UpdateGuidelinesinSTEMIManagement:

FocusonLogisticandSystemApproachtoReperfusionTherapy

WacinBuddhari,MDCardiologyConsultant,BNHHospital

Director,CardiacCatheterizationLaboratoryKingChulalongkornMemorialHospital

Bangkok,Thailand

March 14th, 2018The First Asia Forum in Emergency Medicine

BNH Hospital, Bangkok, Thailand

Disclosure• AdvisoryBoardMember:

– AstraZeneca(dapagliflozin)– BoehringerIngelheim(empagliflozin)– MedtronicAsiaPacific(CoronaryandTranscatheterHeartValve)– MSD(DYSISII)

• LectureHonorarium– AstraZeneca– AbbotVascular– BoehringerIngelheim– DaiichiSankyo– Medtronic– MSD– Novartis– RocheDiagnostics– Sanofi– Sandoz– Takeda

PracticeGuidelines

Plaque rupture

Stableangina

Unstableangina

Non-Qwave MI

Q-waveMI

ST elevation ACS (MI)Non-ST elevation ACS

ECG

+

Degree of thrombosis

Management of ST Elevation MI

Reperfusion

Prevent re-occlusion

STOPInfarction

STOPMyocardial loss

FibrinolysisPrimary PCI

Antiplatelets, Anticoagulant, PCI

Ischemic myocardiumpotentially salvageableby intervention

Necroticmyocardium

100

80

60

40

20

21 43 5 126 2418 123 6 9 6

Hours Days WksIrreversibleinjury

Reversibleinjury

Ischemic myocardium potentially salvageable by reperfusion

“Time is muscle”Acute Myocardial Infarction

Mode of Reperfusion

1’ PCI

Fibrinolysis

REPERFUSION

Occluded LAD Open!!!

2 Reperfusion strategies

• Widely available• Can be given by GP, ER

doctors, gen med or gen cardiologist

• Rate of successful reperfusion varies from 40 – 85%

• Difficult to assess successful reperfusion

• Risk of re-occlusion is 10-20%

• Can be done only in some tertiary centers

• Need experienced interventional cardiologist

• Difficult to get done in a timely fashion (refer cases, after-hour)

• Can open the artery in 90-95% of cases

• Risk of re-occlusion is very low

Fibrinolysis Primary PCI

What’sNewin2017Guidelines?

What’sNewin2017Guidelines?

Modesofpatientpresentation,componentsofischemiatimeandflowchartforreperfusionstrategyselection

Delays

• TreatmentdelaysarethemosteasilyauditedindexofqualityofcareinSTEMI

• Shouldberecorded ineverysystemprovidingcaretoSTEMIpatientsandbereviewedregularly

• Ifprojectedtargettimesarenotmet,theninterventions areneededtoimproveperformance ofthesystem

• Allcomponents ofthesystemdelayrepresentthequalityofcare anditisrecommendedtomeasurethemasqualityindicators

Delays

• Inhospitals andEMS participatinginthecareofSTEMIpatients,thegoalistoreducethedelaybetweenFMCandSTEMIdiagnosis to< 10min

• STEMIdiagnosis referstothetimewhentheECGisinterpretedasST-segmentelevation orequivalentanditisthetimezero toguideappropriatetherapy

• Systemdelayismorereadilymodifiable byorganizationalmeasuresthanispatientdelay,anditisapredictorofoutcomes

Delays

• Forpatientspresentinginanon-PCIcenter,door-intodoor-outtime,definedasthedurationbetweenarrivalofthepatientatthehospitaltodischargeofthepatientinanambulanceen routetothePCIcenter,isanewclinicalperformancemeasure,and< 30minisrecommendedtoexpeditereperfusioncare

OrganizationofSTEMITreatmentinNetworks

• Cleardefinitionofgeographicareasofresponsibility

• Sharedwrittenprotocols,basedonriskstratificationandtransportationbyatrainedphysician,nurse,orparamedicstaffinappropriatelyequippedambulancesorhelicopters

• Pre-hospitaltriageofSTEMIpatientstotheappropriateinstitution,bypassingnon-PCIhospitalsorhospitalswithouta24haday,7daysaweek(24/7)primaryPCIprogram

OrganizationofSTEMITreatmentinNetworks

• Onarrivalattheappropriatehospital,thepatientshouldimmediatelybetakentothecatheterizationlaboratory,bypassingtheemergencydepartment

• Patientspresentingtoanon-PCI-capablehospitalandawaitingtransportationforprimaryorrescuePCImustbeattendedinanappropriatelymonitoredandstaffedarea

• IfthediagnosisofSTEMIhasnotbeenmadebytheambulancecrewandtheambulancearrivesatanon-PCI-capablehospital,theambulanceshouldawaitthediagnosisand,ifaSTEMIdiagnosisismade,shouldcontinuetoaPCI-capablehospital

Logisticsofpre-hospitalcare(1)

Logisticsofpre-hospitalcare(2)

Logisticsofpre-hospitalcare(3)

Recommendationsforreperfusiontherapy(1)

12 3

Recommendationsforreperfusiontherapy(2)

Recommendationsforreperfusiontherapy(3)

Fibrinolytictherapy

MaximumtargettimesaccordingtoreperfusionstrategyselectioninpatientspresentingviaEMSorinanon-PCIcenter

All STEMI should undergo CAG +/- PCI

ImportantTimeTargetsinAcuteSTEMI

QualityIndicators(1)

QualityIndicators(2)

Summary• CurrentguidelinesadvocatesbestpossibleSTEMIcareshould

bedonesystemically,involvingEMS,non-PCIcentersandPCI-capablecenters,workingaswell-planned“network”

• Timingforeachreperfusionstrategyhasbeenredefined

• PrimaryPCIcentershouldoperate24/7• TheultimategoalofthenetworkistoperformedprimaryPCI

inatimelymanortoasmanypatientsaspossible• IfprimaryPCIcannotbedoneinatimelymanor,then

fibrinolytictherapyhastobedeliveredASAP(10minafterDx)withoutanyhesitation

• Timedelayineverystephavetoberecordedandauditedasqualityindicators