What are the gaps in care for myocardial infarction (MI) treatment despite existing clinical infrastructure and guidelines?

Critical Gaps in Myocardial Infarction Care Despite Existing Infrastructure

Despite having established clinical guidelines, trained providers, and infrastructure, the most significant gaps in MI care are the absence of integrated regional STEMI networks, underutilization of emergency medical services by patients, failure to implement quality measurement systems, and the persistent treatment-risk paradox where high-risk patients least likely to receive guideline-based therapies.

Systems-Level Infrastructure Gaps

Absence of Regional STEMI Networks

• The most fundamental gap is the lack of coordinated regional systems of care that integrate pre-hospital, emergency department, and catheterization laboratory services. 1 The European Society of Cardiology explicitly recommends that pre-hospital STEMI management be based on regional networks designed to deliver reperfusion therapy expeditiously, yet these networks remain virtually nonexistent in many locations 1
• Even in high-resource settings, patients transferred for primary PCI frequently pass through emergency departments rather than going directly to the catheterization laboratory, adding critical delays 1
• PCI-capable centers often fail to provide true 24/7 service without delay, despite guideline recommendations 1

Emergency Medical Services Underutilization

• Only 53-60% of MI patients use EMS transport, representing a massive missed opportunity for early intervention. 2, 3 This proportion has not improved significantly over time despite decades of public health campaigns 2
• Patients who self-transport experience median delays of 31 minutes longer to door-to-balloon time and 6 minutes longer to door-to-needle time compared to EMS-transported patients 3
• The gap is particularly concerning because EMS use is independently associated with faster reperfusion therapy delivery (12.1 minutes faster for fibrinolysis, 31.2 minutes faster for PCI) 2

Clinical Care Delivery Gaps

The Treatment-Risk Paradox

• High-risk patients who would benefit most from early invasive strategies are paradoxically less likely to receive them. 1 This represents a fundamental failure in translating evidence into practice
• Although benefit of early invasive strategy is directly proportional to patient risk (TIMI, PURSUIT, GRACE scores, troponin elevation, ST-segment shift magnitude, and age), propensity to receive such treatment is greater in lower-risk patients 1
• This may reflect physician misconceptions about benefit-harm tradeoffs or excessive concerns about treatment complications 1

Quality Measurement and Audit Failures

• The European Society of Cardiology explicitly states there is a gap between optimal guideline-based treatment and actual care, yet systematic quality indicator measurement remains underutilized. 1
• Every 10% increment in guideline adherence is associated with a 10% reduction in hospital mortality, yet hospitals fail to systematically measure and improve compliance 1
• The use of well-defined and validated quality indicators to measure and improve STEMI care is recommended but rarely implemented 1

Pre-Hospital and Diagnostic Gaps

Delayed Recognition and Activation

• The target of obtaining and interpreting a 12-lead ECG within 10 minutes of first medical contact is frequently missed. 1 This represents a critical lost opportunity for early triage and treatment decisions
• Pre-hospital 12-lead ECG capability by paramedics, which demonstrably reduces time to treatment, remains underutilized despite strong evidence 4
• Community education about symptom recognition and the need to call 9-1-1 rather than self-transport remains inadequate 1, 2

Inadequate Pre-Hospital Protocols

• Many communities lack written protocols guiding EMS personnel on destination decisions for suspected ACS patients 1
• Patients with known STEMI or cardiogenic shock should bypass non-PCI-capable hospitals and go directly to interventional centers, but this frequently does not occur 1

Pharmacological and Procedural Gaps

Suboptimal Reperfusion Strategy Selection

• The choice between primary PCI and fibrinolysis is often not based on evidence-based time thresholds. 1, 5 Primary PCI should only be pursued if it can be delivered within 90-120 minutes of first medical contact; otherwise fibrinolysis should be administered 5
• The pharmaco-invasive strategy (fibrinolysis followed by planned angiography at 3-24 hours) is underutilized despite being the most feasible approach when primary PCI cannot be delivered within 120 minutes 1, 5
• If fibrinolysis can be given more than 60 minutes before PCI would be available, it should be administered immediately, yet this decision algorithm is frequently not followed 5

Inadequate Management of Non-Infarct Related Arteries

• Treatment of severe stenosis in non-infarct related arteries should be considered before hospital discharge, but this is inconsistently performed 1
• In cardiogenic shock, non-IRA PCI should be considered during the index procedure, yet this is often deferred 1

Post-Acute Care Gaps

Insufficient Secondary Prevention Implementation

• Early discharge in uncomplicated patients limits time for implementing secondary prevention, yet close collaboration between stakeholders to address this is lacking. 1
• Evidence-based therapies (antiplatelet agents, beta-blockers, lipid-lowering agents, ACE inhibitors) initiated before discharge are associated with incremental survival advantage, but prescription rates remain suboptimal 1

Special Population Management Failures

• Patients taking oral anticoagulants, those with renal insufficiency, and elderly patients represent challenges for optimal antithrombotic therapy, yet dose adjustment protocols are inconsistently applied 1
• Patients with diabetes and those not undergoing reperfusion require additional attention but often do not receive it 1

Resource-Specific Gaps in Low- and Middle-Income Settings

Infrastructure Concentration

• Cardiac catheterization laboratories are clustered in urban locations while the majority of patients live in rural areas 1
• Poor transportation infrastructure and lack of adequately trained/equipped paramedics make access to invasive centers difficult 1

Knowledge and Education Deficits

• Meager public awareness of STEMI symptoms and the "time is muscle" concept hampers prompt treatment seeking 1
• First healthcare providers encountered often have inappropriate credentials and less knowledge about complex MI management 1

Financial and Political Barriers

• Lack of insurance coverage for the majority of the population limits access to expensive procedures and medications 1
• Political and societal support for cardiovascular programs remains focused on infectious disease priorities despite epidemiologic transition 1

Critical Pitfalls to Avoid

• Never delay fibrinolysis while waiting for transfer if PCI cannot be achieved within 120 minutes 5
• Do not skip the pharmaco-invasive strategy in favor of fibrinolysis alone when angiography is accessible within 3-24 hours 1, 5
• Avoid the assumption that having PCI capability means optimal care is being delivered—systematic quality measurement is essential 1
• Do not underestimate the importance of EMS activation—community education about calling 9-1-1 is as important as in-hospital protocols 2, 3