MD Conference Express ACC 2012 - (Page 30)

n S E L E C T E D U P D A T E S I N S T E M I Selected Update: State of the Art in STEMI Care Written by Lori Alexander Appropriate STEMI Care Depends on Timing It has been well established that primary percutaneous coronary intervention (PCI) is superior to fibrinolytic therapy for ST-segment elevation myocardial infarction (STEMI) but only if coronary reperfusion can be established in a timely manner (<90 minutes) by skilled operators. Achieving that goal has been a challenge, however, because of delays in diagnosis as well as in treatment. Two particular areas of concern are the effective use of prehospital electrocardiograms (PH-ECGs) and the appropriate treatment strategy for patients who must be transferred a long distance for PCI. department (ED) physicians and of 10% to 25% for ECGs that are interpreted by EMS personnel. However, studies have also demonstrated that PH-ECG transmission systems can reduce the rate of false-positive activations, because another set of “critical eyes” can review the ECG (usually the on-duty ED physician) before the 4 to 5 member catheterization laboratory team is activated. Various proprietary PH-ECG transmission options currently exist, but their use is by no means universal, because of various technical, financial, and administrative issues. Dr. Rokos cautioned that bringing patients with STEMI based on an ECG interpreted by paramedics directly from the field to the catheterization laboratory during the regular work day may be “great” for D2B times, but the cardiology team should also understand that significant potential exists for receiving a patient that did not have a STEMI. Thus, the role of the ED remains critical in filtering out inappropriate patients, especially if PH-ECG transmission is not available. The goal for efficient STEMI systems should be a <5% rate of inappropriate activation (red zone), as summarized in Table 1 [Rokos et al. Am Heart J 2010]. Table 1. Classification of Appropriate vs Inappropriate Cath Lab Activation. Appropriate Cath Lab Activation → Ideal Angiography and PPCI performed Appropriate Cath Lab Activation → Reasonable • Angiography without PPCI performed • Surgical revascularization indicated • Coronary anatomy is not amenable to PPCI intervention • 'Unavoidable angiogram' per index ECG and/or clinical scenario as documented by the real-time clinicians • No PPCI target-lesion identified but cardiac markers become elevated • Before angiography, true STEMI per index ECG patient dies suddenly • Angiography±PPCI for ROSC following witnessed OHCA from a shockable rhythm. Some ROSC patients may deteriorate and die before angiography Appropriate Cath Lab Activation → Goal is <5% rate • No angiography performed (Cath Lab activation cancelled by a physician) • Angiography without a PPCI target-lesion identified and normal cardiac markers: • Avoidable angiogram based upon erroneous ECG interpretation • Advanced co-morbidities: Patient is not a PPCI candidate PPCI=primary percutaneous coronary intervention: ECG=electrocardiogram; ROSC=return of spontaneous recirculation; OHCA=out of hospital cardiac arrest; Classification based on retrospective and multidisciplinary peer-review of all index clinical data; Green zone represents the ideal scenario, yellow zone represents reasonable scenarios, and red zone occurrences should be minimized (<5%). Prehospital ECGs Ivan Rokos, MD, FACEP, FAHA, FACC, an emergency physician in Los Angeles, California, USA, emphasized that patients with STEMI identified on a PH-ECG consistently have the fastest door-to-balloon (D2B) times. For example, in a Canadian study of 344 STEMI patients, the median D2B time was much shorter for patients who were referred directly to a PCI center by emergency medical services (EMS) personnel who were trained in ECG interpretation than for patients who were referred via interhospital transfer (69 minutes vs 123 minutes) [Le May MR et al. NEJM 2008]. The ACTION Registry – Get with the Guidelines (ARG) study of 7098 STEMI patients who were transported by paramedics to the hospital, showed that the use of a PH-ECG was also associated with a shorter D2B time (median of 61 minutes vs 75 minutes; p<0.001) [Diercks DB et al. JACC 2009]. In addition, a 2053-patient study that evaluated the integration of PHECGs across 10 independent STEMI receiving center networks demonstrated that 86% of patients had a D2B time of ≤90 minutes, 50% were treated with a D2B time of ≤60 minutes, and 25% were treated with a D2B time of ≤30 minutes [Rokos IC. J Am Coll Card CV Interv 2009]. The study also evaluated EMS providers by using the date/time that was autostamped on the PH-ECG as Time 0 (rather than the hospital’s door time) and found that 68% of patients had a rate of EMS-to-balloon time of <90 minutes in these organized STEMI networks. The greatest challenge with PH-ECGs is a higher rate of inappropriate activation of the cardiac catheterization laboratory. Various activation studies have shown rates of false-positive activation of the catheterization laboratory 5% to 10% for ECGs that are interpreted by emergency 30 May 2012 Lastly, Dr. Rokos stated that the ECG criteria that are used to identify patients who require primary PCI need updating. According to the 2004 American College of Cardiology/American Heart Association (ACC/AHA) www.mdconferencexpress.com  http://www.mdconferencexpress.com http://www.mdconferencexpress.com

Table of Contents for the Digital Edition of MD Conference Express ACC 2012

MD Conference Express ACC 2012
Table of Contents
Treatment of AMI in the Post-Herrick Era
The State of Hypertension Guidelines: 2012
ACRIN PA 4005: Coronary CTA in the ED Identifies Low-Risk Patients and Shortens Length of Stay
One-Year STAMPEDE Trial Results
TAVR Associated with Increased Late Mortality from Paravalvular Regurgitation
The CABG Surgery Off- or On- Pump- Revascularization Study (CORONARY)
The Moderate PE Treated with Thrombolysis Study (MOPETT)
Pacemaker Therapy In Patients With Neurally Mediated Syncope and Documented Asystole
Outcomes from the BRIDGE-ACS Trial
ROMICAT II: More Data Evaluating CT-First for Acute Chest Pain ED Triage
Elective PCI at Community Hospitals With Versus Without On-Site Surgery
Results from the TRA 2P-TIMI 50 Trial
The HOST-ASSURE Randomized Trial
New Monoclonal Antibody to PCSK9 Markedly Lowers LDL-C in Patients on Atorvastatin
Oral Rivaroxaban Alone for Symptomatic PE
Neutral Outcomes But Important Insights From FOCUS-CCTRN
Imaging
STEMI
Acute Coronary Syndrome
Antiplatelet Therapy
New Anti-Diabetes Agents Offer Promise in the Fight Against CVD
The New Hypertrophic Cardiomyopathy Practice Guidelines

MD Conference Express ACC 2012

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