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STEMI/Stroke Guidelines for MS Barry Bertolet, MD Vice President MHCA November 8, 2014 1 Slide 2 2 Slide 3 Goals for STEMI First Medical Contact (FMC) to PCI < 90 minutes Door to ECG time < 10 minutes Door In / Door Out Time < 30 minutes FMC to Non-PCI hospital to PCI < 120 minutes EMS specific Ideal for all chest pain patients to have in-field ECG Pre-hospital Activation of STEMI network Diversion to STEMI hospital 3 Slide 4 STEMI Core Measures MeasureCMSTJC Aspirin at arrival Aspirin at DC ACE/ARB/LVSD BB at DC Median Time to Lysis Median Time to PCI Primary PCI w/in 90 min Statin at DC Median time to Transfer -- Median time to ECG -- 4 Slide 5 5 Slide 6 FMC to Device (Direct Presentation Arriving Via EMS) Minutes 6 Slide 7 Arrival at First Hospital to Device (Transfer In for PCI) Minutes 7 Slide 8 ED Arrival to First In-hospital EKG Minutes 8 Slide 9 EKG Within 10 Min of Arrival Direct Presentation, Arriving via POV Percent 9 Slide 10 Time Spent at Referral Facility Minutes 10 Slide 11 Time From Referring to Receiving Hospital Minutes 11 Slide 12 In-hospital Mortality Percent 12 Slide 13 13 Slide 14 14 Slide 15 15 Slide 16 16 RE Slide 17 Atlantic Trial Overall, 1,862 patients were randomized to ticagrelor 180 mg in the ambulance vs in the cath lab. The mean age was 61 years, 19% were women, 19.5% had a body mass index 30 kg/m 2, and 12.7% had diabetes. Radial access was obtained in 68%, aspiration thrombectomy was performed in 52%, stenting was performed in 84% (of which 51% was a drug-eluting stent), unfractionated heparin was used in 67%, and glycoprotein IIb/IIIa inhibitor was used before PCI in 30%. 17 Slide 18 Atlantic Trial The first co-primary endpoint, proportion of participants who did not have 70% resolution of ST-segment elevation before PCI, occurred in 86.8% of the ambulance group vs. 87.6% of the catheterization laboratory group (p = 0.63). ST-segment resolution appeared to be improved by ticagrelor administration in the ambulance among those who did not receive morphine (p for interaction = 0.005). 18 Slide 19 Atlantic Trial The second co-primary endpoint, proportion of participants who did not have TIMI flow 3 before PCI, occurred in 82.6% of the ambulance group vs. 83.1% of the catheterization laboratory group (p = 0.82). Death, MI, or urgent revascularization: 4.3% vs. 3.6% (p = 0.42), respectively Definite stent thrombosis at 30 days: 0.2% vs. 1.2% (p = 0.02), respectively Non-CABG major bleeding (TIMI criteria): 1.3% vs. 1.3% (p = 0.91), respectively 19 Slide 20 Gut Check While we have improved, we have not reached our goals or even the national averages. Due to the rural nature of our state, EMS holds the key for us to make the greatest improvements. 20 Slide 21 Why Do We Care? Myocardial infarction is the leading cause of death in the United States and in Mississippi. Approximately 450, 000 people in the United States die from coronary disease per year and that rate of death is highest in Mississippi. The survival rate for U.S. patients hospitalized with MI is approximately 95%, but this survival dependent upon the delivery of timely and effective therapy. Slide 22 Slide 23 May, 2003 Slide 24 Regional Differences in MI Care (Circ Cardiovasc Qual Outcomes. 2009) Bottom 3 Hospitals with Highest Heart Attack Death Rates Southwest, Mississippi Regional (MS) -- 24.9% Hospital Damas Inc. (PR) -- 24.5% Jefferson Regional Medical (PA) -- 23.9% The percentage of people who died following heart attack or heart failure within 30 days of hospital admission jumped significantly in the worst performing states: Oklahoma Arkansas Tennessee Missouri Louisiana Mississippi Slide 25 D2B Scorecard Pay For Performance Slide 26 Start the Clock! Time is muscle! Timely care is now defined from time of first medical contact (EMS) to that of the infarct-related artery being opened (angioplasty) being less than 90 minutes. Slide 27 Time Is Muscle The Wavefront of Necrosis Slide 28 Cannon CP et al, JAMA 2000 Mortality and DTB Times Slide 29 Acute MI Stent Therapy Slide 30 Clearly