Żurowska-Wolak et al.

Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine

(2019) 27:39
https://doi.org/10.1186/s13049-019-0616-4

ORIGINAL RESEARCH Open Access

The effects of prehospital system delays on

the treatment efficacy of STEMI patients
Magdalena Żurowska-Wolak1, Patryk Piekos2, Jacek Jąkała3 and Marcin Mikos4*

Abstract
Background: Cardiovascular disease accounts for nearly half of all deaths in Poland. The aim of this study was to
assess both the duration and the delays of prehospital treatment in ST-segment elevation myocardial infarction
(STEMI) patients and how it impacts left ventricle ejection fraction (LVEF) measured at the time of discharge and
the frequency of in-hospital patient mortality.
Methods: This study retrospectively analyzed medical records from January 2011 to December 2015 (excluding the
year 2013) of 573 patients who were transported to a hospital with a diagnosis of STEMI.
Results: The mean time of prehospital system delays was 59 min with a maximum time of 152 min and a
minimum time of 23 min. The relationship between reduced LVEF (< 55%) and in-hospital patient mortality and the
relationship between length of time from first medical contact (FMC) to hospital admission was analysed in 515
respondents. Extending the time of FMC to hospital admission by 1 min increased the chances of lowering LVEF by
2% (95% CI: 1.004–1.041) and increased the chances of death by 2% (95% CI: 1.002–1.04) in STEMI patients.
Conclusions: This study emphasised how vital it is to minimise time spent with STEMI patients at the scene of their
cardiovascular event by performing an ECG as quickly as possible and by immediately transporting the patient to
the hospital with the targeted treatment. This may lead to the implementation of additional training in the field of
ECG interpretation, increase the prevalence of teletransmission systems, and improve communication between
Emergency Medical Services (EMS) and catheterization laboratories ultimately reducing patient mortality.
Keywords: ST-segment elevation myocardial infarctions , Prehospital, First medical contact, System delays, Left
ventricular ejection fraction

Background 2006 and 2009, it was 30–32% [2]. In 2014, STEMIs

Cardiovascular disease has accounted for nearly half of accounted for 33% of all ACSs in Poland which received
all deaths in Poland in the last several decades reaching interventional treatment [3].
a total of almost 170,000 deaths annually. Among these Studies show that delaying the treatment of myocardial
deaths, 13,000 are deemed to be caused by an “acute infarction (MI) after the onset of symptoms causes in-
myocardial infarction” [1]. Although this is true, there creased mortality. This was confirmed in cases of
has been a decrease in the number of STEMIs in Poland thrombolytic MI treatment, where the greatest reduction
in recent years due to the improvement in the quality of in 35-day mortality was demonstrated in the group of
diagnosis and care of patients with chest pain. According patients in which fibrinolysis occurred within 2 h after
to the Polish National Registry of Acute Coronary Syn- the onset of symptoms compared to those treated later
dromes (PL-ACS), between 2003 and 2005 the percent- (44% vs. 20%, p = 0.001) [4]. Studies which analyzed in-
age of STEMIs amongst acute coronary syndromes vasive treatment in ACS have also supported the notion
(ACS) was 35–36%. Then a few years later, between of the benefits of rapid intervention. These studies
proved that the 30-day mortality of patients was 1%
* Correspondence: [email protected] when Percutaneous Coronary Intervention (PCI) was
4
Department of Emergency Medical Services, Faculty of Medicine and Health implemented within the first hour of symptoms, 4%
Sciences Andrzej Frycz Modrzewski Krakow University, Gustawa
Herlinga-Grudzińskiego 1, 30-705 Kraków, Poland when treatment took 60 to 90 min, and 6.4% when the
Full list of author information is available at the end of the article

© The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
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Żurowska-Wolak et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2019) 27:39 Page 2 of 7

