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related to the time of onset of the coronary artery occlusion (start symptoms) and the restoration of blood flow. In the acute fase, it is essential to open the occluded coronary as quickly as possible. This can be achieved by thrombolytic drugs or by mechanical revascularization (Percutaneous Coronary Intervention, PCI). Nowadays, stents are used in more than 90% of the PCI procedures, to scaffold the stenosis and to seal dissections against the vessel wall. Hereby, the chance for restenosis is significantly reduced compared to balloon angioplasty alone.

Since an acute myocardial infarction is the reflection of an acute exacerbation of a chronic process, interventions have to focus not only on the acute event, but also on a reduction of the burden of atherosclerosis and the complications of the myo- cardial infarction during follow-up. To achieve this, amongst other interventions, drug therapy is of significant importance. Antithrombotic therapy reduces the risk of new thrombotic events. Beta-blockers decrease myocardial oxygen demand and prevent arrhythmias. ACE-inhibitors reduce left ventricular remodeling, and statins are given to improve cholesterol levels and to achieve plaque stabilization. To lower the risk of sudden cardiac death, an Implantable Cardioverter Defibrillator is implanted in patients with a low ventricular ejection fraction after a large myocardial infarction. A healthy lifestyle, like no tobacco use, healthy diet and regular exercise, is essential for optimal secondary prevention. To achieve this, participation in a cardiac rehabilita- tion program can be very helpful for the patient.

To optimize care and outcome of patients with an acute myocardial infarction many organizations, e.g. the European Society of Cardiology, the American College of Cardiology with the American Heart Association, and The Netherlands Society of Cardiology, have published guidelines for the treatment of patients with myocardial infarction. Guidelines are systematically developed statements to assist practitioners and patients in making evidence-based decisions about appropriate health care for specific clinical conditions. Prior studies and surveys revealed that implementation of guidelines in daily clinical practice will result in a lower number of complications: i.e. fewer patients will develop heart failure related symptoms and re-infarctions, and most important better adherence to guidelines will lower the short- and long-term mortality.

Lack of implementation of guidelines can be explained by several factors: the guidelines themselves, patient- and physician’s constrains, and organizational barri- ers. First, the guidelines themselves: the basis of these guidelines ranges from ran- domized clinical trials to expert panel opinions. The “generalisability” of trial data is sometimes questionable due to the often highly selected study populations enrolled

160 in these randomized trials. Moreover, the guidelines are extensive and complex. Second, some physicians judge guidelines as oversimplified, “cookbook” medicine and a threat for the autonomy of the physicians. Third, patients play a central role in the success of therapy. It takes a lot of effort, time and money to adopt and main- tain a healthier behavior and to use all prescribed drugs. Fourth, optimal treatment of patients with an acute myocardial infarction should be a continuum-of-care; it should include acute and long-term. Therefore, regional ambulance services, general physicians, regional hospitals, cardiologists, nurses and rehabilitation centers should work all together. Guidelines of the different professionals should be aligned to make smooth transition from one setting to the other possible. Besides optimizing care processes, political, economical and financial issues have to be overcome.

Prior acute myocardial infarction quality improvement projects mainly focused on acute cardiac care and secondary prevention strategies during the index hospitaliza- tion phase only. In the last few years, more and more projects installed pre-hospital care systems: networks of collaborating emergency medical services, community hospitals and interventional cardiac centers to foster early reperfusion therapy in pa- tients with acute myocardial infarction. Although, as addressing systematically one phase of myocardial infarction care improves outcome significantly, it can be expected that further improvement of care and outcome can be achieved by maximizing the use of evidence-based therapy during all essential phases of care for patients with an acute myocardial infarction. Therefore, in 2004 we developed and implemented an all-phases integrated quality improvement program: the MISSION! protocol. Chapter 2 describes the rationale, design and implementation of the MISSION! protocol. The aim of MISSION! is to improve acute and long-term care for patients with acute myocardial infarction by implementation of the most recent guidelines of the European Society of Cardiology and the American Heart Association/American College of Cardiology. To our knowledge the concept of MISSION! is unique as it contains all essential phases of acute myocardial infarction care: i.e. the prehospital, inhospital, and outpatient phase, up to 1 year after the index event. By the use of care-tools we created a clinical framework for decision making and treatment. MISSION! concentrates on rapid diagnosis and early reperfusion, followed by active lifestyle improvement and structured medical therapy. Because MISSION! covers both acute and chronic phases of myocardial infarction care, this design implies an intensive multidisciplinary collaboration among all regional health care providers.

Summary, conclusions and future perspectives

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