A personal perspective: can legislated state regional STEMI centers provide timely STEMI treatment while overlooking early fibrinolysis?

Because a patient's odds of surviving a ST-Elevation Myocardial Infarction (STEMI) depend on how much myocardium is salvaged by treatment, this article presents information about whether the Missouri Regional STEMI Center Program, created by state law, can provide STEMI treatment in time to preserve the ischemic heart muscle. The law states that "Patients who suffer a STEMI, as defined in Section 190.100, shall be transported to a STEMI Center." Administration is by the Missouri Department of Health and Senior Services (DHSS) which states that the preferred treatment for STEMI is percutaneous coronary intervention (PCI) and does not mention fibrinolysis when eligible. Level I and II receiving centers are hospitals with catheterization laboratories that perform a high volume of PCI procedures. Level I centers have heart surgery facilities. Level II centers may have such services or may have prompt access to nearby facilities. The law states that the smaller level III and IV hospitals are to stabilize patients for transport to a level I or II center. Although the law lists no patients to be excluded from transport, DHSS is limiting the program to patients picked up at the scene by ambulance. The majority of STEMI patients going to community hospitals by car are not included. Data are presented, showing that when blood flow is restored to the ischemic muscle during infarction before the end of the second hour of symptoms most can be saved. Data also show that only a small fraction of patients with PCI receives it before the end of the second hour of symptoms, whereas many more fibrinolysis patients were treated within 2 hours. Clinical practice data are given, showing mortality rates to increase with longer times to treatment. This information clearly defines timely treatment of STEMI to be that carried out before the end of the second hour of symptoms. Setting forth details of how long after symptom onset will be required to get to the catheterization laboratory shows that not many Missouri Program STEMI patients will get there before the end of the second hour of symptoms when salvageable heart muscle remains. The second thrust of this article is to draw attention to the seriousness of the Missouri Program overlooking the extremely important early fibrinolysis option for achieving treatment during the first 2 hours of symptoms.

Medico-legal issues in cardiology.

The aim of this article is to educate physicians about the current litigation climate in cardiology and cardiac surgery, with a focus on the most frequently litigated areas of practice, including failure to diagnose and treat myocardial infarction, coronary artery bypass graft surgery, percutaneous coronary intervention, and the use of tissue plasminogen activator. Empirical research on cardiology malpractice is presented, along with a sampling of up-to-date cases designed to illustrate common issues and important themes. The principles for reducing legal liability are also discussed, including the informed consent process, spoliation of records, and the role of documentation. Finally, practical recommendations are provided for cardiologists and cardiac surgeons to limit their legal liability.