STEMI NewsBy Carol Scott, R.N., and Joseph Fredi, M.D., F.A.C.C.

STEMI Network

Vanderbilt Heart and Vascular Institute Publication Summer 2011 • Volume 4 • Issue 5VanderbiltSTEMI.com

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Evidence-Based STEMI Care Continues to Make Gains (Continued from page 5)

Treatment options for ST elevationmyocardial infarction (STEMI) havesignificantly expanded over the pasttwo decades. Studies showing benefit ofaspirin, beta-blockers, ACE-inhibitors,statins, clopidogrel, glycoproteininhibitors (GP IIb/IIIa), thrombolytics,and use of primary PCI have led todecreases in mortality and changes inthe ACC/AHA STEMI guidelines. 1-6

However, the implementation ofguidelines into clinical practice remainsa significant challenge, and we strive toprovide evidence-based therapy on anindividual basis daily.

The April 27 issue of the Journal of theAmerican Medical Associationinvestigates trends in evidence-basedtreatments in STEMI patients andassociation with mortality rates. Over a12-year period (1996- 2007), evidence-based practices were evaluated. Thepractices included reperfusion strategies(pPCI vs. thrombolytic vs. CABG),pharmacologic therapies (ACEinhibitors, aspirin, beta blockers,

clopidogrel, and statins) and other in-hospital treatments (GP IIb/III3ainhibitors and heparin). The databaseincluded 61,237 patients from 75hospitals in Sweden. Primary PCI ratesincreased from 12 percent to 61percent while in-hospital thrombolysisrates decreased from 63 percent to 3percent during the study period. Allevidence-based pharmacologictherapies increased during the studyperiod. ACE inhibitor (or ARB) useincreased from 39 percent to 69percent. GP IIb/IIIa inhibitorsincreased from 0 percent to 55 percent(approved in 1998). Clopidogreladministration increased from 0percent to 82 percent (approved inEuropean market in mid-1998) andstatin therapy use increased from 23percent to 83 percent. Over thisperiod, the mortality rates decreasedsignificantly. In-hospital mortality ratedecreased from 12.5 percent to 7.2percent. Also, 30-day mortality ratedecreased from 15 percent to 8.6percent and the one-year mortality ratedecreased from 21 percent to 13.3percent (P<0.001).7

Real-world databases in the UnitedStates such as the ACTION Registryand the American Heart Association’sGet with the Guidelines (GWTG)program also try to quantify quality ofcare on national, regional and hospitallevels to help inform doctors andpatients how well evidence-based careis delivered. From July 2009 – June2010, the combined ACTION andAHA database contained 21,972coronary interventions on STEMIpatients from 621 sites in the UnitedStates that voluntarily submit data.Eight-nine (89) percent of STEMIpatients received primary percutaneouscoronary intervention (pPCI). Door-to-Balloon (D2B) times were <90minutes in 73 percent of patients whopresented in PCI-centers and 27percent in patients who requiredtransfer to a near-by PCI center. The

in-hospital mortality rate for that yearwas 5.7 percent. This mortality rateincluded patients who completedthrombolytic therapy (10 percent) andpPCI as well as patients who were notthought to be candidates forreperfusion (3,195 patients, 12percent). In addition, >90 percent ofpatients received aspirin, beta blockersand heparin; 82 percent of patientsreceived clopidogrel; and 64 percent oftherapies included glycoprotein IIb-IIIainhibitors. Treatment strategies did notchange within the 12-month studyperiod. Interestingly, 63 percent ofSTEMI patients were first evaluated inthe emergency room setting and 25percent of patients were evaluated inthe cath lab. Only 7 percent of patientsreceived evaluation outside of thesetraditional settings.8

