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1 Reviewing the Latest Research and Chest Pain Guidelines and Hot Topics for 2015 Presenter Disclosure Information Kathleen Zell, RN, MSN Maureen Corl, MSN-DNP, APRN-CNP Reviewing the latest research and chest pain guidelines and hot topics for 2015 FINANCIAL DISCLOSURE: None UNLABELED/UNAPPROVED USS DISCLOSURE: None 2 1

2 Presenter Disclosure Information Kathleen Zell, RN, MSN, Executive Director, Heart and Vascular Services at UPMC Shadyside Maureen Corl, MSN-DNP, APRN-CNP, Chest Pain and Heart Failure Network Coordinator, The Christ Hospital Reviewing the latest research and chest pain guidelines and hot topics for 2015 FINANCIAL DISCLOSURE: None UNLABELED/UNAPPROVED USS DISCLOSURE: None 3 Objectives Review and Discuss Cardiovascular Data 2015 Review Hot Topics

3 What You Need to Know Nationally Acute Coronary Syndrome (ACS) will strike 935,000 people a year in the United States and out of the 935,000; 250,000 will be STEMI heart attacks. Some estimates as high as 50% of cardiac arrest victims are STEMI patients Out of hospital cardiac arrest has a survival rate of 11.4%. Heart Disease and Stroke Statistic 2011 Update: A Report From the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation 2011;123:e18-e , American Heart Association 5 Heart Disease and Stroke Statistics 2015 Update by Dariush Mozaffarian, Emelia J. Benjamin, Alan S. Go, Donna K. Arnett, Michael J. Blaha, Mary Cushman, Sarah de Ferranti, Jean-Pierre Després, Heather J. Fullerton, Virginia J. Howard, Mark D. Huffman, Suzanne E. Judd, Brett M. Kissela, Daniel T. Lackland, Judith H. Lichtman, Lynda D. Lisabeth, Simin Liu, Rachel H. Mackey, David B. Matchar, Darren K. McGuire, Emile R. Mohler, Claudia S. Moy, Paul Muntner, Michael E. Mussolino, Khurram Nasir, Robert W. Neumar, Graham Nichol, Latha Palaniappan, Dilip K. Pandey, Mathew J. Reeves, Carlos J. Rodriguez, Paul D. Sorlie, Joel Stein, Amytis Towfighi, Tanya N. Turan, Salim S. Virani, Joshua Z. Willey, Daniel Woo, Robert W. Yeh, and Melanie B. Turner Circulation Volume 131(4):e29-e322 January 27,

4 Prevalence (unadjusted) estimates for poor, intermediate, and ideal cardiovascular health for each of the 7 metrics of cardiovascular health in the American Heart Association 2020 goals, US children aged 12 to 19 years, National Health and Nutrition Examination Survey (NHANES) 2011 to *Healthy diet score data reflects 2009 to 2010 NHANES data. Prevalence (unadjusted) estimates of poor, intermediate, and ideal cardiovascular health for each of the 7 metrics of cardiovascular health in the American Heart Association 2020 goals among US adults aged 20 to 49 years and 50 years, National Health and Nutrition Examination Survey (NHANES) 2011 to *Healthy diet score data reflects 2009 to 2010 NHANES data. 4

5 Proportion (unadjusted) of US children aged 12 to 19 years meeting different numbers of criteria for ideal cardiovascular health, overall and by sex, National Health and Nutrition Examination Survey 2009 to Dariush Mozaffarian et al. Circulation. 2015;131:e29- e322 Age-standardized prevalence estimates of US adults aged =20 years meeting different numbers of criteria for ideal cardiovascular health, overall and by age and sex subgroups, National Health and Nutrition Examination Survey 2009 to

6 Age-standardized prevalence estimates of US adults aged 20 years meeting different numbers of criteria for ideal cardiovascular health, overall and in selected race subgroups, National Health and Nutrition Examination Survey 2009 to Prevalence for meeting 5 criteria for ideal cardiovascular health among US adults aged 20 years (age standardized) and US children aged 12 to 19 years, overall and by sex, National Health and Nutrition Examination Survey 2005 to 2006 and 2009 to

