Reviews Highlights From the 2013 ACCF/AHA Guidelines for the Management of ST-Elevation Myocardial Infarction and Beyond
Address for correspondence: Jacqueline E. Tamis-Holland, MD Division of Cardiology Mount Sinai Saint Luke’s Hospital 1111 Amsterdam Avenue, S&R 3 New York, NY 10025 [email protected]
Jacqueline E. Tamis-Holland, MD; Patrick O’Gara, MD Department of Medicine (Tamis-Holland), Division of Cardiology, Mount Sinai St Luke’s Hospital, New York, New York; Department of Cardiovascular Medicine (O’Gara), Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
ST-segment elevation myocardial infarction (STEMI) is considered a cardiology emergency requiring immediate recognition and treatment aimed at successful and early reperfusion to ensure optimal outcomes. The American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) have issued guidelines for the diagnosis and management of patients with acute myocardial infarction since 1990. These guidelines are based on clinical research exploring reperfusion modalities and adjunctive therapies. They are further supported by expert opinion where randomized trial evidence is lacking. In January 2013, the ACCF/AHA released the most recent guidelines for the management of patients with STEMI. This review focuses on the newest and most important recommendations taken from the 2013 ACCF/AHA Guidelines for the Management of STEMI and highlight important new studies that have emerged over the past year.
Background Approximately 700 000 patients each year are discharged from hospitals throughout the United States with an acute coronary syndrome including ST-elevation myocardial infarction (STEMI), non–ST-elevation myocardial infarction, and unstable angina.1 Among patients with acute coronary syndromes, 25% to 40% present with STEMI.2 STEMI is considered a cardiology emergency requiring immediate recognition and treatment aimed at successful and early reperfusion to ensure optimal outcomes. The American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) have issued guidelines for the diagnosis and management of patients with acute myocardial infarction since 1990, with subsequent versions dedicated solely to the management of patients with STEMI.3 These guidelines are based on clinical research exploring reperfusion modalities and adjunctive therapies. They are further supported by expert opinion where randomized trial evidence is lacking. In January 2013, the ACCF/AHA released the most recent guidelines for the management of patients with STEMI.4 A comprehensive literature review was conducted through November 2010 encompassing all relevant trials; selected publications were
The authors have no funding, financial relationships, or conflicts of interest to disclose. Received: November 26, 2013 Accepted with revision: January 4, 2014
added through August 2012. Since the publication of the 2013 guidelines, several additional studies on the treatment of patients with STEMI have emerged. This review focuses on the newest and most important recommendations taken from the 2013 ACCF/AHA Guidelines for the Management of STEMI and highlights important new studies that have emerged over the past year.
Review Developing and Improving Community Systems of Care–Mission: Lifeline Reperfusion therapy for STEMI is a continuum of care beginning with the onset of a patient’s symptoms and the activation of emergency medical services (EMS), and ending only after the patient has achieved adequate restoration of coronary blood flow and given therapies for residual ischemia. Every community has a different system in which patients rely on such care, and this is often dependent on local geographic constraints, including the location and number of hospitals with and without percutaneous coronary intervention (PCI) capabilities, as well as the network of EMS. In 2007, the AHA launched Mission: Lifeline, a program aimed at encouraging communities to develop their own system of care to optimize therapy for patients with STEMI.5 The goal is to increase the proportion of reperfusion-eligible patients who receive Clin. Cardiol. (in press) Published online in Wiley Online Library (wileyonlinelibrary.com) DOI:10.1002/clc.22258 © 2014 Wiley Periodicals, Inc.
