Guidelines for emergency Care: Results of RESICA+31 Registry. Arch Cardiovasc Dis. 105 (2012) 262-70. doi: 10.1016/j.acvd.2012.03.001. 18. Fosbol EL, Granger CB, Jollis JG, Monk L, Lin L, Lytle BL, Xian Y, Garvey JL, Mears G, Corbett CC, Peterson ED, Glickman SW. The impact of a statewide prehospital STEMI strategy to bypass hospitals without percutaneous coronary intervention capability on treatment times. Circulation. 127 (2013) 604-12. doi: 10.1161/CIRCULATIONAHA.112.118463. 19. Le May MR, Wells GA, So DY, Glover CA, Froeschl M, Maloney J, Dionne R, Marquis JF, O'Brien ER, Dick A, Sherrard HL, Trickett J, Poirier P, Blondeau M, Bernick J, Labinaz M. Reduction in mortality as a result of direct transport from the field to a receiving center for primary percutaneous coronary intervention. J Am Coll Cardiol. 60 (2012) 1223-30. doi: 10.1016/j.jacc.2012.07.008. 19 Authors contribution: Abdulwasya Almawiri, Jan F. Vojacek, Josef Bis, Josef Stasek data acquisition Abdulwasya Almawiri, Jan F. Vojacek, Ziad Albahri manuscript preparation