Acute myocardial infarction: acute coronary intervention at any hospital versus acute coronary intervention at specialized centers only

The acute coronary syndromes (ACS) are currently divided into those with ST elevation (STE-ACS = ST elevation myocardial infarction [STEMI]) and those without ST elevation (NSTE-ACS). The latter are further divided into NSTE-ACS with risk factors and NSTE-ACS without risk factors. For NSTE-ACS patients with risk factors an invasive strategy within 72 h after presentation is recommended, whereas NSTE-ACS patients without risk factors can be treated conservatively, without a routine invasive diagnosis. In patients with STE-ACS, primary angioplasty is the reperfusion therapy of choice. These recommendations concerning the invasive strategies are valid only under three conditions: (1) primary angioplasty has to be performed within 2 h after diagnosis of an STE-ACS; (2) door-to-balloon times for STE-ACS have to be < 60 min; (3) the invasive procedures have to be performed by experienced investigators at hospitals with a sufficient annual PCI (percutaneous coronary intervention) volume. The last point is based on studies which showed a volume-outcome relationship for PCIs in ACS patients and hospital mortality. In Germany, a nationwide supply with such an invasive strategy for ACS patients is currently possible, even within the recommended time frames. Therefore, local networks have to be established to achieve this goal. However, at least in regions with a high density of invasive centers, such networks should take the investigators' experience and the annual interventional volumes of the participating hospitals into account.