In the past decades, evidence has mounted for the benefits of primary percutaneous coronary intervention (PCI) over thrombolysis during ST-segment elevation myocardial infarction (STEMI) as it establishes more consistent and predictable epicardial artery recanalization, reduces recurrent ischemia and reinfarction, and improves survival . Hospitals with established interventional cardiology programs have opened and maintained primary PCI programs with dedicated teams of interventional cardiologists, nurses, and technicians who are available around the clock to perform urgent coronary revascularization for STEMI patients.

It is now well conceived that prolonged duration of ischemic time during STEMI is directly related to permanent myocardial damage and increased mortality . Accordingly, all the major cardiology societies, including the American Heart Association, American College of Cardiology, and European Society of Cardiology, have prioritized the goal of minimizing the time of myocardial ischemia by setting clear objectives on timely reperfusion during STEMI . Initiatives, such as the American Heart Association’s “Mission: Lifeline,” that call for community and hospital measures to further reduce the time to reperfusion have emerged. Beyond professional guidelines and recommendations, the reperfusion delay during STEMI is being monitored by insurers, payers, and governmental organizations both in the United States and outside of the United States as a quality measure for hospital performance, thus adding more pressure on rapid activation of the catheterization laboratory team.

Similarly to STEMI patients, there is a subset of non-ST-segment elevation myocardial infarction patients, which is defined as high risk, with refractory angina, heart failure symptoms, hemodynamic instability, and life-threatening arrhythmias, who should undergo urgent revascularization within two hours according to the recommendations of all the cardiology associations . Urgent coronary angiography with an intention for revascularization should also be performed in the subset of patients who present to the hospital after cardiac arrest . These urgent interventions, when performed in a timely manner, improve patient outcomes and should be performed both during the day and during off hours despite the growing burden on hospital systems and catheterization laboratory teams.

Up-stream activation of the cath lab teams by emergency medical services (EMS) technicians and emergency department physicians is a crucial element in the process of STEMI management to shorten the time to reperfusion and has an impact on patient outcomes. It is expected that because of time constraints in the evaluation process of a suspected STEMI patient, such a system will be imperfect and that some activations may eventually be “false positives.” There is a need to maintain a continuous learning process to identify elements that may improve the sensitivity without compromising the specificity of this process. One of these elements is the study by Patel et al. in this issue of Cardiovascular Revascularization Medicine , which assesses the rates of inappropriate activation of the catheterization laboratory team during a period of eight years and describes clinical predictors for inappropriate catheterization laboratory team activation. Only cases of suspected STEMI that triggered activation of the catheterization laboratory team were included in the study. This analysis provides important insights into the rates and reasons for inappropriate catheterization laboratory team activation, especially given the high rate (17.9%) of the cases that were deemed as inappropriate activation. Interestingly, despite improvement in clinical care, the rates of inappropriate activation remain high throughout the study period. In-depth assessment of the reasons for inappropriate activation indicates that the vast majority of the cases were the result of incorrect diagnosis of STEMI and that only a small minority (1.4%) were patients who actually had STEMI but were poor candidates for PCI. This finding is encouraging because it is theoretically possible that by training personnel and perhaps by utilizing advanced technologies it might be possible to reduce the rates of STEMI misdiagnosis.

Efforts to shorten the reperfusion time should continue despite the inevitable price of false catheterization laboratory team activations, but at the same time, there should be a search for new tools to improve the accuracy of STEMI diagnosis. Telemedicine is a modality that is currently underutilized in the setting of acute care. It is possible to create a chain of communication based on mobile applications that would be able to transfer patient clinical data, electrocardiograms, and even images of the patient to various members of the communication chain. Among the members could be the EMS team on the field, emergency department physicians, cardiology fellows, the attending cardiologist, and even the interventional cardiologist who is on-call. This approach may facilitate more accurate diagnosis of STEMI and is supported by the data presented by Patel et al. , which indicated that most cases of inappropriate activation were due to electrocardiographic misdiagnosis (for example, 27% of the patients had ST-segment elevation patterns without reciprocal ST-segment depression changes). Furthermore, beyond achieving correct diagnosis, when utilized by emergency medical system teams or by a referring hospital without catheterization laboratory capabilities, these modalities may further decrease the reperfusion times by allocating resources, such as selection of medical centers that have immediate availability of a catheterization laboratory team.

Inclusion of the cardiology fellow or attending physician early on in the chain of communication may further facilitate correct electrocardiographic diagnosis and, in borderline cases, trigger urgent echocardiographic assessment to rule in or rule out STEMI without causing significant delay in catheterization laboratory team activation.

The endeavor for improvement of care and prognosis of STEMI patients should continue with the leadership of the interventional cardiology community. New modalities and technologies that are now available should be utilized to improve patient care, so when a true STEMI patient arrives at the hospital and the physician is crying out, “Wolf,” the team will be ready.