we can do better Slide 31 EMS Requirements Equip all ambulances in state with ECG machines by 2012 Ambulance services should obtain EKG within 15 minutes for typical chest pain in anyone > 30 years, and atypical chest pain in all patients 50 and older EMS should interpret and transfer ECG to affiliated ED EMS personnel need training / certification in ECG interpretation of STEMI eLearning: Rapid STEMI ID Slide 32 EMS Requirements + EKG patients directly to PCI hospital if 90 minutes window obtainable from first med contact to PCI AND patient is hemodynamically stable + EKG patients directly to PCI hospital if 90 minutes window obtainable from first med contact to PCI BUT patient is hemodynamically UNSTABLE Go to nearest ED Activate Air Transport immediately for transfer to PCI center Slide 33 EMS Requirements If no pre-hospital ECG available for a chest pain patient who arrives at a non-PCI hospital Keep the patient on the EMS stretcher until ECG performed If EKG results + transfer to PCI hospital with SAME ambulance if patient hemodynamically stable Slide 34 EMS Territorial Boundaries Broken It is imperative for EMS to be able to cross county lines when necessary for reperfusion. EMS services should cross-cover for adjacent EMS in another county. A Heart Attack should take priority over many non- life threatening medical conditions. Slide 35 Pre-Hospital Activation Slide 36 STEMI Network (24/7) PCI Centers Jackson St. Dominic MBHS UMMC CMMC Hattiesburg Forrest General Hospital Wesley Meridian Jeff Anderson Hospital Rush Hospital Tupelo North Mississippi Medical Center Oxford Baptist Memorial Hospital North Mississippi South Haven Baptist Memorial Hospital Desoto Corinth Magnolia Regional Health Center Vicksburg River Region Hospital Greenville Delta Regional Medical Center Columbus Baptist Memorial Hospital Golden Triangle Pascagoula Singing River Health Systems Gulfport Gulfport Memorial Hospital McComb South West Regional Medical Center Slide 37 Interventional Cardiac Catheterization Laboratory Facility Designation 24/7 capability within 30 minutes of notification Acceptance of all patients regardless of bed availability. Hospital has on-site cardiac surgery back up and meets procedural volume standards of at least 200 PCIs and 36 primary PCIs per year. Slide 38 Interventional Cardiac Catheterization Laboratory Facility Designation Interventional cardiologist volume of at least 75 PCIs per year and 11 primary PCIs per year. Ongoing data monitoring in ACTION-GWTG Concurrent feedback to the EMS Slide 39 In-Hospital Mortality by Age and Guidelines Adherence: Observations from CRUSADE - Boden et al, AHA 2005 Adj. OR: 0.71 (0.67-0.75)0.79 (0.75-0.83) Age Group Slide 40 American College of Cardiology Benchmark tPA dose for Acute Ischemic Stroke AIS 0.9 mg/kg IV infused over 1 hour 100 kg: Administer 10% of total dose as initial bolus over 1 minute; THEN 0.81 mg/kg as continuous infusion over 60 min; not to exceed total dose of 90 mg >100 kg: Administer 9 mg (10% of 90 mg) as IV bolus over 1 min; THEN 81 mg as a continuous infusion over 60 min Slide 68 Slide 69 Slide 70 Slide 71 Dont Delay Meta-analysis of over 58K ischemic stroke patients treated with IV tPA with 4.5 hours of onset Every 15 minute acceleration in start of IV tPA: 4% greater odds of walking independently at discharge 3% greater odds of discharge home 4% lower odds of death 4% lower odds of symptomatic hemorrhagic transformation JAMA 2013 309(23): 2480-8 Slide 72 Updated Acute Ischemic Stroke Guidelines (Jan 2013) AHA Limited number of radiographic and laboratory tests are required prior to administering IV tPA: Blood glucose check Non-contrast head CT These recommendations are directed at meeting a door to treatment time of Blood Pressure Management American stroke association Ischemic stroke current recommendation: SBP 220 or DBP 121-140: Nicardipine or labetalol DBP > 140 : Nitroprusside Stroke 2003: 34: 1056-1083 Slide 77 Appendix D: Pre-hospital Stroke Protocol 1) Initial assessment, transport ASAP: ABCs Obtain time of symptom onset (Last time known well) ___________; Source of information _____________________________________; Contact information _______________________________________. 