7 Age-standardized prevalence estimates of US adults meeting different numbers of criteria for ideal and poor cardiovascular health, for each of the 7 metrics of cardiovascular health in the American Heart Association 2020 goals among US adults aged 20 years, National Health and Nutrition Examination Survey 2009 to Age-standardized cardiovascular health status by US states, Behavioral Risk Factor Surveillance System,

8 Prevalence of ideal, intermediate, and poor cardiovascular health metrics in 2006 (American Heart Association 2020 Impact Goals baseline year) and 2020 projections assuming current trends continue. US age-standardized death rates* from cardiovascular diseases, 2000 to

9 Prevalence (%) of current smoking for adolescents and adults, by sex and age (National Health Interview Survey, ; National Survey on Drug Use and Health, ). Percentage of sodium from dietary sources in the United States 2005 to

10 Total US food expenditures away from home and at home, 1977 and Age-adjusted trends in mean serum total cholesterol among adults 20 years old by race and survey year (National Health and Nutrition Examination Survey: , , and ). 10

11 Extent of awareness, treatment, and control of high blood pressure by race/ethnicity and sex (National Health and Nutrition Examination Survey: ). Diabetes mellitus awareness, treatment, and control in adults 20 years of age (National Health and Nutrition Examination Survey: ). 11

12 Deaths attributable to diseases of the heart (United States: ). Percentage breakdown of deaths attributable to cardiovascular disease (United States: 2011). 12

13 Hospital discharges for cardiovascular disease (United States: ) Hospital discharges (ICD-9) for the 10 leading diagnostic groups (United States: 2010) 13

14 Reason for pacemaker implantation. Trends in cardiovascular procedures, United States: 1979 to

15 Direct and indirect costs of cardiovascular disease (CVD) and stroke (in billions of dollars), United States, 2011 The 23 leading diagnoses for direct health expenditures, United States, 2011 (in billions of dollars) 15

16 Circulation : EMS Dispatch CPR Prearrival Instructions to Improve Survival from OOHCA Circulation : EMS Dispatch CPR Prearrival Instructions to Improve Survival from OOHCA 2011, American Heart Association 32 16

17 Circulation : EMS Dispatch CPR Prearrival Instructions to Improve Survival from OOHCA 2013, American Heart Association 17

18 LH1 Highlights of the Circulation Median D2B times declined 32 minutes from 96 minutes 64 minutes over the 6 year period. The most outstanding institutions are now regularly achieving times under 60 minutes through strategies including coordination with EMS and the collection and dissimination of a Pre Hospital ECG. REHOSPITAL ECG. Circulation. 2011, 124: August,

19 Slide 35 LH1 This is my favorite circ to support D2B of 60 minutes and the necessity for pre-hospitalactivation to make that happen. Lori Hollowell, 6/5/2014

20 2013, American Heart Association Highlights 20 to30% of OHCA patients who survive who survive to hospital admission have evidence of STEMI including LBBB on their presenting ECG. Recommendation includes OHCA cases should be tracked but not publicly reported or used for overall PCI performance ranking, which would allow accountability for management but would not penalize high-volume CRCs for following the 2010 AHA Guidelines for CPR and ECC. Circulation, 2013;128: July 2013 Impact of PCI Performance Reporting on Cardiac Resuscitation Centers 2013, American Heart Association 38 19