time exceeded 90 min [5]. Additionally, numerous longer Results

observations confirmed this data by showing that every This study investigated the duration of system delays in
30 min of delay in treatment resulted in an increase in the treatment of STEMI patients. System delays are
the risk of death in MI patients by 7.5% annually [6]. For divided into the patient-dependent, the prehospital, and
this reason, in accordance with the recommendations of the in-hospital phases. Patient-dependent delay is the
the European Society of Cardiology (ESC) of 2012 as time elapsed from the onset of symptoms to the emer-
well as of 2017 [7, 8], all hospitals and EMS participating gency call whose mean in the this study was 71 (24–202)
in the treatment of STEMI patients should record and minutes. The maximum time of patient-dependent delay
monitor any delay in treatment and strive to achieve the was 6845 min and a minimum of 1 min. Prehospital
following goals; system delay is the time that expires after a patient calls
for the EMS to their hospital admission. This time is
 the time from the first medical contact (FMC) to dependent on the ambulance and the mean of this delay
the first ECG performed by the EMS should be ≤10 was 59 (50–72) minutes with a maximum time of 152
min in order to quickly diagnose STEMI min and minimum time of 23 min. The time from
 the time from FMC to mechanical reperfusion of admitting the patient to the hospital to mechanical re-
the occluded artery should be ≤90 min and in some perfusion of the occluded artery in the catheterization
patients (high-risk patients with a large MI and with laboratory (door-to-balloon time) is the in-hospital sys-
symptoms lasting < 2 h) even ≤60 min. tem delay. The mean of in-hospital time was 35 (28–45)
minutes with a maximum time of 333 min and a mini-
The aim of this study was to assess both the duration mum of 11 min.
and the delays of prehospital treatment in STEMI In order to quantify and measure prehospital delays,
patients and how it impacts LVEF measured at the time the time of the first emergency call, the time of ambu-
of discharge and the frequency of in-hospital patient lance arrival, the duration of EMS work at the scene,
mortality. and finally hospital transportation time must all be
included in the calculations (Table 1). The mean time it
Methods took the EMS to perform an ECG once they were at the
This study was carried out in a center of interventional scene was 10 (6–18) minutes with a minimum time of 1
cardiology and by six EMS teams in the Cracow agglom- min and a maximum time of 85 min. In 50.3% of cases
eration which transported patients to a 24-h (n = 184), the time of performing an ECG by the EMS
catheterization laboratory. Patients who were delivered was in accordance with the ESC guidelines, which rec-
to the hospital by EMS from the scene of STEMI onset ommend the time from the FMC to ECG to be ≤10 min.
from January 2011 to December 2015 were included in In 91.5% of cases (n = 515), the door-to-balloon time
the study (excluding the year 2013). Only patients who was in accordance with the ESC guidelines, which rec-
were transported to a hospital with a diagnosis of ommend that it should last a maximum of 60 min. As
STEMI (534 patients plus 62 patients who were ultim- part of the assessment of in-hospital delays, the patients’
ately diagnosed as STEMI ICD10 code: I21.0, I21 or waiting time for the procedure and the duration of PCI
I21.2) were selected for further analysis. Of these 596 were examined. Delays in the catheterization laboratory
STEMI patients, 573 patients were considered for fur- are presented in Table 2.
ther analysis. The time from the FMC to the mechanical reperfusion
The analysis of medical records was used as the research of the occluded artery in the catheterization laboratory
method in this study. Hospital documentation which in- (contact-to-device time) was then calculated. Total
cluded patient history, diagnostic test results, and a EMS
ambulance record was retrospectively analysed. The data Table 1 Distribution of Time in System Delays - Prehospital
obtained in the study was collected and stored using Phase
Microsoft Office Excel software. Statistical analysis was Prehospital Phase
performed using the Statistica 10.0 program (StatSoft, Inc.
Time from Time Spent Hospital
STATISTICA software, version 10.0) and the IBM SPSS Emergency at the Scene Transport
Software program version 23. A 5% margin of error and a Call to FMC (n = 447) Duration
significance level of p < 0.05 were accepted. A comparison (n = 573) (n = 447)
in the distribution of system delay times in terms of me (IQR) 10 (7–13) 24 (19–30) 22 (17–28)
minutes minutes minutes
qualitative variables was performed using the U Mann-
Whitney test and the Kruskall-Wallis test. The relation- min 1 min 1 min 5 min
ship between age, distance, and times was examined by max 52 min 71 min 89 min
the Spearman’s rank correlation coefficient. me (IQR) interquartile range median, min minimum, max maximum
Żurowska-Wolak et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2019) 27:39 Page 3 of 7

