What are the essential components of a regional ST‑elevation myocardial infarction (STEMI) network to ensure rapid, guideline‑directed reperfusion and coordinated post‑acute care?

Essential Components of a Regional STEMI Network

All communities must create and maintain regional STEMI networks that coordinate pre-hospital and hospital-based care to minimize total ischemic time and reduce mortality. 1

Core Infrastructure Requirements

Pre-Hospital System Components

Emergency Medical Services (EMS) must acquire and interpret a 12-lead ECG within 10 minutes of first medical contact and immediately activate the catheterization laboratory. 1 This single action is the most critical determinant of timely reperfusion. 1

• EMS physicians and paramedics require specific training in STEMI diagnosis, triage algorithms, and direct communication protocols with receiving hospitals. 1
• Pre-hospital fibrinolysis capability should be available when anticipated first-medical-contact-to-device time exceeds 120 minutes. 1
• EMS must bypass non-PCI-capable hospitals and transport directly to PCI centers when the 120-minute window can be met. 1

Hospital Network Architecture

The network must include both PCI-capable centers providing 24/7 service and non-PCI-capable hospitals with standardized transfer protocols. 1

PCI-Capable Centers Must Deliver:

• 24-hour, 7-day primary PCI service with experienced operators (≥75 PCI cases/year) and high-volume centers (≥36 primary PCI cases/year). 1
• Direct catheterization laboratory access, bypassing the emergency department and intensive care unit entirely. 1
• Door-to-balloon time ≤90 minutes for direct presentations and first-medical-contact-to-device time ≤120 minutes for transfers. 1
• Cardiac surgical backup for mechanical complications, though on-site surgery is not mandatory if transfer protocols exist. 1

Non-PCI-Capable Hospitals Must Provide:

• Door-to-ECG time ≤10 minutes and immediate STEMI diagnosis. 1
• Door-to-needle time ≤30 minutes for fibrinolysis when transfer exceeds 120 minutes. 1
• Door-in-door-out time ≤30 minutes for immediate transfer to PCI centers. 1
• Standardized antithrombotic protocols (aspirin, P2Y12 inhibitor, anticoagulation) initiated before transfer. 1

Communication and Coordination Systems

A central triage system must coordinate all STEMI activations across EMS agencies and hospitals. 1 The Vienna STEMI Registry demonstrated that implementing this coordination reduced in-hospital mortality from 16% to 9.5% by increasing reperfusion rates from 66% to 86.6%. 1

• Single emergency telephone activation system linking EMS, emergency departments, and catheterization laboratories. 1
• Real-time catheterization laboratory activation by EMS before hospital arrival. 1, 2
• Standardized written protocols defining reperfusion strategy selection based on symptom duration and anticipated delays. 1

Time-Based Reperfusion Algorithms

For Symptom Onset ≤3 Hours:

Primary PCI and fibrinolysis demonstrate comparable mortality when fibrinolysis is delivered within 2-3 hours of symptom onset. 1 Therefore:

• If first-medical-contact-to-device time ≤120 minutes: proceed with primary PCI. 1
• If first-medical-contact-to-device time >120 minutes: administer fibrinolysis within 10 minutes, then transfer for angiography at 3-24 hours. 1

For Symptom Onset 3-12 Hours:

Primary PCI is superior to fibrinolysis for mortality and reinfarction outcomes in this window. 1 Therefore:

• Primary PCI is mandatory regardless of anticipated delays. 1
• Fibrinolysis should only be used if primary PCI is absolutely impossible (e.g., extreme geographic isolation). 1

Absolute Indications for Immediate Primary PCI (Regardless of Time):

• Cardiogenic shock or acute severe heart failure. 1
• Contraindications to fibrinolysis (active bleeding, recent stroke, recent surgery). 1
• Failed fibrinolysis (<50% ST-segment resolution at 60-90 minutes). 1
• Resuscitated cardiac arrest with ST-elevation on post-resuscitation ECG. 1

Quality Monitoring and Continuous Improvement

Networks must collect and report standardized quality metrics to audit practice and drive improvement. 1

Mandatory Performance Metrics:

Metric	Target	Impact on Mortality
Door-to-ECG	≤10 minutes	Reduces diagnostic delay [1]
Door-to-balloon (direct)	≤90 minutes	Directly linked to 30-day mortality [1]
First-medical-contact-to-device (transfer)	≤120 minutes	Improves survival in transferred patients [1]
Door-to-needle (fibrinolysis)	≤30 minutes	Shorter times reduce mortality [1]
Door-in-door-out (transfer)	≤30 minutes	Facilitates timely PCI [1]

The Mission: Lifeline STEMI Systems Accelerator demonstrated that coordinated regional networks increased the proportion of patients meeting guideline goals from 50% to 55% for direct presentations and 44% to 48% for transfers. 2

Data Collection Requirements:

• Real-time tracking of all time intervals from symptom onset through reperfusion. 1, 2
• Monthly reporting to all network participants with benchmarking against national standards. 1, 2
• Root-cause analysis of cases exceeding time targets. 1, 2
• Annual review of mortality, reinfarction, and bleeding outcomes stratified by reperfusion strategy. 1

Stakeholder Engagement and Governance

Successful networks require formal agreements among hospitals, EMS agencies, regional public health departments, and local governments. 1

• Designated medical director with authority to modify protocols based on performance data. 1, 2
• Quarterly multidisciplinary meetings including EMS, emergency physicians, interventional cardiologists, and hospital administrators. 1, 2
• Elimination of competitive barriers between hospitals that delay transfer or fragment care. 3
• Participation in national quality programs (Mission: Lifeline, D2B Alliance) to access benchmarking data and best practices. 1, 2

Common Pitfalls and How to Avoid Them

The most frequent failure is overreliance on primary PCI when delays exceed 120 minutes, resulting in worse outcomes than immediate fibrinolysis would have achieved. 1 The Vienna Registry showed that PPCI usage increased from 16% to 60% while fibrinolysis decreased from 50.5% to 26.7%, yet mortality improved because the network enforced strict time-based algorithms. 1

• Avoid the "PCI at any cost" mentality: fibrinolysis within 3 hours is equivalent to delayed PCI. 1
• Do not allow emergency department evaluation to delay catheterization laboratory activation: EMS must activate directly. 1
• Do not perform PCI on non-culprit vessels during the acute procedure unless the patient is in cardiogenic shock. 1
• Do not use routine thrombus aspiration or defer stenting, as these strategies do not improve outcomes and may cause harm. 1

Networks must map every possible patient presentation route and eliminate gaps where patients fall outside coordinated protocols. 1 The Mayo Clinic STEMI Protocol demonstrated feasibility across 28 hospitals spanning 150 miles, achieving door-to-balloon ≤90 minutes in 75% of direct presentations and door-to-needle ≤30 minutes in 70% of fibrinolysis cases. 4