Thursday, January 17, 2008

From the Field to Angiogram.

Here's an interesting study in the New England Journal of Medicine.

There have been several studies that fairly conclusively demonstrated that reducing the time from the symptoms of a particularly dangerous type of heart attack (the so-called ST-segment elevation myocardial infarct or STEMI) to the time of balloon angioplasty saves lives. Getting this symptom-to-balloon time down is of course partly a function of physician skill. But the biggest determinant has to do with the nature of the system that's in place to move the patient from initial transportation to assessment to cath lab team mobilization.

Getting this time down involves tremendous planning, resources, and careful thinking. This study looked at door-to-balloon time (the time the patient hits the hospital to the time the angioplasty balloon is inflated (thus opening a clogged artery). It seems to show that if paramedics in the field are taught and allowed to diagnose STEMI's, then patients can be transported directly from the street to the cath lab thus bypassing the emergency room.

Using this strategy, the door-to-balloon time was shaved from 123 to 69 minutes. Judging from morbidity/mortality results of previous studies, this is no small amount and probably has important clinical significance. In fact, inpatient mortality went from 5.7% down to 3.0% using direct transport.

This study was not randomized nor blinded and numerous confounders can be assumed and postulated. It is noteworthy however that the baseline characteristics between the direct transport and emergency room transport groups are surprisingly similar which suggests that these clinical benefits may be real and not explainable by such confounding variables.

These results are preliminary but definitely tantalizing. It seems unlikely to me however, that a randomized trial testing this approach will ever be done and this data may be the best that we get.

Might it be enough?

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