Need for Centers to Care for Patients With Acute Coronary Syndromes

Acute myocardial infarction (MI) characterized by ST-segment elevation on the ECG has been the subject of more randomized trials and outcome studies than any other area of medicine. Recently, non–ST-elevation acute coronary syndromes (ACS) have taken an equal position in terms of clinical study and clinical relevance. Additionally, through a series of frustrations1 and triumphs,2 the critical nature of prehospital management of ACS has been underscored. This attention is appropriate, given the dominance of coronary artery disease (CAD) as the leading global cause of death and disability. Despite this abundance of evidence, however, ample studies have reported the common failure to deliver the standard of care in clinical practice. We believe that the establishment of regional centers for ACS, if linked with the communities in which they exist and if approached in a reasonable fashion with appropriate financial incentives, would result in much more effective and efficient care of this dominant public health problem. Our understanding of medical quality and prevention of medical errors has advanced substantially in the past decade. By conducting clinical trials that measure outcomes as the primary measure, we can develop standards of care, and adherence to these standards of care can be used to estimate quality.3,4 Specifically, on the basis of theories developed from discovery science and clinical observations, clinical trials can address the consequences of new therapies or new approaches to treatment for populations of patients. When an adequate trial provides definitive evidence, a clinical practice guideline (CPG) recommendation can carry a Level of Evidence A or B and Class I status (if a beneficial practice) or Class III status (if detrimental). When such a recommendation can be quantified, it then can become a performance indicator. For example, patients with ST-segment elevation ACS should receive reperfusion therapy as a medical emergency. …