lecture aha 2009 stemi focused update
TRANSCRIPT
8/7/2019 Lecture AHA 2009 STEMI Focused Update
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2009 PCI and STEMIFocused Update
Eric R. Bates, M.D.
ACC/AHA 2009 Joint STEMI/PCI Guidelines Focused Update
Professor of Internal Medicine
University of Michigan
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ACC/AHA 2009 STEMI/PCI GuidelinesFocused Update
Based on the ACC/AHA Guidelines for theManagement of Patients With ST-Elevation
ACC/AHA 2009 Joint STEMI/PCI Guidelines Focused Update
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Myocardial Infarction (STEMI) and theACC/AHA/SCAI Guidelines on PercutaneousCoronary Intervention (PCI): A Report of the
ACC/AHA Task Force on Practice Guidelines
JACC 2009;54:2205-41; Circulation 2009;120:2771-306.
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Recommendations for Triage andTransfer for Percutaneous
ACC/AHA 2009 Joint STEMI/PCI Guidelines Focused Update
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Coronary Intervention for Patientswith STEMI
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Recommendations for Triage andTransfer for PCI (for STEMI)
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NEW
Recommendation
Each community should develop a
STEMI system of care following thestandards developed for Mission
Lifeline including:
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• Ongoing multidisciplinary teammeetings with EMS, non-PCI-capable hospitals (STEMI ReferralCenters), & PCI-capable hospitals
(STEMI Receiving Centers)
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Recommendations for Triage andTransfer for PCI (for STEMI) (cont.)
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NEW
Recommendation
STEMI system of care standards in
communities should also include:• Process for prehospitalidentification & activation
• Destination protocols to STEMI
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Receiving Centers• Transfer protocols for patients
who arrive at STEMI ReferralCenters and are primary PCI
candidates, and/or are fibrinolyticineligible and/or in cardiogenicshock
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Recommendations for Triage andTransfer for PCI (for STEMI) (cont.)
NEW
Recommendation
IIIIIIIIIIII IIaIIaIIaIIaIIaIIaIIaIIaIIaIIaIIaIIa IIbIIbIIbIIbIIbIIbIIbIIbIIbIIbIIbIIb IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII IIaIIaIIaIIaIIaIIaIIaIIaIIaIIaIIaIIa IIbIIbIIbIIbIIbIIbIIbIIbIIbIIbIIbIIb IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII IIaIIaIIaIIaIIaIIaIIaIIaIIaIIaIIaIIa IIbIIbIIbIIbIIbIIbIIbIIbIIbIIbIIbIIb IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIaIIaIIaIIaIIaIIaIIaIIaIIaIIaIIaIIa IIbIIbIIbIIbIIbIIbIIbIIbIIbIIbIIbIIb IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII
It is reasonable to transfer highrisk patients who receive fibrinolytictherapy as primary reperfusion
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therapy at a non-PCI capable facilityto a PCI-capable facility as soon aspossible where either PCI can be
performed when needed or as apharmacoinvasive strategy.
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Recommendations for Triage andTransfer for PCI: *High Risk Definition
• Defined in CARESS-in-AMI as STEMI patientswith one or more high-risk features:
– extensive ST-segment elevation
– -
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– previous MI
– Killip class >2, or
– left ventricular ejection fraction <35% for inferior MIs;
• Anterior MI alone with 2 mm or more
ST-elevation in 2 or more leads qualifies
Di Mario et al. Lancet 2008;371.
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Recommendations for Triage andTransfer for PCI: *High Risk Definition
• Defined in TRANSFER-AMI as >2 mm ST-segment elevation in 2 anterior leads or STelevation at least 1 mm in inferior leads withat least one of the following:
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– – heart rate >100 beats per minute – Killip Class II-III – >2 mm of ST-segment depression in the anterior
leads – >1mm of ST elevation in right-sided lead V4
indicative of right ventricular involvement
Cantor et al. N Eng J Med 2009;360:26.
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Recommendations for Triage and
Transfer for PCI (for STEMI) (cont.)