Table 2 Distribution of Time in System Delays - Hospital Phase difference in the time from first entering the ambulance
Hospital Phase to PCI implementation between people with normal and
Time to Coronagraphy PCI Duration reduced LVEF.
(n = 573) (n = 563) In-hospital deaths, 38 out of 573 patients (6.7%), oc-
me (IQR) 15 (11–21) minutes 20 (15–25) minutes curred most frequently in the first day of hospitalization
min 1 min 5 min (52.6%). A comparison between people who died in the
max 282 min 98 min
hospital and those discharged from the hospital is
presented in Table 4. The average age of patients who
me (IQR) interquartile range median, min minimum, max maximum
died in the hospital was 6.3 years higher than those
discharged from the hospital. There was no significant
ischemic time (TIT) which is the time from the onset of difference in the mean distance from where the patient
pain to PCI was also determined. The mean time of TIT was first taken to the hospital between those who died
was 170 (125–300) minute with a maximum time of and those who had been discharged from the hospital.
6968 min and a minimum time of 48 min. There was no significant difference in time from the ar-
The mean time from FMC (EMS arrival at the site) to rival of the ambulance to the site of the event to hospital
PCI was 87 (74–103) minutes with a maximum time of admission between people who died and those who did
395 min and a minimum of 38.5 min. The ESC recom- not. The mean time from FMC to the mechanical reper-
mendations regarding the time from FMC to mechanical fusion of the occluded artery in people who died was
reperfusion of the occluded artery of ≤90 min was met significantly longer (by 9 min) than in those patients
in 55.6% of cases (n = 313). However, for 368 patients who were discharged from the hospital.
with symptoms lasting less than 2 h, the contact-to-de- In the group of patients in whom PCI was performed
vice recommendation time of ≤60 min was met only in within 60 min after hospital admission, the influence of
6.8% (n = 25). prehospital treatment ‘s duration on the value of the
maximum LVEF and in-hospital death was evaluated.
The influence of the duration of prehospital treatment on Among the 515 respondents meeting this criteria, 432
the value of the maximum left ventricle ejection fraction (83.9%) patients had a reduced maximum LVEF and 38
and in-hospital death (6.7%) of the respondents died in the hospital. A
Echocardiography with the assessment of maximal LVEF one-dimensional model showed that prolonging the time
was performed in 552 patients (96.3%). The comparison from FMC to patient hospital admission significantly
between people who had normal maximum LVEF (LVEF influenced the chance of a reduced LVEF value and
≥55%) and those who had it reduced (LVEF < 55%) are in-hospital death. Extending this time by 1 min increased
presented in Table 3. There is no difference in the mean the chances of lowering LVEF by 2% (95% CI: 1.004–
age between people with normal maximum LVEF and 1.041) and increased the chances of death by 2% (95%
those with lowered LVEF. The mean distance from the CI: 1.002–1.04).
place where the patient was taken to the hospital is Additionally, multivariable regression models were
higher by 2.2 km in people with LVEF < 55%. The mean performed for all pre-hospital procedures tested. The re-
time from FMC to handing over the patient to the hos- sults in these models include the administration of
pital was significantly longer (by 5 min) in people with antiplatelet/ anticoagulant drugs (heparin, clopidogrel or
reduced ejection fraction. There was no significant both) because they have been significantly associated

Table 3 Comparison of Variables Between Subjects with Normal LVEF (≥55%) and Reduced LVEF(< 55%)
Variable LVEF n x Sd me IQR p
Age [years] ≥ 55% 74 63.6 10.2 – – 0.6A
< 55% 478 64.4 11.9 – –
Distance from Hospital [km] ≥ 55% 74 – – 8.2 3.2–19.2 0.01B
< 55% 478 – – 11.1 5.4–23.4
Time from FMC to Hospital ≥ 55% 74 – – 44 36–54 0.005B
Admission [min]
< 55% 478 – – 49 41–61
Time from FMC to PCI [min] ≥ 55% 74 – – 84 70–95 0.076B
< 55% 478 – – 87 75–103
LVEF left ventricular ejection fraction, n sample, x sample mean, Sd standard deviation, me mean, IQR interquartile range, p p value
A - p value from t-Student test
B - p value from U Mann-Whitney test
Żurowska-Wolak et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2019) 27:39 Page 4 of 7

