MD Conference Express ACC 2012 - (Page 31)
guidelines, STEMI is defined as ST elevation of ≥1 mm in 2 contiguous leads, new (or presumed new) left bundle branch block, or isolated posterior MI. He proposed that the criteria for STEMI should be broadened to include “semi-STEMI”—ST elevation <1 mm but with associated reciprocal changes—and “STEMI-equivalent”—any ECG pattern that lacks classic ST elevation but is associated with an acute coronary occlusion that requires primary PCI (eg, true posterior MI, diffuse inferolateral STdepression with concomitant ST-elevation in lead aVR, de Winter T-waves [de Winter et al. N Engl J Med 2008], and certain cardiac arrest patients who have been resuscitated from a shockable rhythm). Importantly, Dr. Rokos emphasized that all frontline providers should be familiar with various ST-elevation mimics that cause inappropriate activations, including narrow QRS complex (eg, normal early repolarization, pericarditis) and wide/ tall QRS complex (eg, ventricularly paced rhythms, left ventricular hypertrophy) rhythms. Optimal Reperfusion Strategies with Expected Delays According to the current standard of care for patients with STEMI, fibrinolysis is recommended when transferring the patient will mean a D2B time of >90 minutes (ACC/ AHA guidelines) and >120 minutes (European Society of Cardiology guidelines). Even among the best-performing hospitals, the D2B time is not optimal in most cases, said Timothy D. Henry, MD, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota, USA. According to data from the ARG Registry, the D2B time was <90 minutes for only 18% of patients. Overall in the United States, only an estimated 15% to 20% of patients with STEMI who are transferred for primary PCI have a D2B time of <2 hours. The low rate of optimal time to PCI has a negative effect on outcomes, with the advantage of PCI over fibrinolysis decreasing as the PCI-related delay increases, said Duane S. Pinto, MD, MPH, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA. For every 10-minute delay to PCI, there is a significant reduction in the mortality difference between PCI and fibrinolysis [Nallamothu BK et al. Am J Cardiol 2004]. The standard of care for patients with STEMI is based on randomized trials, where D2B times are shorter than in realworld practice. Dr. Pinto and his colleagues reviewed data from the National Registry of Myocardial Infarctions and found that overall, the outcomes were better for patients who were transferred for PCI compared with patients who had onsite fibrinolytic therapy. The differences were not as pronounced when the outcomes for matched patients were compared. When the results were stratified according to time, the patients who benefited the most from transfer-
PCI were those for whom the delay was shorter [Pinto DS et al. Circulation 2011]. Facilitated PCI was developed in an attempt to improve outcomes for STEMI patients with an expected delay to treatment. Giving fibrinolytic therapy before planned PCI was an excellent idea, said Dr. Henry, but based on data from initial randomized clinical trials, the authors of a key meta-analysis concluded that facilitated PCI provided no benefit [Keeley EC et al. Lancet 2006]. Dr. Henry suggested that the results of the meta-analysis need to be reconsidered, based on the newer practice patterns that include earlier and more frequent use of potent thienopyridines and more recent clinical trial data, especially for patients with an expected delay >120 minutes. There was wide variation in the fibrinolytics that were given across the trials in the metaanalysis; the patients were relatively low-risk, treated in a PCI hospital, or transferred only a short distance; and the studies that were done in the era prior to the introduction and use of potent thienopyridines. In addition, the majority of patients were from the ASSENT 4 trial, which used fulldose fibrinolytic, and “early generation antiplatelet and antithrombin regimens [Van de Werf F et al. Lancet 2006]. Furthermore, although 45% of patients were managed in a hospital with onsite PCI, none of us would give a fibrinolytic, without high potency thienopyridine, and go to the catheterization laboratory in a PCI hospital,” said Dr. Henry. In addition, ASSENT 4 excluded patients with anticipated delays to PCI of >3 hours—“exactly the patients we’re concerned about,” he added. More recently, pharmacoinvasive PCI has been studied as an option for patients with an expected delay to PCI. The difference between facilitated PCI and pharmacoinvasive PCI strategies is primarily timing, with facilitated PCI referring to PCI done immediately after fibrinolytic therapy and pharmacoinvasive PCI referring to PCI done within a few hours after fibrinolytic therapy. Recent data support the pharmacoinvasive approach, including both randomized trials that have demonstrated that fibrinolysis, followed by immediate transfer for PCI, has outcomes that are superior to fibrinolysis with standard of care, and registry data that have shown that a pharmacoinvasive approach in patients with delays >120 minutes has outcomes that are similar to patients who present to a PCI center [Di Mario C et al. Lancet 2008; Cantor WJ et al. N Engl J Med 2009; Bohmer E et al. J Am Coll Card 2009; Larson D et al. Eur J Heart 2011]. The use of pharmacoinvasive PCI in regional STEMI systems in the United States and Canada has shown that half-dose fibrinolysis, combined with immediate transfer for PCI, may be a safe and effective option for patients with STEMI who have expected delays due to transfer to a hospital with PCI facilities.
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Highlights from the American College of Cardiology 61st Annual Scientific Session
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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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