NEW
Recommendation
IIIIIIIIIIII IIaIIaIIaIIaIIaIIaIIaIIaIIaIIaIIaIIa IIbIIbIIbIIbIIbIIbIIbIIbIIbIIbIIbIIb IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII IIaIIaIIaIIaIIaIIaIIaIIaIIaIIaIIaIIa IIbIIbIIbIIbIIbIIbIIbIIbIIbIIbIIbIIb IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII IIaIIaIIaIIaIIaIIaIIaIIaIIaIIaIIaIIa IIbIIbIIbIIbIIbIIbIIbIIbIIbIIbIIbIIb IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIaIIaIIaIIaIIaIIaIIaIIaIIaIIaIIaIIa IIbIIbIIbIIbIIbIIbIIbIIbIIbIIbIIbIIb IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII
Consideration should be givento initiating a preparatory
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plus antiplatelet) regimen priorto and during patient transfer
to the catheterizationlaboratory.
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Recommendations for Triage and
Transfer for PCI (for STEMI) (cont.)
Patients who are not highrisk who receive fibrinolytic therapyas primary reperfusion therapy at a
Modified
Recommendation
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non-PCI capable facility may beconsidered for transfer to a PCI-capable facility as soon as
possible where either PCI can beperformed when needed or as apharmacoinvasive strategy.
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Pathway: Triage and Transfer for PCI
(in STEMI) —(cont.)
• STEMI pts best suited for fibrinolytic
therapy are those presenting early aftersymptom onset with low bleeding risk
•
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2009 STEMI Focused Update. Appendix 5
, ,transfer to a PCI-capable facility may beconsidered, especially if symptoms
persist and failure to reperfuse issuspected.
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Pathway: Triage and Transfer for PCI(in STEMI)
• Those presenting to a non-PCI-capable
facility should be triaged to fibrinolytictherapy or immediate transfer for PCI.
• Decision depends on multiple clinical
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2009 STEMI Focused Update. Appendix 5
observations that allow judgment of: – mortality risk of the STEMI
– risk of fibrinolytic therapy
– duration of the symptoms when first seen – time required for transport to a PCI-capable facility
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Triage and Transfer for PCI (in STEMI)
• The duration of symptoms should continue to
serve as a modulating factor in selecting areperfusion strategy for STEMI patients.
• While patients at high risk (e.g., CHF, shock,
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2009 STEMI Focused Update. Appendix 5
contraindications to fibrinolytic therapy) arebest served with timely PCI, inordinate delaysbetween the time from symptom onset and
effective reperfusion with PCI may provedeleterious, especially among the majority ofSTEMI patients at relatively low risk.
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CC
y R e d u c t i o n
( % )
y R e d u c t i o n
( % )
DD
100100
8080
6060
4040
1.1. Time is MyocardiumTime is Myocardium
2. Infarct Size is Outcome2. Infarct Size is Outcome
BBAA
Extent ofExtent ofMyocardial SalvageMyocardial Salvage
M o r t a
l i t
M o r t a
l i t
2020
00
00 44 88 1212 1616 2020 2424Time From Symptom Onset to Reperfusion Therapy, hTime From Symptom Onset to Reperfusion Therapy, h
Critical TimeCritical Time--dependent Perioddependent PeriodGoal: Myocardial SalvageGoal: Myocardial Salvage
TimeTime--independent Periodindependent PeriodGoal: Open InfarctGoal: Open Infarct--Related ArteryRelated Artery
Gersh BJ, et al.Gersh BJ, et al. JAMA.JAMA. 2005;293:979.2005;293:979.
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Primary end point = death, recurrent MI, severe heartfailure, or cerebrovascular event within 6 months1.00
0.90
0.80
v e n t - F r e e S u r v i v a l
Rescue PCI 84.6%
95% Cl, 78.7-90.5
Conservative therapy 70.1%
REACT: Primary End Point
ACC/AHA 2009 Joint STEMI/PCI Guidelines Focused UpdateGershlick AH, et al. N Engl J Med . 2005; 353:2758.
0.70
0.60
0.00
0 20 40 60 80 100 120 140 160 180 200Days After Randomization
P r o b a b i l i t y o f E , . - .