Table 4 Comparison of Variables Between Patients Who Died in the Hospital and Those Discharged from the Hospital
Variable Death? n x Sd me IQR p
Age [years] no 535 63.9 11.6 – – 0.001A
yes 38 70.3 13.9 – –
Distance from Hospital [km] no 535 – – 10.30 5.2–22.1 0.09B
yes 38 – – 6.80 2.9–18.0
Time from FMC to Hospital no 535 – – 48 41–60 0.2B
Admission [min]
yes 38 – – 51.5 44–62
Time from FMC to PCI [min] no 525 – – 86 74–101 0.005B
yes 34 – – 105 79–118.5
LVEF left ventricular ejection fraction, n sample, x sample mean, Sd standard deviation, me mean, IQR interquartile range, p p value
A - p value from t-Student test
B - p value from U Mann-Whitney test

with decreased left ventricular contraction in previously So far, the health care system has focused on shortening
performed multivariable models. After taking into ac- the time from the moment of admitting the patient to
count the influence of age, sex, presence of diabetes, the hospital and performing PCI (door-to-balloon time)
hypertension, hypercholesterolemia, renal failure, shock keeping this as a determinant of good care for a patient
and the administration of drugs (heparin, clopidogrel), with a MI.
the overall effect the duration of time from FMC to Door-to-balloon time did initially compose the major-
patient hospital admission on LVEF and in-hospital ity of the delays seen in patients with a MI. In 27,080 pa-
death was decreased and became statistically insignifi- tients analysed in 661 centers in the USA in the years
cant (Tables 5 and 6). between 1994 and 1998, the mean time from first symp-
toms to hospital admission was 96 min. While the mean
Discussion time from hospital admission to PCI (door-to-balloon)
The aim of this study was to assess both the duration was 116 min (IQR 85–163) [9]. This makes it very clear
and the delays of prehospital treatment in STEMI pa- that reducing door-to-balloon time was the national tar-
tients and how it impacts LVEF measured at the time of get for the treatment of heart attacks in the United
discharge and the frequency of in-hospital patient mor- States. The 2013 American Heart Association (AHA)
tality. Delays in prehospital treatment for patients with guidelines recommended keeping this time below 90
an MI consist of patient-dependent delays and system min. Furthermore, the 2012 ESC guidelines proposed
delays. System delays are determined by the ambulance that hospitals which can perform PCI should seek to re-
that transports the patient and in part by the hospital duce door-to-balloon time to ≤60 min. Once these rec-
that implements the final treatment of PCI. The reduc- ommendations were put into place, in-hospital delays
tion of the time from the onset of symptoms to reperfu- have been significantly reduced. In the US in 2005, the
sion therapy is a priority in the treatment of patients door-to-balloon mean time was 86 min (IQR 65–109),
with MI. and in 2011 it dropped to 63 min (IQR 47–80) [10]. In
The time after a MI patient comes into contact with Poland between 2003 and 2006 (from October 2003 to
health services is the component of time which depends March 2006), the mean time of door-to-balloon was 50
solely on the healthcare system. This time before PCI is min (IQR 32–85) [11] and in 2009 it was 25 min
influenced by two independent phases which are the (PL-ACS) [2]. In this study, the mean time of door-to--
pre-hospital phase and catheterization laboratory phase. balloon was 35 (28–45) minutes. This result is in line
Table 5 The Relationship Between the Occurrence of Reduced Table 6 The Relationship Between the Occurrence of In-
LVEF and the Time from FMC to Patient Hospital Admission - Hospital Death and the Time from FMC to Patient Hospital
One-Dimensional and Multivariable Model Admission - One-dimensional and Multivariable Model
ORa 95% CI ORb 95% CI ORa 95% CI ORb 95% CI
Time from FMC 1.022 1.004 1.041 1.017 0.994 1.042 Time from FMC 1.022 1.002 1.04 1.005 0.976 1.035
to Patient Hospital to patient hospital
Admission admission
OR Odds Ratio OR Odds Ratio
CI Confidence Interval CI Confidence Interval
a a
one-dimensional model one-dimensional model
b b
multivariable model including drugs + age + sex + distance + diabetes + multivariable model including drugs + age + sex + distance + diabetes +
hypertension + hypercholesterolemia + renal failure + shock hypertension + hypercholesterolemia + renal failure + shock
Żurowska-Wolak et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2019) 27:39 Page 5 of 7

