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The American Heart Association recommendation for care of an ST-segment elevation myocardial infarction (STEMI) is to provide percutaneous coronary intervention (PCI) as the first line of treatment, if it is possible, in a timely manner. This is defined as a reperfusion device within 90 minutes of first medical contact. This has evolved from “door to balloon”; the interval now begins with the first medical contact as the diagnostic (paramedic) electrocardiogram (ECG) and concludes with the device (e.g., wire, balloon) deployed. This recognizes the significant role of paramedics in an integrated STEMI system of care. An optimized prehospital interval could involve transporting the patient directly to a PCI-capable facility, bypassing the closest emergency department (ED); this process is called STEMI bypass. Guidelines state that the treating paramedics should “be capable of managing complications associated with acute coronary syndrome.” In many systems, primary care paramedics (PCP) are the first on scene because chest pain calls are high priority and the closest unit is dispatched. In some systems, there are no advanced care paramedics (ACP) at all. Can PCP safely care for and transport a STEMIbypass patient? Dispatching the more distant ACP, for example, would delay the time to aspirin, or first shock in the event that this evolves to a cardiac arrest. Requiring an ACP to transport a STEMI-bypass would also delay reperfusion. A pilot study conducted by Cantor et al. concluded that STEMI patients could be safely transported directly to PCI by paramedics without advanced care training. The paper published in this volume by Mitchell et al. echoes this recommendation and adds to our understanding of how to best use the skills and resources of paramedic services to safely minimize ischemic time. In the Mitchell paper, a PCP STEMI bypass program in a Canadian urban/suburban paramedic service is described (contact time with paramedics: 29 minutes, 40 seconds). This program began in 2006 and presents safety data for 2011-2016. Although a significant (59%) proportion had clinically important events, complications were transient and often resolved with no therapy. Furthermore, a smaller proportion would be addressed differently by ACP (many were hypotension responding to fluid, which could be addressed by PCP where they can initiate intravenous [IV] and fluid bolus). They conclude that PCP can safely conduct a STEMI bypass. This adds to the growing body of evidence on the role of paramedics in an integrated STEMI system of care, which includes two other Canadian papers recently published in CJEM. Bussieres et al. present a rural environment with longer transport times (> 30 minutes to the PCI centre). Data on 1,114 patients over a period of 8 years reveal 18.5% major events and 12.2% minor for PCP STEMI bypass. Kwong et al. recently presented data from an urban paramedic service. One year of data included 232 PCP-only STEMI bypass, of which 21/232 (9.1%) had indications for an ACP intervention. Eleven patients experienced cardiac arrest; 10 were successfully resuscitated (5 of these by PCPs). What does this add to our understanding of a STEMI bypass? Evidence-based guidelines recommend direct to PCI, but these same guidelines say the treating paramedics should be capable of managing

ST-segment elevation myocardial infarction (STEMI) bypass: The importance of paramedics in an integrated STEMI system of care