This article demonstrates the successobserved in STEMI treatments. As aresult of advances in STEMI caredemonstrated through clinical trials,new guidelines are recommended andproviders begin to implement therecommendations and STEMI patientsbenefit by living longer and havingfewer complications. The SwedishRegistry demonstrates the associationwith evidence-based therapies andmortality rates. Causality betweenincrease in evidence-based therapiesand the decline in mortality ratescannot be confirmed given theobservational nature of the study andnumerous confounding factors. TheACTION Registry and AHA Get withthe Guidelines program have similarevidence-based practice compliance asstudied from 2009-2010 whencompared to the Swedish registry.Vanderbilt participates in theACTION Registry as a tool formonitoring quality and safety against anational benchmark. VanderbiltUniversity Medical Center has alsodemonstrated its ability to completeevidence-based practice on a consistent (Continued on page 6)

Evidence-Based STEMI Care Continues to Make GainsBy Eric Thomassee, M.D., and Robert L. Huang, M.D., M.P.H.

basis. In 2010, 97 percent of patientsreceived statin therapy and betablockers at time of discharge.Clopidogrel was used in 95 percent ofpatients and aspirin use was 100percent. ACE inhibitor use was 85percent in all patients at time ofdischarge and 97 percent amongpatients whose ejection fraction was<40 percent. Primary PCI wascompleted in 96 percent of all STEMIpatients. The in-hospital mortality ratefor Vanderbilt was 3.7 percentcompared to a national average of 5.9percent.

1. Yusuf S, Zhao F, et al. Clopidogrel in UnstableAngina to prevent Recurrent Events TrialInvestigators. Effects of clopidogrel in addition toaspirin in patients with acute coronarysyndromes without ST segment elevation.NEJM. 2001; 345 (7): 494-502

2. Freemantle N, Cheland J, et al. Beta Blockageafter Myocardial Infarction: systematic review andmeta regression analysis. BMJ. 1999; 318 (7200);1730-1737

3. Baigent C, Keech A, Kearney PM, et al.Cholesterol Treatment Trialists’ (CTT)Collaborators. Efficacy and safety of cholesterol-lowering treatment: prospective meta-analysis ofdata from 90,056 participants in 14 randomizedtrials of statins. Lancet. 2005; 366 (9493): 1267-1278

4. ACE inhibitor Myocardial InfarctionCollaborative Group. Indications for ACEInhibitors in the early treatment of acutemyocardial infarctions: systematic overview ofindividual data from 100,000 patients inrandomized trials. Circulation. 1998; 97(22):2202-2212

5. Dagenais GR, Pogue J, et al. Angiotensin-coverting-enzyme inhibitor in stable vasculardisease without left ventricular systolic dysfunctionor heart failure: a combined analysis of three trials.Lancet. 2006; 368(9535): 581-588

Eric Thomassee, M.D.

Joseph L. Fredi, M.D., F.A.C.C.

In 2010 the Vanderbilt STEMI Network saw much improvement in reperfusiontimes for patients suffering an ST elevation myocardial infarction. Vanderbilt Heartis pleased to report our door-to-balloon (D2B) results for patients presenting to theVanderbilt Emergency Department and the door 1-to-door 2-to balloon time(DD2B) results for patients who were transferred from outlying communities.

The median D2B time for patients presenting to the Vanderbilt ED was 51minutes. The median D2B time in 2009 was 55 minutes.

The median DD2B time for patients transferred from an outlying facility within a60-mile radius (zone 1) of Vanderbilt that participates in the Vanderbilt STEMINetwork was 119 minutes. This is down from 129 minutes last year.

The median DD2B time for patients transferred from an outlying facility within a120-mile radius (zone 2) of Vanderbilt that participates in the STEMI Network was126.5 minutes. Last year, the median time was 164 minutes.

We feel that a part of this success is due to the communication and feedback thatVanderbilt provides after every case, which includes a phone call from theinterventional cardiologist to the referring physician notifying him of the results ofthe cardiac catheterization, and a detailed spread sheet that includes the timeintervals, goals and cumulative time the next day. This information is sent toeveryone involved in the care of the patient: EMS, referring hospital ED physicianand nurses, air or ground transport service, and personnel at Vanderbilt.