with both AHA and European Resuscitation Council Door-to-balloon time focuses only on the last phase of
recommendations. treatment in STEMI patients. This study proved that
When focusing on total time from FMC to PCI, with modifications in earlier phases, it is possible to im-
Poland had comparable results to other European na- prove the care of STEMI patients. The influence of how
tions. According to PL-ACS reports between 2004 and fast EMS procedures were performed on STEMI patients
2007, the mean time from FMC to PCI was 124 min in on the outcomes of the final treatment was assessed.
Poland [12]. In Germany, the Czech Republic, Croatia, The one-dimensional model in this study showed that
and Lithuania, the time from FMC to PCI was 120 min. prolonging the time from FMC to patient hospital ad-
The shortest times were reported in Belgium (60 min) mission significantly influenced the chance of a reduced
and in Sweden (69 min). The longest times reported LVEF value and in-hospital death, though in the multi-
were in France (170 min) and Serbia (177 min) [12]. variable model this relationship did not maintain its sig-
Among 3312 patients with STEMI in Cologne, Germany nificance. Longer durations of the prehospital phase was
in the years between 2006 and 2012, the mean time from directly correlated with greater distances in which some
FMC to PCI was 65 min (IQR 48–91) when the patient patients had to travel in order to reach the hospital. In
was transported directly to the hospital where PCI was this study, patients who had to travel greater distances
performed. This time was 89 min (IQR 72–115) when resulted in the reduction of LVEF in those analyzed pa-
the patient was brought by ambulance and 107 min tients. Patients who came from greater distances,
(IQR 85–148) when the patient was transported from though, had an unchanged door-to-balloon time as in all
another hospital [13]. In Cracow in 2009, the time from those cases the PCI team was notified in advance of the
FMC to PCI was on average 93 min in patients who patient’s arrival and was adequately prepared.
were directly transported to the catheterization labora- A review in Denmark with a group of 6209 patients,
tory. In cases where the patient was transported from observed a significant increase in mortality with an in-
hospital emergency departments to catheterization la- crease in system delays times (> 1 h 15.4% vs. 1-2 h
boratories, the average time was between 175 min (in 23.3% vs. 2-3 h 30.8%, p > 0.001) [22]. Also, Koul et al.
Cracow) and 193 min (outside of Cracow) [14]. In showed a significant relationship between FMC to PCI
Warsaw, the mean time of contact-to-device time was delay and one-year mortality in a group of 13,790 pa-
159 min in patients transported from other hospitals. tients. In their work, extending system delay time over 1
This time decreased to 115 min in patients who were h resulted in a significant increase in the chance of death
brought directly to the site of PCI after the EMS con- by 26% (OR = 1.26, 95% CI: 1.03–1.55). With a delay of
sulted the catheterization laboratory with ECG teletrans- more than 2 h, this chance of death was even increased
mission [15]. In this study, the mean time from FMC to by 51% (95% CI: 1.23–1.86) [23].
PCI was 87 (74–103) minutes. This evidence makes it This study, in accordance with others similar works,
clear that correctly transporting patients to the appropri- showed that the duration of system delays, between
ate location is crucial in order to diminish delays. It is FMC and PCI, was directly tied to an increased chance
worth noting, though, that the time of FMC in other in in-hospital patient death. As previously stated, short-
studies was chosen differently. In some studies, FMC ening system delays may be achieved by notifying the
was noted at the time of arrival of a medical rescue team PCI team in advance. Additionally, other sources note
at the place of the cardiovascular event [16, 17]. In that by omitting the emergency department and directly
others, FMC was the time the ECG was performed by sending the patient to the invasive cardiology depart-
the EMS [18, 19, 20]. Moreover, other studies used the ment also shortens system delays [24].
time of the patient’s phone call to the EMS as FMC [21]. Focus should be placed on minimizing delays in the
Using the time patients called the ambulance as FMC prehospital phase as this is the longest delay in the
may be unreliable because that phone call would be the healthcare of STEMI patients as noted in this study and
only way to assess the patient’s condition. In this study, confirmed in others. Literature on this matter notes that
STEMI was confirmed by ECG in patients with a history the best way to accelerate the diagnosis of STEMI in a
of chest pain but the exact time of recording was not patient, consequently shortening system delays, is by
able to be assessed in 36.1% of cases. For this reason, the performing an ECG faster after FMC. In Germany, the
decision was made to include the travel time of EMS in mean time of performing an ECG after FMC was 5 min
the time of FMC. Therefore, the diagnosis of STEMI by (IQR 3-10 min) [25]. Furthermore, it would be beneficial
ECG is by definition the moment of FMC which is in ac- to minimize time spent with the patient at the scene of
cordance with the ESC guidelines of 2017. Unification of cardiac event in order to transport the patient to the
these definitions could help guide both the monitoring hospital more quickly where PCI may be performed.
and comparisons made between different centers in the Ultimately, one of the most crucial elements in short-
quality of STEMI patient care. ening system delays can be found in ECG interpretation
Żurowska-Wolak et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2019) 27:39 Page 6 of 7