Repeated thrombolysis 68.7%95% Cl, 61.1-76.4
P =.004
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Pharmacoinvasive Strategy
ACC/AHA 2009 Joint STEMI/PCI Guidelines Focused UpdateVerheugt F. N Engl J Med . 2009;360:2779.
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Onset ofsymptoms of
9-1-1EMS
EMS on scene• Encourage 12-lead ECGs
Not PCIcapable
HospitalHospital fibrinolysisfibrinolysis::
DoorDoor– –toto– –needleneedle
≤ 30 min≤ 30 min
InterInter--hospitalhospitaltransfertransfer
Options for Transport of Patients withSTEMI and Initial Reperfusion Treatment
ACC/AHA 2009 Joint STEMI/PCI Guidelines Focused Update
EMS TransportEMS Transport
spatc • ons er pre osp a r no y c
if capable and EMS–to–needlewithin 30 min
GOALS
PCIcapable
“Golden Hour” = 1st 60 min Total ischemic time: within 120 min
PatientPatient EMSEMS Prehospital fibrinolysisPrehospital fibrinolysis
EMSEMS– –toto– –needleneedle
≤ 30 min≤ 30 min
EMS transportEMS transport
EMSEMS--toto--balloon ≤ 90 minballoon ≤ 90 min
Patient selfPatient self--transporttransport
Hospital doorHospital door--toto--balloonballoon
≤ 90 min≤ 90 min
DispatchDispatch1 min1 min
5min
8min
Antman EM, et al. Circulation. 2004;110: 588.
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Pathway: Triage and Transfer for PCI (in STEMI)
STEMI patient who is acandidate for reperfusion
Initially seen at a PCIcapable facility
Initially seen at anon-PCIcapable facility
Send to Cath Lab forprimary PCI(Class I, LOE:A)
Transfer for primaryPCI(Class I, LOE:A)
Initial Treatment
with fibrinolytictherapy(Class 1, LOE:A)
NOT HIGH RISKHIGH RISK
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2009 STEMI Focused Update. Appendix 5
Prep antithrombotic (anticoagulantplus antiplatelet) regimen
Diagnostic angio
Medicaltherapy only
PCI CABG
Transfer to a PCI
facility may beconsidered(Class IIb,LOE:C),especially ifischemicsymptoms
persist andfailure toreperfuse issuspected
facility isreasonable forearly diagnosticangio & possiblePCI or CABG(Class IIa,LOE:B),
High-riskpatients asdefined by 2007STEMI FocusedUpdate shouldundergo cath(Class 1: LOE B)
At PCIfacility,evaluatefor timingofdiagnosticangio
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Interhospital STEMI Transfer
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Iwashyna J et al.Circ in press
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Triage and Transfer for PCI (in STEMI)
• American Heart Association’s Mission
Lifeline is an initiative to encouragecloser cooperation and trust amongstrehos ital care roviders and cardiac
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care professionals.
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Triage and Transfer for PCI (in STEMI)
• Each community and each facility in thatcommunity should have an agreed-upon planfor how STEMI patients are to be treated,including: – which hos itals should receive STEMI atients
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2009 STEMI Focused Update. Appendix 5
from EMS units capable of obtaining diagnosticECGs
– management at the initial receiving hospital, and
– written criteria & agreements for expeditious
transfer of patients from non-PCI-capable to PCI-capable facilities
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Triage and Transfer for PCI (in STEMI)
• Need for the development of regionalsystems of STEMI care through stakeholder
efforts to evaluate ACS care using: – standardized performance & quality improvement
measures, (e.g., endorsed by the ACC, AHA, Joint
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,
Services) – standardized quality-of-care data registries
designed to track and measure outcomes,complications and adherence to evidence-based
processes of care• NCDR ACTION Registry ® • American Heart Association “Get With the Guidelines”
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ACC/AHA 2009 Joint STEMI/PCI Guidelines Focused Update
• National initiative
• Improve quality of care + outcomes in STEMI
• Improve health care system readiness and response to STEMI.
Jacobs A, et al. Circulation . 2007;116:217.