In fact, many of you have told us that the feedback provided has fostered a sense ofcompetition among your staff to have bragging rights of the best time from whenthe STEMI patient arrives at the ED until the patient departs for Vanderbilt. Weencourage referring EDs to ask for the overall DD2B time of the receiving PCIfacility if you don’t currently receive this information. Otherwise, it's like taking atest and not getting a grade. Measuring results allows you to know how your facilityperformed in terms of the 90-minute D2B goal and how it can improve.

6. de Boar S et al. High-risk patients with ST-elevation myocardial infarction derive greatestabsolute benefit from primary percutaneouscoronary intervention: Results from the PrimaryCoronary Angioplasty Trialist versusThrombolysis (PCAT)-2 Collaboration.American Heart Journal. 2011. 161 (3): 500-507

7. Jernberg et al. Association between Adoptionof Evidence-Based Treatment and Survival ofPatients with ST-Elevation Myocardial Infarction.JAMA 2011; 305 (16): 1677-1684

8. Cardiosource. 2011. ACTION Registry-GWTG results: July 1, 2009-June 30, 2010.American College of Cardiology. June 6, 2011.www.cardiosource.org

Robert Huang, M.D.

Carol Scott, R.N.

A B C D E F G H I J K L M N O P R S

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This bar graph reflects the median DD2B times for2010 for both zone 1 and zone 2 referring facilitiesthat participate in the Vanderbilt STEMI Network.

Hospitals A, B, C, D, E, F, G, J, K, L, M, O, and P arein zone 1. Hospitals H, I, N, R and S are in zone 2.

Why Choose LifeFlight?By Jeanne Yeatman R.N., EMT, Program Director, Vanderbilt LifeFlight

Case Study Acute Pericarditis vs STEMI: A Diagnostic Dilemmaby Joseph Fredi, M.D., F.A.C.C.

Acute pericarditis accounts forapproximately 5 percent of patientswho present to an Emergency Roomfor chest pain. At least 70 percent ofall cases of acute pericarditis areidiopathic. These are often referred toas “viral” but, in fact, the etiology isunclear. Pericarditis is not uncommonfollowing cardiac surgery. Infectiousetiologies such a bacterial, fungal,protozoal and mycobacterial infectionscan result in pericarditis, but are rare.Pericarditis can occur post myocardialinfarction as a result of directpericardial injury from transmuralinfarction (hours to days post-MI), orfrom an immunological responseknown as Dressler syndrome (weekspost MI). Other causes are related toconnective tissue disorders such asrheumatoid arthritis, SLE, scleroderma,and inflammatory bowel disorders.Acute pericarditis can be the result ofuremic renal failure, radiation injury,neoplastic pericardial involvement,drugs or chest wall trauma. There areother causes as well.

The chest pain associated with acutepericarditis is usually severe. Unlikechest discomfort of myocardialischemia, the quality of the pain isusually different. Typically the qualityof the pain is pleuritic, and theradiation pattern is unlike myocardialischemia; pericardial pain typicallyradiates to the trapezius ridge. It doesnot involve the left arm or anteriorneck and lower jaw and is almostalways worsened upon lying supine andimproved by leaning up and forward.

A 29-year-old male presents to Vanderbilt’sEmergency Department with c/o chest pain x 4hours described as tightness and “like somethingsitting on my chest.” Denies radiation to arms,neck or back. Denies ripping or tearing pain.Denies SOB, N/V, recent fever or cough. Deniesrecent drug use. Rates pain as 6/10.

Most patients with acute pericarditisare very uncomfortable, can have afever, and are always tachycardic. Theonly other abnormal physical finding isthe pericardial friction rub caused bythe contact of the visceral and parietalpericardial layers. If heard, a pericardialfriction rub is pathognomonic forpericarditis. The rub is usually bestheard by having the patient leanforward and can have one to threecomponents. It is dynamic, varies inintensity, and is best heard at the lowerleft sternal region.

