Conclusions

In summary, delays in early identification and treatment of acute MI patients with reperfusion therapy result in significant loss of myocardium and significant, quantifiable increases in mortality. While patient-mediated delays have yet to be resolved, delays in the emergency department have been effectively addressed by a continuous quality improvement (CQI) program that includes gathering of data on door-to-drug time, the frequency with which all patients, as well as subgroups of patients are treated, with reperfusion therapy, the use and kind of adjunctive drugs, and outcomes. A 30-min door-to-drug time as recommended by the NHAAP, can be achieved safely and effectively through a CQI program that continuously scrutinizes the process of care in relationship to time. As recommended in the ACC/AHA guidelines, primary angioplasty for ST-seg-ment elevation left bundle-branch block MI should be performed when dilatation can be effected within 90 min of hospital arrival, and in hospitals with a volume of angioplasty experience at the individual operator and institutional level that exceeds the minimal figures (39). Protocols which designate the process as well as the responsibility for implementation will facilitate early identification and treatment of patients with ST-segment elevation acute MI. Elements of hospital process that are driven by hospital policy and "turf" issues without benefit to the patient significantly delay reperfusion therapy and result in worse outcomes. A seamless patient-oriented protocol will promote a team approach to the care of these patients, which will result in best-expected outcomes.

Transport of patients by EMS leads to earlier treatment in the emergency department, as does identification through prehospital 12-lead ECGs that are transmitted to the hospital. Ideally, the physician-cardiology community should be involved in the EMS planning process for input into key issues that impact on timely treatment, such as diversion practices.

When talking with patients about recognizing and responding to a possible heart attack, providers need to be aware of the common misconceptions and knowledge deficiencies. They should dispel the myth of the "Hollywood" heart attack, acknowledging that while some heart attacks are sudden and intense and involve collapse, most start slowly with mild pain or discomfort. Providers also need to explain that, in addition to chest discomfort, patients may experience a feeling of being short of breath; sweating; pain in the arms, back, neck, jaw, or stomach; a feeling of being "sick to your stomach" or lightheaded. Providers should promote the notion of, "when in doubt, check it out", acknowledging that it is normal to be uncertain about what is wrong or embarrassed or afraid about calling 9-1-1, leading to untoward delays in getting help. In addition, providers can stress that the only way to know for sure is to be evaluated in a hospital emergency department. It is important that they also emphasize that patients will be taken seriously and treated respectfully if they come to the emergency department with possible heart attack signs, even "false alarms." Providers should actively address the benefits of artery-opening treatment and the importance of getting treatment quickly to stop a heart attack in its tracks. Furthermore, the role of early treatment in preventing death or severe heart muscle damage that will affect the quality of life should be directly explained. Patients should be reminded that heart attacks are the number one cause of death among women (as well as men) and that the risk increases greatly with age, especially after menopause. Finally, providers need to discuss individual patient's heart attack risk and what to do if faced with possible heart attack warning signs—including family and friends in the discussions—and develop an action plan with patients in advance.

Early patient recognition and action by calling 9-1-1 can result in early heart attack care by the healthcare system, the best kind short of prevention.

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