1
timely reperfusion. The guidelines encourage that each community participate in Mission: Lifeline, fostering all relevant agencies to work together as 1 system in a collaborative environment so that involved personnel can recognize and help find solutions to problems resulting in obstacles to achieving guideline recommended goals for reperfusion therapy (Class I, level of evidence [LOE] B).This collaboration should include all stakeholders responsible for delivery of care, beginning with the EMS system and including the emergency department (ED) and cardiology services and administration of each participating hospital. Part of this program includes the scheduling of regular meetings to address quality improvement and provide feedback to all participants involved in the delivery of STEMI care. It is recommended that EMS be trained to perform electrocardiograms (ECGs) in the field on all patients presenting with upper body discomfort suggestive of an acute STEMI (Class I, LOE B). EMS should transmit ECGs to the local ED, and provide prenotification of the patient’s imminent arrival. The emphasis is placed on developing systems to bypass non-PCI centers in situations when it is anticipated that first medical contact to device time can be achieved within 90 minutes. (Class I, LOE B). For PCI centers there should be an activation system allowing the ED to activate the catheterization lab with a single call sent simultaneously to all relevant parties. Furthermore, the catheterization laboratory team should be expected to arrive in the catheterization laboratory and be available to receive patients within 20 minutes of being paged. Hospitals that routinely implement such protocols, and those centers with committed leadership and regulatory committees overseeing care for STEMI patients, have been shown to have the most consistent and fastest reperfusion times.6 Recently, it has been proposed that consideration should also be given to bypassing the ED in those patients when a diagnosis is made in the field by EMS and the cardiac catheterization lab is prenotified of the patient’s arrival and can accept the patient immediately. A report from the Acute Coronary Treatment and Intervention Outcomes Network (ACTION) registry–Get With The Guidelines (GWTG)7 demonstrated that patients who were referred by EMS directly to the catheterization lab for primary PCI, thereby bypassing the ED, had a first medical contact to device time that was on average 20 minutes shorter than those patients who were evaluated first in the ED before going to the catheterization lab. Hospitals and EMS systems are encouraged to develop protocols that may facilitate this approach in appropriate patients. For hospitals without PCI capabilities, efforts need to be made by the non-PCI hospital to improve the transfer time to a PCI-capable facility, especially when fibrinolytic therapy has not been given. A critical component of this time includes the ‘‘door in-door out’’ time at the referring facility. In ideal situations this should be under 30 minutes, although this metric has not yet been used in public reporting. Protocols that allow the referring hospital to directly activate the catheterization lab at the receiving hospital and begin arranging transfer without having to wait for acceptance from a receiving hospital, and protocols that emphasize avoidance of routine intravenous infusions, or delaying
2
Clin. Cardiol. (in press) J.E. Tamis-Holland and P. O’Gara: Review of current STEMI guidelines Published online in Wiley Online Library (wileyonlinelibrary.com) DOI:10.1002/clc.22258 © 2014 Wiley Periodicals, Inc.
transfer while awaiting the copying of patient charts, may help to improve transfer times and should be implemented by hospitals. When fibrinolytic therapy is intended as the method of reperfusion, it should be administered within 30 minutes of first medical contact (Class I, LOE B). In a recent observational analysis from the National Cardiovascular Data Registry,8 the authors demonstrated an encouraging improvement in the door-to-balloon time for patients presenting to PCI hospitals in the United States over time. Unfortunately, despite this improvement over the 4 years that were studied, in-hospital mortality remained the same. This information has highlighted the need to shift our focus from improving door-to-balloon time to improving total system performance in STEMI, beginning with the onset of symptoms and emphasizing prehospital systems of care. Further small reductions in door-to-balloon times are not as likely to improve outcomes as compared to efforts aimed at reducing symptom onset to balloon times, or first medical contact to balloon times. Strategies for Reperfusion Rapid and timely reperfusion is recommended for all eligible patients presenting within 12 hours of symptom onset. Primary PCI is the reperfusion strategy of choice when it can be delivered in a timely manner by competent operators in an experienced facility (Class I, LOE A). The use of some form of reperfusion therapy, however, is more important than the choice of therapy. When determining the choice of reperfusion therapy (ie, primary PCI vs fibrinolysis), certain issues help to guide decision making. Figure 1 outlines the possible approaches to reperfusion depending on the patient’s mode of presentation and anticipated time to receive PCI. Only one-third of hospitals in the United States are currently capable of performing primary PCI.9 Studies have shown that transfer for primary PCI can be performed safely and with good results even if transfer times are delayed.10 Unfortunately, real-world doorto-device times for transfer patients are actually much longer than those reported in these studies, with median times for patients transferred for primary PCI of 149 minutes.11 Less than 15% of patients transferred for primary PCI have a door-to-balloon time
Address for correspondence: Jacqueline E. Tamis-Holland, MD Division of Cardiology Mount Sinai Saint Luke’s Hospital 1111 Amsterdam Avenue, S&R 3 New York, NY 10025 [email protected]
Jacqueline E. Tamis-Holland, MD; Patrick O’Gara, MD Department of Medicine (Tamis-Holland), Division of Cardiology, Mount Sinai St Luke’s Hospital, New York, New York; Department of Cardiovascular Medicine (O’Gara), Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
ST-segment elevation myocardial infarction (STEMI) is considered a cardiology emergency requiring immediate recognition and treatment aimed at successful and early reperfusion to ensure optimal outcomes. The American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) have issued guidelines for the diagnosis and management of patients with acute myocardial infarction since 1990. These guidelines are based on clinical research exploring reperfusion modalities and adjunctive therapies. They are further supported by expert opinion where randomized trial evidence is lacking. In January 2013, the ACCF/AHA released the most recent guidelines for the management of patients with STEMI. This review focuses on the newest and most important recommendations taken from the 2013 ACCF/AHA Guidelines for the Management of STEMI and highlight important new studies that have emerged over the past year.
