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Einstein explained to those of us who could understand (of whom your commentator is one only when he is listening to a lecture by a competent physicist; the understanding leaks away rapidly when the lecture ends) that, on a grand scale of velocity and gravity, time is relative. In certain extreme circumstances, time slows. Unfortunately for us mere mortals, manipulation of time by using Einstein's methods is not possible. Our only avenue of intervention is what we can accomplish in the little time that we are provided. That ability is the subject of an article that follows in this issue of the Texas Heart Institute Journal.1
Shorter is better. Less is more. These statements are accepted wisdom in the current treatment of ST-elevation myocardial infarction (STEMI). It's a given that a shorter “door-to-balloon” time (DBT) means a smaller MI. In fact, a short DBT is an accepted indicator of a high quality of care of STEMI patients. In marketing terms, “time is muscle, and muscle is life.” This mantra, along with the need for an objective measure that can be used to report quality-of-care outcomes to the public, has placed the DBT squarely in the sights of every institution that provides care for patients who experience MI. This measure has become so central that emergency medical services and hospitals have been slow to adopt a more important variable in infarct treatment—the time from onset of symptoms to reperfusion—as a quality measure for the treatment of acute MI.
The DBT is, in fact, a firmly established predictor of outcome after primary percutaneous coronary intervention. However, a reasonable question might be, Is the outcome really determined by the DBT, or is it determined by the experience, training, and systematic care offered by the best institutions and emergency services? In other words, if 2 institutions are compared and the one with the lower average DBT reports superior outcomes, is the difference in outcomes a direct result of the difference in DBT, or is DBT a surrogate for systematic institutional (and emergency service) use of all the beneficial cardiologic, medical, and lifestyle interventions that may affect the outcome? This question would seem to apply to single-center studies, as well.
Consider a comparison of 2 college sports teams. We can use scoring ability as an objective measure of their performance, and we can use the rate of athlete matriculation or advancement to professional sports as a surrogate for the quality of each program. Both of the measures of quality are a function of the training, coaching, and academic mentoring that athletes receive, but neither measure may directly affect winning percentage. Moreover, both measures neglect recruiting and the type of athlete most likely to choose one institution over another.
For STEMI, this is the type of question that Minutello and associates1 wished to address. Analyzing data from a very small sample of patients with STEMI, the authors asked whether DBT corresponded to any measure of infarct severity, enzyme release, left ventricular function, or death in a homogeneous patient cohort that was treated at a single institution. In discussions of STEMI, this issue has been the “gorilla in the room,” because the question of the importance of DBT has always been dealt with in a multicenter fashion. Minutello and associates essentially asked, Is the crucial factor the treatment center or the time? In this instance, it was clearly the time. They report a logarithmic association between DBT and enzyme measures of infarct size that was, in turn, a predictor of survival and recovery of left ventricular function. The data are convincing and in line with the multicenter trials, suggesting that the American Heart Association's marketing program is on the side of the angels.
What does this mean for the rest of us? Get it together, move quickly, and get 'er done as fast as possible. More people die of heart attacks than of almost any other condition. From a public health perspective, nationwide emergency-service providers need to organize a STEMI network similar to that which is already in place for managing trauma. From an institutional perspective, DBT is the right measure of quality to use. From both the public health and the institutional perspectives, however, systemization of care is the only route to consistently providing the best quality of care. No excuses are left for not having such systems in place. Cooperation and coordination with the American Heart Association to develop systems on a local basis is an urgent matter.
Address for reprints: James M. Wilson, MD, 6624 Fannin St., Suite 2480, Houston, TX 77030