Cath Lab Digest - January 2008 - (Page 28)

28 ACVP MANAGEMENT/STEMI INTERVENTIONS JANUARY 2008 Searching for the Key to D2B Dan Scharbach, Regional Director, Invasive Cardiovascular Services, Providence Health System, Portland Service Area, Portland, Oregon T here is nothing like a nice snowstorm in Portland to get you started writing an article. It doesn’t snow in Portland, you say? Well, sometimes it does, and the effect is total chaos. The end result is a three-hour transportation delay and time to write. How does this relate to acute myocardial infarction (AMI) timeto-treatment, or what is now being labeled door-to-balloon (D2B)? AMIs occur under all weather conditions, even in snowstorms. In fact, statistics might indicate they are more likely to happen in such cir- Figure 1. An example of a simple-to-read chart utilized by Providence Health System. It breaks down every component of care during the 90-minute window. The chart was developed by one of Providence’s ED team leaders. cumstances. If you already have a response barrier such as weather, every minute you can save through a well-developed D2B protocol is even more valuable. While attending conferences throughout the country, even as recently as three years ago, you would only occasionally encounter formal presentations on D2B protocols. STEMI NEWS ‘False-Positive’ Activation of Cardiac Catheterization Laboratory May Occur in Some Patients With Suspected STEMI P hysicians caring for patients suspected of having a heart attack may trigger “false-positive” activation of the cardiac catheterization laboratory based on test results suggestive of a heart attack, according to a study in the December 19 issue of the Journal of the American Medical Association. Allowing the emergency department physician to activate the cardiac catheterization laboratory is a key strategy to reduce the time to receiving treatment for patients with ST-segment elevation myocardial infarction (STEMI). “Time to reperfusion is a major determinant of outcome in patients presenting with an STEMI,” the authors write. Guidelines recommend that the emergency department physician make the decision regarding reperfusion therapy, such as coronary angiography, within 10 minutes of interpreting the initial diagnostic electrocardiogram (ECG), which may be challenging because clinical decisions are often made without a previous ECG result for comparison or time to observe ST-segment changes or cardiac biomarker results. A variety of other serious conditions aside from a myocardial infarction may also cause ST-segment elevation. The researchers add that although rapid reperfusion is important, the potential clinical and financial consequences associated with “false alarms” need to be considered. David M. Larson, MD, of the Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, and colleagues conducted a study to determine the prevalence and outcomes of “false-positive” catheterization laboratory activation for patients with a suspected STEMI. The study included a total of 1,345 patients who were enrolled from March 2003 to November 2006. The patients were part of a registry from a regional system that included transfer of patients with STEMI from 30 community and rural hospitals with pre-transfer catheterization laboratory activation for percutaneous coronary intervention (PCI) at a tertiary cardiovascular center in Minnesota. Of the 1,335 patients with suspected STEMI who underwent angiography, 187 (14 percent) did not have a clear culprit coronary artery, and 127 (9.5 percent) did not have significant coronary artery disease. Of the 14 percent of patients with no clear culprit artery, 64 (4.8 percent) had positive and 123 (9.2 percent) had negative cardiac biomarker results. Of the 1,335 patients who had angiography, cardiac biomarker results were negative in 149 (11.2 percent) patients. The rate of death at 30 days was 2.7 percent without vs. 4.6 percent with a culprit coronary artery. “… the issue of false-positive catheterization laboratory activation remains a significant concern because unnecessary emergency coronary angiography is not without risk to the patient and may impose a burden on limited human and physical catheterization laboratory resources,” the authors write. “This critical decision process must balance the risk of a false alarm with the consequences of delaying myocardial reperfusion.” “In the setting of increased emphasis on rapid door-to-balloon times, the consequences of false-positive catheterization laboratory activation need to be considered. False-positive catheterization laboratory activation may be another quality metric to monitor for a STEMI program.” In an accompanying editorial, Frederick A. Masoudi, MD, MSPH, of the Denver Health Medical Center, Denver, comments on the findings regarding treatment for STEMI. “The study by Larson et al should stimulate further development of quality measurement and reporting efforts. In the case of primary PCI, the view of quality should extend beyond the time to treatment to include patient selection, and ultimately to outcomes. While efforts to improve the quality of care will—and should—continue, the science of improvement must advance so that clinicians can be increasingly confident that efforts to deliver the right care to the right patient at the right time are improving and extending patients’ lives.” Source: JAMA. 2007;298(23):2754-2760;2790-2791.

Table of Contents Feed for the Digital Edition of Cath Lab Digest - January 2008

Cath Lab Digest - January 2008 Central Baptist Hospital Contrast Media Use in High-Risk Patients An Ergonomic Survey of Cath Lab Repetitive Stress Injuries Contents Clinical Editor’s Corner Takotsubo Cardiomyopathy, a.k.a., Transient Left Ventricular Apical Ballooning Syndrome: An Acute Coronary Syndrome Imposter Searching for the Key to D2B STEMI Intervention News STEMI Interventions: Commentary The Massachusetts Stent Study The Value of Educating Staff Ask the Clinical Instructor: A Q&A Column for Those New to the Cath Lab SICP* Chapter Updates The Society of Invasive Cardiovascular Professionals Holds an RCIS Review Course at New Cardiovascular Horizons 18:20 To Denver — One Student’s First Clinical Experience CEU Education Center Meetings Calendar What Do You Think? Clinical & Industry News Classifieds The Ten-Minute Interview with…Heather Vardon, RN Advertisers Index

Cath Lab Digest - January 2008

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