and the physical exam. The ability to assess ECGs by FMC. The goal should be to minimize the time spent
various groups of medical professions has been evaluated with patients at the site of the event and perform an
in several studies. In one study in a group of paramedics, ECG as quickly as possible in order to transport the
the correct diagnosis of myocardial infarction ranged patient more efficiently to the hospital with the targeted
from 59 to 94%. In a group of emergency medicine doc- treatment (PCI). This time depends partly on the
tors, a correct diagnosis was seen in 77 to 93% of the patient’s condition as well as on the distance to the
time, and finally in a group of cardiologists, the correct catheterization laboratory. It is therefore important to
diagnosis was established in up to 81 to 95% of cases remind members of the EMS in meetings or in ECG
[26, 27, 28]. ECG teletransmission to the catheterization interpretation trainings on the key role time plays while
laboratory is a key piece in shortening delays. In Poland, treating patients with STEMI.
the teletransmission system has been developing since
Abbreviations
2001 and is now available in almost 100% of State Emer- ACS: acute coronary syndromes; AHA: American Heart Association;
gency Medical Service Ambulances. In Cracow, Poland, EMS: Emergency Medical Services; ESC: European Society of Cardiology;
it has been accessible since 2013. However, teletransmis- FMC: first medical contact; LVEF: left ventricle ejection fraction;
MI: myocardial infarctio; PCI: Percutaneous Coronary Intervention; PL-
sioncannot ultimately replace the knowledge and com- ACS: Polish National Registry of Acute Coronary Syndromes; STEMI: ST-
petence of EMS members. This is because there are segment elevation myocardial infarction; TIT: total ischemic time
sometimes situations when either human error, equip-
Acknowledgements
ment failure, or lack of Global System for Mobile com- Acknowledgements Not Applicable.
munications may make teletransmission impossible to
perform. Funding
Currently, the consensus among medical practitioners Funding Not Applicable.

is that the preferred method of STEMI treatment is PCI. Availability of data and materials
The European Society of Cardiology guidelines of 2018, All data generated or analysed during this study are included in this
however, also addresses the possibility of implementing published article.
fibrinolysis by paramedics in pre-hospital conditions in Authors’ contributions
cases of prolonged transport. Fibrinolytics are therefore All authors gathered and analyzed the data then read and approved the
supplied by ambulances in several European and in final manuscript.
Northern American countries [29, 30]. The European
Ethics approval and consent to participate
Society of Cardiology guidelines of 2018 suggest that in 122/6120/185/2015.
situations when the maximum time from diagnosis of
STEMI to primary PCI is above 120 min, fibrinolysis Consent for publication
Consent Not Applicable.
should be considered and, if possible, used in the pre--
hospital setting [8]. Administering such medications Competing interests
shortens the time of opening the occluded artery and is The authors declare that they have no competing interests.
especially useful in rural areas [31]. However, medical
emergency personnel in Poland are not legally able to Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in
administer fibrinolytics. Poland, though, has a dense net-
published maps and institutional affiliations.
work of catheterization laboratories (165 for a popula-
tion of 38.5 million), and in most cases, the time from Author details
1
Jagiellonian University Medical College, Faculty of Health Sciences, Division
diagnosis of STEMI to primary PCI is less than 120 min.
of Emergency Medical Services, Kraków, Poland. 2Department of Anatomy,
Jagiellonian University Medical College, Kraków, Poland. 3Cracow Center of
Conclusions Invasive Cardiology, Electrotherapy and Angiology, Scanmed, Kraków, Poland.
4
Department of Emergency Medical Services, Faculty of Medicine and Health
In conclusion, focusing on the time of FMC with the
Sciences Andrzej Frycz Modrzewski Krakow University, Gustawa
health care system to the start of reperfusion therapy is Herlinga-Grudzińskiego 1, 30-705 Kraków, Poland.
important because it takes into account the total time of
Received: 27 December 2018 Accepted: 15 March 2019
delays which are modifiable by the health care system.
Understanding the weak elements of this “survival
chain” may allow for the implementation of appropriate References
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