Lecture AHA 2009 STEMI Focused Update

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



ACC/AHA 2009 STEMI/PCI GuidelinesFocused Update

Based on the ACC/AHA Guidelines for theManagement of Patients With ST-Elevation


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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.



Recommendations for Triage andTransfer for Percutaneous


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Coronary Intervention for Patientswith STEMI



Recommendations for Triage andTransfer for PCI (for STEMI)

III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII

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)



Recommendations for Triage andTransfer for PCI (for STEMI) (cont.)

III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII

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



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.



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.



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.



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.



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.



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.



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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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



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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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.



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.



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



Pharmacoinvasive Strategy

ACC/AHA 2009 Joint STEMI/PCI Guidelines Focused UpdateVerheugt F. N Engl J Med . 2009;360:2779.



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


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.



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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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




• American Heart Association’s Mission

Lifeline is an initiative to encouragecloser cooperation and trust amongstrehos ital care roviders and cardiac


21

care professionals.




• 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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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




• 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”




• 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.

Documents

Lecture AHA 2009 STEMI Focused Update