[Transportation of patients with acute infarction to the closest center with available emergency angioplastic services: why, when, where, and how?].
The success of acute myocardial infarction therapy depends on the ability to achieve prompt reperfusion of the occluded coronary artery and of the corresponding microcirculation. The significant failure rate of thrombolysis and primary angioplasty, often considered as mutually exclusive therapies, is due, in daily clinical practice, to both pathophysiological factors and to delay in the access to care. The introduction of new fibrinolytic and antithrombotic drugs and the differentiated use of primary angioplasty, pre-hospital thrombolysis and rescue angioplasty according to the different risk profile of the patient will probably lead to the optimization of current therapeutic regimens. However, logistic, technical and organizational problems commonly encountered in everyday practice could cause significant delays in the access to care and thus reduce benefits in spite of such a refined strategy. Therefore, the optimization of in- and out-of-hospital organizational aspects is also required if the benefits of therapeutic regimens for acute myocardial infarction are to be increased. Such a strategy should lead to the earlier administration of the optimal drug regimen and enable quicker assessment of the reperfusion status and more timely admission and/or transfer of high-risk patients directly to the catheterization laboratory. We propose a simple model of patient management in which different patient subgroups could be submitted to different treatment regimens according to their specific risk and to the modality of access to care. Such a model is based on the clinical stratification of risk, on telematic connection among care centers and on the facilitation of hospital admission. In Italy, the use of such a model could reduce the average time to reperfusion by 90-120 min and thus improve survival after acute myocardial infarction.