From Concept to Reality

> Perseverance is not a long race: it is many short races one after another.> > —Walter Elliott, 19th Century spiritual writerThe treatment and outcome of patients with ST-segment elevation myocardial infarction (STEMI) has improved dramatically over the 30 years since I graduated from medical school. In 1982, bed rest, treatment of complications such as ventricular arrhythmias or mural thrombus and prayer (for those so inclined) were the standard of care. In the first decade, pharmacological therapy was developed, and the open artery hypothesis was confirmed. The Second International Study of Infarct Survival (ISIS-2) trial demonstrated the benefit of not only aspirin, but also the combination of aspirin and streptokinase1 leading to a series of randomized clinical trials to determine the preferred fibrinolytic and adjunctive medications. The second decade was filled with trials that compared fibrinolytic therapy with primary percutaneous coronary intervention (PCI), which ultimately confirmed primary PCI as the preferred method of reperfusion if performed in a timely manner in high-volume centers.2 European trials extended the benefits of PCI to STEMI patients who presented to non-PCI centers requiring transfer for primary PCI.3,4 In particular, the Danish Multicenter Randomized Study on Thrombolytic Therapy versus Acute Coronary Angioplasty in Acute Myocardial Infarction (DANAMI-2), a well-designed, multicenter, randomized trial including 24 referral hospitals and 5 PCI centers in Denmark, was stopped early when it demonstrated a significant reduction in the primary end point of death, reinfarction, and stroke at 30 days (8% for primary PCI versus 13.7% for fibrinolysis, P <0.001).4Article see p 189These randomized clinical trials stimulated interest in regional STEMI systems in the United States, but many believed it would be challenging to replicate the results seen in a small European country with short-duration transfers (mean, 34 miles) and an organized national emergency medical system (EMS).5 In 2002, …