When patients present to an emergencyroom with chest pain and suspectedMI, a timely ECG is critical and mustbe obtained within 10 minutes ofpresentation. Differentiating the acutepericarditis ECG and the STEMI ECGcan be challenging at times. The ECGin acute pericarditis can be completelynormal but when abnormal cansometimes mimic a STEMI. The ECGchanges typically include ST elevation,which can be diffuse, but can also beseen in selected regions such as inferioronly. Distinguishing from a trueSTEMI can be particularly challengingwhen this occurs. Unlike ST elevationfrom STEMI, ST elevation frompericarditis does not have reciprocal STdepression. The morphology of the STsegment resembles early repolarizationand is a concave upward shape. Theother finding that can be helpful, ifpresent, is PR depression. PRdepression can sometimes be the onlyECG abnormality and frequentlyprecedes the ST elevation. Finally,sinus tachycardia is the normal rhythmbut occasionally can also present withatrial fibrillation.

It is common that patients exhibit amild leukocytosis. Serum electrolytesin isolated acute pericarditis should benormal. It is not uncommon to havemild cardiac biomarker elevation of theserum troponin and CK-MB levels,especially for those that exhibit STelevation. This is due to involvementof the epicardial surface from theinflammatory process. Thesedimentation rate and C-reactiveprotein levels are elevated in the manycases of acute pericarditis.

Gold Star Recognition We would like to recognize and congratulate these referring facilities for outstanding transfer times for STEMI patients:

Three Rivers Hospital on 3/04/2011: DD2B = 97 minutesTransported by AirEvac

Scene STEMI by Smith Co EMS on 4/01/2011: E2B = 101 minutesTransported by Smith Co EMS and AirEvac

Scene STEMI by Houston Co EMS on 4/06/2011: E2B = 110 minutesTransported by Houston Co EMS and LifeFlight

Horizon Medical Center on 4/18/2011: DD2B = 82 minutes and E2B = 137 minutesTransported by Humphreys Co EMS and LifeFlight

University Medical Center on 5/10/2011: DD2B = 86 minutesTransported by LifeFlight

Heritage Medical Center on 5/27/2011: DD2B = 94 minutes and E2B = 125 minutesTransported by Bedford Co EMS and LifeFlight

Scene STEMI by Moore Co EMS on 6/01/2011: E2B = 102 minutesTransported by Moore Co EMS and LifeFlight

Scene STEMI by Hickman Co EMS on 6/03/2011: E2B = 95 minutesTransported by Hickman Co EMS and LifeFlight

DD2B (door 1-to-door 2-to balloon time) • E2B (EMS arrival on scene to balloon time)

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Physical Exam:

BP – 139/84

P – 70

R – 16

T – 97.1

SaO2 – 100% on room air

General: Awake, alert, in no acute distress

HEENT: negative, no lymphadenopathy

Respiratory: even, unlabored, clear to asculation bilaterally

Cardiac: rate regular rhythm, no murmurs

Diagnostic Tests: ECG

STAT Labs: Troponin 5.5

What is your diagnosis?

Review this ECG and then visit ourwebsite VanderbiltSTEMI.com and click on STEMI newsletter to seethe answer and to view thecatheterization video of this case.

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Joseph L. Fredi, M.D., F.A.C.C.

Treatment is focused on pain relief –typically with narcotic analgesics –in the acute setting and the institutionof anti-inflammatory treatment. Non-steroidal anti-inflammatory agents(NSAIDs) should be the first-linetreatment for acute pericarditis. High-dose aspirin is another option.Both may need to be accompanied bytreatment for gastric protection.Colchicine is helpful as an adjuvant toNSAIDs. Treatment withcorticosteroids has been associated withan increased rate of relapse and are nowgenerally reserved for patients that donot respond to first-line measures.Initial use of corticosteroids is nowdiscouraged.