2) Administer high concentration oxygen, as needed, to maintain O2 Sat >94 percent. 3) Position patient with head/shoulders elevated to 15-30 degrees (unless contraindicated). 4) Maintain NPO. 5) Blood glucose < 60, treat per protocol. 6) Do not treat high blood pressure without physician approval. 7) Perform Stroke Scale Cincinnati Stroke Scale. 8) Transport patient to the appropriate facility: a. Transport patient to the closest hospital capable of treating the patient with IV Alteplase (Stroke Capable or Primary/Comprehensive Stroke Center). Hospitals not able to diagnose and treat stroke patients (Level 4 hospitals) may be by- passed. EMS may use discretion based on transport time or other unforeseen factors. b. Consider transport of the stroke patient with severe symptoms (hemiplegia, aphasia, neglect, stably intubated) to a Comprehensive Stroke Center if symptom onset to hospital arrival time is greater than 3 hours and less than 6 hours. c. Transport patient to the closest appropriate facility if unstable (e.g., cardiac arrest, unstable airway). 9) IV NS KVO once en route. 10) EKG once en route. 11) Notify receiving facility of estimated arrival time of acute stroke patient, Stroke Scale finding, and time of onset. Slide 78 Transport Guidelines Transport patient to the closest hospital capable of treating the patient with IV Alteplase (Stroke Capable or Primary/Comprehensive Stroke Center). Hospitals not able to diagnose and treat stroke patients (Level 4 hospitals) may be bypassed. EMS may se discretion based on transport time or other unforeseen factors. Consider transport of the stroke patient with severe smptoms (hemiplegia, aphasia, neglect, stably intubated) to a Comprehensive Stroke Center if symptom onset to hospital arrival time is greater than 3 hours and less than 6 hours. Transport patient to closest appropriate facility if unstable (e.g., cardiac arrest, unstable airway) Slide 79 Appendix E: Alteplase (t-PA) Drip and Ship Transfer Protocol for Ischemic Stroke ******************************Use only Alteplase*************************************** 1) Symptom onset time: __________________ (Last time known well). 2) Document BP < 180/105 prior to departure: ___________________. 3) Initial NIHSS ________________; NIHSS at departure: ______________ (scored by ER physician/staff). 4) Activate EMS for transfer (consider air transport). 5) Two (2) peripheral IVs (18 gauge, AC or higher, if possible). 6) Time t-PA initiated: Total dose: __________, weight (kg) __________. a. Bolus dose time: __________, Dose __________ mg. b. Infusion dose time: __________, Dose __________ mg. (1 hour infusion) c. Completion time: __________. 7) After t-PA infusion completed, start NS at 80cc/hr to infuse remaining t-PA in tubing. 8) O2 as necessary to maintain O2 sat > 94%. 9) HOB 15-30 degrees (unless contraindicated). 10) If IV infusion blood pressure medication has been initiated, record: a. Medication __________; current dose __________. b. Titration instructions to maintain BP < 180/105: ____________________________________________________. c. Hold infusion blood pressure medication for BP < 140/80. 11) Vitals and neuro checks every 5 minutes. 12) Hypertension: If BP > 180/105. a. HR > 60: Labetalol 10mg IV over 2 minutes, repeat as needed after 5 minutes. May repeat 3 times. b. HR < 60: Nicardipine (Cardene) 5 mg/hour (at a concentration of 0.1 mg/ml); increased by 2.5 mg/hour every 15 minutes to a maximum of 15 mg/hour; consider reduction to 3 mg/hour after response is achieved. 13) Stop t-PA for: A. Neurologic deterioration. B. Airway Edema. C. Time discontinued: _____________. Slide 80 Slide 81 Summary and Future Challenges Maximize use of IV Alteplase Establish networks of hospitals Direct appropriate patients for intervention Few Neurology/Stroke specialists Vastly different resources in state regions Networking of stoke centers with stroke ready hospitals Tele-stroke services Slide 82 82