Background Approximately 700 000 patients each year are discharged from hospitals throughout the United States with an acute coronary syndrome including ST-elevation myocardial infarction (STEMI), non–ST-elevation myocardial infarction, and unstable angina.1 Among patients with acute coronary syndromes, 25% to 40% present with STEMI.2 STEMI is considered a cardiology emergency requiring immediate recognition and treatment aimed at successful and early reperfusion to ensure optimal outcomes. The American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) have issued guidelines for the diagnosis and management of patients with acute myocardial infarction since 1990, with subsequent versions dedicated solely to the management of patients with STEMI.3 These guidelines are based on clinical research exploring reperfusion modalities and adjunctive therapies. They are further supported by expert opinion where randomized trial evidence is lacking. In January 2013, the ACCF/AHA released the most recent guidelines for the management of patients with STEMI.4 A comprehensive literature review was conducted through November 2010 encompassing all relevant trials; selected publications were
The authors have no funding, financial relationships, or conflicts of interest to disclose. Received: November 26, 2013 Accepted with revision: January 4, 2014
added through August 2012. Since the publication of the 2013 guidelines, several additional studies on the treatment of patients with STEMI have emerged. This review focuses on the newest and most important recommendations taken from the 2013 ACCF/AHA Guidelines for the Management of STEMI and highlights important new studies that have emerged over the past year.
Review Developing and Improving Community Systems of Care–Mission: Lifeline Reperfusion therapy for STEMI is a continuum of care beginning with the onset of a patient’s symptoms and the activation of emergency medical services (EMS), and ending only after the patient has achieved adequate restoration of coronary blood flow and given therapies for residual ischemia. Every community has a different system in which patients rely on such care, and this is often dependent on local geographic constraints, including the location and number of hospitals with and without percutaneous coronary intervention (PCI) capabilities, as well as the network of EMS. In 2007, the AHA launched Mission: Lifeline, a program aimed at encouraging communities to develop their own system of care to optimize therapy for patients with STEMI.5 The goal is to increase the proportion of reperfusion-eligible patients who receive Clin. Cardiol. (in press) Published online in Wiley Online Library (wileyonlinelibrary.com) DOI:10.1002/clc.22258 © 2014 Wiley Periodicals, Inc.
