Early Diagnosis and Treatment of STEMI. Disclosures. Case 3/24/2011. Use and Impact of Pre-Hospital Electrocardiogram. None

Transcription

1 Early Diagnosis and Treatment of STEMI Use and Impact of Pre-Hospital Electrocardiogram John Coletta, M.D., F.A.C.C. None Disclosures Case 75 yo called EMS for chest pain Onset of pain less than 1hr Upon EMS arrival patient was hemodynamically y stable. Patient was administered ASA 325mg and oxygen Pre-hospital ECG was performed 1

2 Case Case ECG transmitted to St John Medical Center Cath Lab activated Introduction This is 911, what is your emergency?... Scope of the problem: Estimated 500,000 cases of STEMI each year nationwide 1/3 of patients with STEMI will die in the first 24hrs from the onset of ischemia Antman EM, Anbe DT, Armstrong PQ, Bates ER, Green LA, Hand M, Hochman JS, Krumholz HM, Kushner FG, Lamas GA, Mullany CJ, Ornato JP, Pearle DL, Sloan MA, Smith SC Jr. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of Patients with Acute Myocardial Infarction) Available at /guidelines/stemi/index.pdf 2

3 Introduction Scope of the problem: (cont d) About half (53%) of patients with STEMI utilized EMS for transfer to the hospital 16% DROVE THEMSELVES 1 in 300 patients transferred to the hospital by private vehicle suffer cardiac arrest en route Antman EM, Anbe DT, Armstrong PQ, Bates ER, Green LA, Hand M, Hochman JS, Krumholz HM, Kushner FG, Lamas GA, Mullany CJ, Ornato JP, Pearle DL, Sloan MA, Smith SC Jr. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of Patients with Acute Myocardial Infarction) Available at /guidelines/stemi/index.pdf Outline Definitions Cause Timely Diagnosis and Initiation of Therapy Models of Care Continuation of Case Outline Definitions ST Elevation STEMI Thromb s Thrombus Cause Timely Diagnosis and Initiation of Therapy Models of Care Continuation of Case 3

4 Definitions ST Elevation Myocardial Infarction Occlusion of epicardial coronary vessel resulting in transmural infarction of myocardium Cell death / necrosis Identified by history and ECG ECG Changes suggestive of STEMI in 2 contiguous leads New left bundle branch block Definitions What is ST elevation? Elevation of the ST segment above the TP segment TP segment no electrical activity it Line drawn between consecutive TP segments defines the baseline P T P T Electrocardiogram 4

5 Definitions Thrombus Complex of platelets, thrombin and fibrin Similar to a brick wall Bricks = platelets Mortar = fibrin and thrombin Outline Definitions Cause Plaque rupture Th b f i Thrombus formation Timely Diagnosis and Initiation of Therapy Models of Care Continuation of Case 5

6 Cause Thrombus Found in >90% of patients with STEMI Found in 35-70% of patients with USA/NSTEMI Antman EM, Anbe DT, Armstrong PQ, Bates ER, Green LA, Hand M, Hochman JS, Krumholz HM, Kushner FG, Lamas GA, Mullany CJ, Ornato JP, Pearle DL, Sloan MA, Smith SC Jr. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of Patients with Acute Myocardial Infarction) Available at /guidelines/stemi/index.pdf Thrombus Abrupt rupture of lipid rich plaque Presentation of plaque contents to bloodstream Activation of platelets and coagulation cascade Thrombus formation Abrupt occlusion of epicardial coronary artery Progression of Plaque Formation Antman EM, Anbe DT, Armstrong PQ, Bates ER, Green LA, Hand M, Hochman JS, Krumholz HM, Kushner FG, Lamas GA, Mullany CJ, Ornato JP, Pearle DL, Sloan MA, Smith SC Jr. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of Patients with Acute Myocardial Infarction) Available at /guidelines/stemi/index.pdf 6

7 From ACC Interventional Cardiology Review 2008: Thrombosis, Clotting Cascade and Anticoagulant Agents, David Molireno, M.D. Thrombus is composed of three components: Fibrin, platelets, and thrombin Fibrin Fibrinolytics Plasminogen Activators UK, SK t-pa r-pa, TNK Platelets Anti-platelets ASA thienopyrodeines Thrombin Anti-thrombins Bivalirudin argatroban From ACC Interventional Cardiology Review 2008: Thrombosis, Clotting Cascade and Anticoagulant Agents, David Molireno, M.D. Cause In the absence of adequate collateral blood flow, if left uninterrupted, a wave of cell necrosis begins at the endocardium and spreads to the epicardium 7

8 Outline Definitions Cause Timely Diagnosis and Initiation of Therapy Models of Care Continuation of Case Survival Despite many advances in treatment there is an abysmal change in overall mortality for STEMI patients First described in 1967, the Killip classification is a fast and simple tool for determining in-hospital mortality Survival 8

9 One Year Mortality Cardiac Survival Relationship of door-toballoon time to cardiac survival in patients treated for STEMI with primary percutaneous coronary intervention 9

10 Pre-Hospital ECG (phecg) Symptom onset to reperfusion 1. Symptom onset to EMS arrival 2. EMS arrival-to-hospital arrival 3. Hospital arrival-to-diagnostic al ECG 4. Diagnostic ECG-to-drug/balloon Overwhelming evidence that phecg can reduce the time to reperfusion 10

11 A significantly higher proportion of patients with phecg fell within guideline timelines GREAT! RIGHT!? In 2007, of all patients transported to hospitals by EMS for STEMI only 27% utilized phecg 11

12 Pre-Hospital ECG (phecg) Symptom onset to reperfusion 1. Symptom onset to EMS arrival 2. EMS arrival-to-hospital arrival 3. Hospital arrival-to-diagnostic al ECG 4. Diagnostic ECG-to-drug/balloon Overwhelming evidence that phecg can reduce the time to reperfusion 12

13 Outline Definitions Cause Timely Diagnosis and Initiation of Therapy Models of Care Continuation of Case 13

14 Models of Care Can EMS Obtain ECG 90% of EMS serving largest 200 US cities have ECG available in ambulance Use of phecg has recently been shown NOT to increase time from symptom onset to hospital arrival Can EMS Interpret / Communicate ECG 14

15 Barriers to phecg Programs Cost Upgrading equipment Acquisition, transmission, receiving Training Risk of bypassing ER Misdiagnosis Intracranial hemorrhage Aortic dissection Barriers to phecg Programs Patient reluctance to call EMS In whom do we obtain a phecg? ~5% pts calling EMS for CP have STEMI Which symptoms warrant phecg Barriers to phecg Programs Other thoughts Will PCI-capable hospitals benefit financially from patients being diverted from non-pci-capable facilities No specific reimbursement for phecg If changed, would this lead to overuse Who will oversee this use? 15

16 Decreasing Door-to-Balloon Outline Definitions Cause Timely Diagnosis and Initiation of Therapy Models of Care Continuation of Case Case 75yo with chest pain EMS arrival 1740 ECG 1744 Arrival to SJMC

17 99% Mid Left Circumflex 17

18 Case Case 18

19 Case Summary STEMI caused by abrupt vessel closure >90% due to thrombus Rapid restoration of flow is associated with decreased morbidity and mortality Despite availability ailabilit phecg are underused in the US Use of phecg is associated with decreased door to treatment times Most importantly, phecg shows significant trends to decreased morbidity and mortality Thank You 19