When faced with a patient having chestpain and ST elevation, it can beoccasionally difficult to distinguishfrom a true STEMI. If there is doubt,then emergent cardiac catheterization isindicated to help exclude acute vesselocclusion.

Usually acute pericarditis improveswith treatment but it can be relapsingin a minority of patients; colchicine canbe very helpful for recurrent orrelapsing pericarditis. Some patientswill develop a larger pericardial effusionand these patients may exhibit signs ofcardiac tamponade. Finally, followingacute pericarditis a small number ofpatients will develop constrictivepericarditis; the primary manifestationof such is right-sided CHF.

In summary, acute pericarditis accountsfor up to 5 percent of ER visits forchest pain. The primary challenge forthe clinician is to distinguish this froma STEMI. This brief review hasfocused on how this may beaccomplished fully recognizing that, onoccasion, it is impossible to determinepericarditis vs. STEMI. These patientsshould be considered for emergentcardiac catheterization. In thesepatients systemic anti-coagulationand/or thrombolytic therapy arecontraindicated because of the risk ofhemorrhage into the pericardial space.These patients should undergoemergent cardiac catheterization fordefinitive diagnosis.

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The use of helicopters to transportpatients to hospitals has been part ofthe United States health care systemsince the 1970s. The beneficial impactof helicopter transport for STEMIpatients has come to light in the past10 years.

Using a medical helicopter to transporta STEMI patient can be lifesaving.Although time is a critical factor in thetransfer and transport of STEMIpatients, there are other factors toconsider, as well. When providers callfor helicopter transport, we hope theyconsider the following when makingthis important choice:

System capability and air medicalcrew training

• Ideally, the patient should be treatedwithin a system, such as theVanderbilt STEMI Network, whichallows for seamless and timelytransfer. The group of hospitals andEMS services in this networkcombines forces with Vanderbilt tomaximize patient outcome andminimize risk.

• LifeFlight’s medical crew receivesintensive training in a hospitalenvironment and has constantavailability with attending physiciansfor medical control and consultation.

Transport vehicle

• LifeFlight’s helicopters are state-of-the-art aircraft made for the EMSmission profile.

• The patient cabin is climatecontrolled and has more than 40square feet of space for the patientand two crew members.

• Flying at a top speed of 165 mph,LifeFlight can deliver the STEMIpatient quickly and safely to thereceiving hospital.

• During the transport, the medicalcrew has full access to the patient toperform monitoring and initiateprocedures.

The ability to maintain the patientcabin within a comfortabletemperature range

• STEMI patients require special care.Being subjected to heat stress in anunairconditioned helicopter issuboptimal for both the patient andmedical crew; all of LifeFlight’saircraft are air conditioned.

Responsibility for the patient

• Upon transfer of care to the LifeFlightcrew, the burden of patientresponsibility falls to LifeFlight, itsmedical control and VanderbiltUniversity Medical Center.

Helicopter transport to a PCI-capablehospital has its advantages but only if itis timely and the air medical crew iswell-trained and the vehicle transport isadequately equipped.

By Jeanne Yeatman R.N., EMT

EMT Danny Hardy,STEMI coordinator, Carol Scott, R.N., heart patient CharlotteHaffner, and director of Giles EMS, Roy Griggs,display the chest bandsfor the AutoPulse, ahands-free CPR device.Haffner organized anestate sale to raise fundsto support the GilesCounty EMS.

The Vanderbilt LifeFlight Emergency Conference will be heldAug. 16-17 in Nashville. This conference is designed foremergency care providers including EMTs, paramedics, nursesand other health care providers. Topics will be presented by avariety of physicians, nurses, paramedics and other experts.Contact Liz Reeves at (615) 322-1547 orcarol.e.reeves@vanderbilt.edu for more information or log onto www.VULifeflight.com.