1
timely reperfusion. The guidelines encourage that each community participate in Mission: Lifeline, fostering all relevant agencies to work together as 1 system in a collaborative environment so that involved personnel can recognize and help find solutions to problems resulting in obstacles to achieving guideline recommended goals for reperfusion therapy (Class I, level of evidence [LOE] B).This collaboration should include all stakeholders responsible for delivery of care, beginning with the EMS system and including the emergency department (ED) and cardiology services and administration of each participating hospital. Part of this program includes the scheduling of regular meetings to address quality improvement and provide feedback to all participants involved in the delivery of STEMI care. It is recommended that EMS be trained to perform electrocardiograms (ECGs) in the field on all patients presenting with upper body discomfort suggestive of an acute STEMI (Class I, LOE B). EMS should transmit ECGs to the local ED, and provide prenotification of the patient’s imminent arrival. The emphasis is placed on developing systems to bypass non-PCI centers in situations when it is anticipated that first medical contact to device time can be achieved within 90 minutes. (Class I, LOE B). For PCI centers there should be an activation system allowing the ED to activate the catheterization lab with a single call sent simultaneously to all relevant parties. Furthermore, the catheterization laboratory team should be expected to arrive in the catheterization laboratory and be available to receive patients within 20 minutes of being paged. Hospitals that routinely implement such protocols, and those centers with committed leadership and regulatory committees overseeing care for STEMI patients, have been shown to have the most consistent and fastest reperfusion times.6 Recently, it has been proposed that consideration should also be given to bypassing the ED in those patients when a diagnosis is made in the field by EMS and the cardiac catheterization lab is prenotified of the patient’s arrival and can accept the patient immediately. A report from the Acute Coronary Treatment and Intervention Outcomes Network (ACTION) registry–Get With The Guidelines (GWTG)7 demonstrated that patients who were referred by EMS directly to the catheterization lab for primary PCI, thereby bypassing the ED, had a first medical contact to device time that was on average 20 minutes shorter than those patients who were evaluated first in the ED before going to the catheterization lab. Hospitals and EMS systems are encouraged to develop protocols that may facilitate this approach in appropriate patients. For hospitals without PCI capabilities, efforts need to be made by the non-PCI hospital to improve the transfer time to a PCI-capable facility, especially when fibrinolytic therapy has not been given. A critical component of this time includes the ‘‘door in-door out’’ time at the referring facility. In ideal situations this should be under 30 minutes, although this metric has not yet been used in public reporting. Protocols that allow the referring hospital to directly activate the catheterization lab at the receiving hospital and begin arranging transfer without having to wait for acceptance from a receiving hospital, and protocols that emphasize avoidance of routine intravenous infusions, or delaying
2
Clin. Cardiol. (in press) J.E. Tamis-Holland and P. O’Gara: Review of current STEMI guidelines Published online in Wiley Online Library (wileyonlinelibrary.com) DOI:10.1002/clc.22258 © 2014 Wiley Periodicals, Inc.
transfer while awaiting the copying of patient charts, may help to improve transfer times and should be implemented by hospitals. When fibrinolytic therapy is intended as the method of reperfusion, it should be administered within 30 minutes of first medical contact (Class I, LOE B). In a recent observational analysis from the National Cardiovascular Data Registry,8 the authors demonstrated an encouraging improvement in the door-to-balloon time for patients presenting to PCI hospitals in the United States over time. Unfortunately, despite this improvement over the 4 years that were studied, in-hospital mortality remained the same. This information has highlighted the need to shift our focus from improving door-to-balloon time to improving total system performance in STEMI, beginning with the onset of symptoms and emphasizing prehospital systems of care. Further small reductions in door-to-balloon times are not as likely to improve outcomes as compared to efforts aimed at reducing symptom onset to balloon times, or first medical contact to balloon times. Strategies for Reperfusion Rapid and timely reperfusion is recommended for all eligible patients presenting within 12 hours of symptom onset. Primary PCI is the reperfusion strategy of choice when it can be delivered in a timely manner by competent operators in an experienced facility (Class I, LOE A). The use of some form of reperfusion therapy, however, is more important than the choice of therapy. When determining the choice of reperfusion therapy (ie, primary PCI vs fibrinolysis), certain issues help to guide decision making. Figure 1 outlines the possible approaches to reperfusion depending on the patient’s mode of presentation and anticipated time to receive PCI. Only one-third of hospitals in the United States are currently capable of performing primary PCI.9 Studies have shown that transfer for primary PCI can be performed safely and with good results even if transfer times are delayed.10 Unfortunately, real-world doorto-device times for transfer patients are actually much longer than those reported in these studies, with median times for patients transferred for primary PCI of 149 minutes.11 Less than 15% of patients transferred for primary PCI have a door-to-balloon time
