March 14 th, 2018 The First Asia Forum in Emergency Medicine BNH Hospital, Bangkok, Thailand Update Guidelines in STEMI Management: Focus on Logistic and System Approach to Reperfusion Therapy Wacin Buddhari, MD Cardiology Consultant, BNH Hospital Director, Cardiac Catheterization Laboratory King Chulalongkorn Memorial Hospital Bangkok, Thailand
Disclosure Advisory Board Member: AstraZeneca (dapagliflozin) Boehringer Ingelheim (empagliflozin) Medtronic Asia Pacific (Coronary and Transcatheter Heart Valve) MSD (DYSIS II) Lecture Honorarium AstraZeneca Abbot Vascular Boehringer Ingelheim Daiichi Sankyo Medtronic MSD Novartis Roche Diagnostics Sanofi Sandoz Takeda
Practice Guidelines
Management of ST Elevation MI Plaque rupture Stable angina Unstable angina Non-Q wave MI Q-wave MI Degree of thrombosis STOP Infarction Non-ST elevation ACS ST elevation ACS (MI) STOP Reperfusion Myocardial loss Fibrinolysis Primary PCI + ECG Prevent re-occlusion Antiplatelets, Anticoagulant, PCI
Acute Myocardial Infarction Time is muscle Ischemic myocardium potentially salvageable by reperfusion 100 80 60 Ischemic myocardium potentially salvageable by intervention 40 20 Reversible injury Necrotic myocardium 1 2 3 4 5 6 12 18 24 3 6 9 12 6 Irreversible injury Hours Days Wks
Mode of Reperfusion 1 PCI REPERFUSION Occluded LAD Open!!! Fibrinolysis
2 Reperfusion strategies Fibrinolysis 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% Primary PCI 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
What s New in 2017 Guidelines?
What s New in 2017 Guidelines?
Modes of patient presentation, components of ischemia time and flowchart for reperfusion strategy selection
Delays Treatment delays are the most easily audited index of quality of care in STEMI Should be recorded in every system providing care to STEMI patients and be reviewed regularly If projected target times are not met, then interventions are needed to improve performance of the system All components of the system delay represent the quality of care and it is recommended to measure them as quality indicators
Delays In hospitals and EMS participating in the care of STEMI patients, the goal is to reduce the delay between FMC and STEMI diagnosis to < 10 min STEMI diagnosis refers to the time when the ECG is interpreted as ST-segment elevation or equivalent and it is the time zero to guide appropriate therapy System delay is more readily modifiable by organizational measures than is patient delay, and it is a predictor of outcomes
Delays For patients presenting in a non-pci center, door-in to doorout time, defined as the duration between arrival of the patient at the hospital to discharge of the patient in an ambulance en route to the PCI center, is a new clinical performance measure, and < 30 min is recommended to expedite reperfusion care
Organization of STEMI Treatment in Networks Clear definition of geographic areas of responsibility Shared written protocols, based on risk stratification and transportation by a trained physician, nurse, or paramedic staff in appropriately equipped ambulances or helicopters Pre-hospital triage of STEMI patients to the appropriate institution, bypassing non-pci hospitals or hospitals without a 24 h a day, 7 days a week (24/7) primary PCI program
Organization of STEMI Treatment in Networks On arrival at the appropriate hospital, the patient should immediately be taken to the catheterization laboratory, bypassing the emergency department Patients presenting to a non-pci-capable hospital and awaiting transportation for primary or rescue PCI must be attended in an appropriately monitored and staffed area If the diagnosis of STEMI has not been made by the ambulance crew and the ambulance arrives at a non-pcicapable hospital, the ambulance should await the diagnosis and, if a STEMI diagnosis is made, should continue to a PCIcapable hospital
Logistics of pre-hospital care (1)
Logistics of pre-hospital care (2)
Logistics of pre-hospital care (3)
Recommendations for reperfusion therapy (1) 2 3 1
Recommendations for reperfusion therapy (2)
Recommendations for reperfusion therapy (3)
Fibrinolytic therapy
Maximum target times according to reperfusion strategy selection in patients presenting via EMS or in a non-pci center All STEMI should undergo CAG +/- PCI
Important Time Targets in Acute STEMI
Quality Indicators (1)
Quality Indicators (2)
Summary Current guidelines advocates best possible STEMI care should be done systemically, involving EMS, non-pci centers and PCIcapable centers, working as well-planned network Timing for each reperfusion strategy has been redefined Primary PCI center should operate 24/7 The ultimate goal of the network is to performed primary PCI in a timely manor to as many patients as possible If primary PCI can not be done in a timely manor, then fibrinolytic therapy has to be delivered ASAP ( 10 min after Dx) without any hesitation Time delay in every step have to be recorded and audited as quality indicators