Acute Coronary Syndrome (ACS) are events due to the rupture/erosion of a coronary atherosclerotic plaque, with activation of the coagulation cascade and critical reduction of the flow, which is expressed in a spectrum of clinical scenario ranging from infarction with ST elevation (STEMI)1, to non ST elevation ACS (NSTE-ACS)2.
Timely reperfusion therapy, either pharmacological or via percutaneous coronary intervention (PCI)1, is indicated for patients with STEMI. Patients with NSTE-ACS should undergo initial risk stratification, followed by invasive evaluation, depending on the patient's risk profile2. (Figure 1).
It is necessary to create an effective network among hospitals, to make available the fastest and most effective therapy for the greatest number of patients with ACS. The European Society of Cardiology (ESC) guidelines suggest the implementation of such regional networks1. Achieving this goal is possible only by sharing a common protocol.
The province of Teramo was equipped with a cardiological network in 2011. There are 2 simple structures, a structure with a spoke CCU (Giulianova) and the Hub structure with CCU and Cath-lab (Teramo). The simple structures refer to the Hub center when direct access to cath-lab is required and to spoke CCU for those patients who do not require immediate coronary angiography. Spoke CCU unit refers to Hub center for the access of patients with ACS to the cath-lab3.
On the basis of epidemiological data4 it can be expected that in the province of Teramo there are about 230-250 STEMI and 450-500 NSTE-ACS/year. Teramo's cath-lab performed 248 primary PCIs on STEMI, and 390 PCIs on NSTE-ACS.
In the spoke CCU in 2021, there were 1005 patients hospitalized with ACS. Almost all of them were transferred/transported for coronary angiography according to risk stratification. There were 326 patients discharged with a diagnosis of ACS undergoing PCI.
That data made it necessary to transport the patient in hemodynamics for angiography study and interventional procedure, and possible retransfer to the spoke center. This strategy is called service. The advantages and safety of this procedure have already been described7.
The implementation of service strategy would make a clear increase in interventional procedures foreseeable (ideally the approximately 100 patients with ACS accessing the Spoke CCU should undergo PCI with adequate timing in 70% of cases) and an optimization of work for the centers and of patient care.