was causing the majority of heart attacks. Before then, mortality if you had an acute STEMI was about 40 percent. Today, mortality in most cities is under 10 percent and usually it is in the 4 to 6 percent range. Clearly, he said, “we have made incredible progress.”

Over the past 30 years, we have learned that there are two major ways to open heart vessels: chemically or through mechanical means (percutaneous coronary intervention, or PCI). PCI is the current state of the art in treatment, but only one quarter of U.S. hospitals now have the capacity to provide it.

What has become obvious over the past 30 years, Ornato said, is that time is critical for patients. Just as “the golden hour” became a mantra in trauma care, “time is muscle” became the mantra for acute myocardial infarction (MI) care in the mid-to-late 1980s. Since then, we have really tried to better understand the trauma center model and apply its lessons to acute MI. A number of models have emerged, including Boston EMS, Minneapolis Heart Institute, and others. Now, the American Heart Association—analogous to the American College of Surgeons in this case—has helped identify the key components of a successful STEMI system and has launched a nationwide program called “Mission Lifeline.”

While a successful STEMI system has many similarities with trauma centers and regional systems of trauma care, Ornato continued, “There are also some very harsh differences.” Most general medical service hospitals rely upon cardiovascular care to stay alive financially. Therefore, a very important piece of the puzzle has been to ensure that we carve out an important role for medical centers that are not PCI centers—the functional equivalent of a Level I trauma center. “Non-PCI centers must be included as part of an integrated network,” he said, “and we have sought to strike a delicate balance, such that patients are not being diverted to PCI centers when it is not medically necessary.”

CONSIDERATIONS IN REGIONALIZING CARDIAC ARREST

Lance Becker, professor of emergency medicine and director of the Center for Resuscitation Science at the University of Pennsylvania, discussed cardiac arrest and related topics such as hypothermia and post-resuscitation care. Becker noted that there is wide variability in survival rates for cardiac arrest in communities in this country, ranging from 2 to 18 percent; however, we do not understand the causes of that variability. One goal of regionalization should be to aid in reducing variability.

Becker noted that cardiac arrest differs from most conditions, because about half of the cases in the United States take place inside hospitals. Moreover, it is a very time-sensitive illness. In some of the treatment modalities used for cardiac arrest, survival rates have been shown to differ based on



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