Letter to the editor Reperfusion Strategies in Hospitals Without Primary Percutaneous Coronary Intervention

To the Editor,

In the article by Carol Ruiz et al.,¹ in which the authors used data from a registry, they performed a detailed analysis of the factors associated with a prolonged total ischemia time and, ultimately, the final prognosis of patients with acute ST-elevation myocardial infarction (STEMI) referred for primary percutaneous coronary intervention.¹ The authors highlighted, with its inclusion in the title, the importance of the place of first medical contact. In addition to other individual patient characteristics, it is known that the longest delays in accessing primary percutaneous coronary intervention occur particularly with patients whose first medical contact takes place in hospitals without catheterization facilities. It is also known that, even in very established health care networks, a significant number of patients referred for primary percutaneous coronary intervention are treated outside the recommended times, especially when they require interhospital transfer.^2,3 As the authors themselves remark, there is growing interest in investigating other determining factors, care of older patients,⁴ overnight and weekend care, and more circumstantial aspects such as chronobiological factors related to the final outcome.⁵ All of this in an attempt to establish the best treatment for individual patients throughout the health care process. Therefore, it somewhat surprised us that, in their section on “proposals for improvement”, the authors highlight key actions but do not mention the option of implementing pharmaco-invasive strategies in remote areas and centers with no interventional facilities. The efficacy of this strategy has been widely demonstrated in trials and registries,^6,7 so it is difficult to comprehend that a health care network, such as that represented by the Codi Infart (Infarct Code) in Catalonia, does not include as a suggestion for improvement the option of offering individualized treatment, at least for patients with no contraindications for intravenous fibrinolysis that present in the first 3 hours from onset to centers with no interventional facilities. Many hospitals and health care areas will find it difficult to meet the quality criteria recommended in the clinical practice guidelines for performing primary percutaneous coronary intervention.⁸ Currently, there is no doubt about the gold standard treatment for STEMI, but it seems somewhat misguided that a health care network should have a single objective of primary angioplasty, even though they will not be able to meet the recommended times in a percentage of cases. A statement or opinion is needed from one of the major Spanish STEMI health care networks on establishing equal access (in time and form) to effective reperfusion for patients in areas with logistical or geographical limitations. Such a discussion, which has been presented and held in other major registries,⁹ is needed to adapt treatment, as much as possible, to the patient and the specific conditions of his or her situation.

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