21 PCI versus Fibrinolysis consideration in the STEMI How long should the practitioner wait for PCI in a lytic eligible patient? When is the benefit of catheter-based therapy lost and fibrinolysis becomes the preferred option? Circulation. 2010:122:S787-S817 This paper provides the emergency physician with the total elapsed time he or she should wait for PCI, at which point the survival benefit of the invasive strategy is lost and the patient should receive a Fibrinolytic agent. Part 10: ACS: 2010 AHA Guidelines for CPR and ECC Mission: Lifeline Update and Hot Topics 2015 Barriers to Timely Access to Care (STEMI) The patient Failure to promptly recognize symptoms Hesitation to seek medical attention Time to transport Mandated delivery to the closest hospital, regardless of PCI capabilities Long transport in rural areas Decision process on arrival Clot-busting drugs vs. PCI Off hours Transfer to PCI facility Time to implement treatment strategy Procedural factors Team assembly 2013, American Heart Association 20

22 Cardiac Resuscitation Systems of Care Increase Community Response and Action Increase incidence of By-Stander CPR Improve public access to AED s Improve Professional Coordination Dispatch First Responders EMS Emergency Departments In-Hospital Providers Promote Effective and Continuous Care Effective and Continuous CPR Induction of Therapeutic Hypothermia Prompt PCI when indicated Multidisciplinary approach throughout continuum of care Improve Regional Systems of Care Develop and Implement regional system of care approach to OOHCA Patients Increase monitoring and reporting of OOHCA incidence Promote data collection 21

23 Systems of Care Each community should develop a system of care following the standards developed for Mission Lifeline (AHA) including: Ongoing multidisciplinary team meetings with EMS, non-pci, and PCI centers A process for pre-hospital identification and activation Destination protocols Transfer protocols for referral centers for appropriate patients 2011, American Heart Association The Ideal Community Hands Only CPR with a goal of achieving >50% bystander CPR Early activation of 911 Apply AED before EMS arrival Designated Community Champion Multidisciplinary group to monitor, provide feedback and improve processes and outcomes Implements and maintains public access defibrillation program 22

24 The Ideal Patient Recognizes the symptoms of STEMI Realizes the importance of: Activating emergency medical services (EMS) via promptly Getting treatment quickly Is familiar with the local hospital s role in STEMI care Understands the implications of inter-hospital transfer for PCI Is supported by the ideal system, which: Promotes culturally competent education efforts Includes patient representatives on community planning coalitions Provides coordinated and patient-centered care 2011, American Heart Association The Ideal Hospital Standardized POE protocols dictate transport of STEMI patients directly to a receiving hospital based on: Specific criteria for risk; including cardiac arrest Contraindications to thrombolysis The proximity of the nearest PCI service Patients presenting to a referral hospital are treated according to standardized triage and transfer protocols Initiates hypothermia as soon as possible, when indicated Transports early patients resuscitated from OHCA to Receiving Center to allow angiography of cath eligible/appropriate patients as soon as possible, to achieve goal of first door to device within 120 minutes Implements and maintains ability to treat re-arrest including mechanical CPR AND/OR pharmacological support if indicated 2011, American Heart Association 23

25 The Ideal Receiving Hospital Pre-hospital ECG diagnosis of STEMI, ED notification and cath lab activation occurs according to standard algorithms Algorithms facilitate: A short ED stay for the STEMI patient Transport directly from the field to the cath lab Single-call systems from STEMI-referral hospitals immediately activate the cath lab Primary PCI is provided as routine treatment for STEMI 24-7 Has plan for and ability to treat re-arrest, including mechanical CPR AND/OR pharmacological support Capable of assessment of need for ICD placement and providing appropriate follow up Defers assessment of prognostication and withdrawal of care for at least 72 hours after Cardiac Resuscitation 2011, American Heart Association The Ideal System of Care Register with Mission: Lifeline Conducts multidisciplinary meetings that include Community, EMS, Referral Centers, & Receiving Center representatives or staff to monitor and improve Cardiac Resuscitation care process and outcomes Has process for pre-hospital identification and activation of STEMI in patients resuscitated from OHCA Destination protocols to Receiving Center There is mutual respect for the critical role of each player in the system 2011, American Heart Association 24

26 Circulation : EMS Dispatch CPR Prearrival Instructions to Improve Survival from OOHCA Questions 25