The ACC/AHA focused update of guidelines for STEMI and PCI have been released. They offer new insight into which patients should be given thrombolytics prior to transfer for PCI. They also give a “shout out” to Mission: Lifeline!
2009 Focused Updates: ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction (Updating the 2004 Guideline and 2007 Focused Update) and ACC/AHA/SCAI Guidelines on Percutaneous Coronary Intervention (Updating the 2005 Guideline and 2007 Focused Update)
Here are some highlights (with emphasis added in some key areas):
STEMI Patients Who Are Candidates for Reperfusion
The 2007 STEMI Focused Update describes several strategies for reperfusion, among them facilitated PCI and rescue PCI. These terms are no longer used for the recommendations in this update so that the contemporary therapeutic choices that lead to reperfusion as part of the treatment of patients presenting with STEMI can be described without these potentially misleading labels.
Very interesting indeed!
A detailed discussion about facilitated PCI and rescue PCI follows (including the ASSENT-4, FINESSE, REACT, CARESS, and TRANSFER-AMI trials). And then:
[A] pathway has been suggested for the care of STEMI patients that has been divided into those patients presenting to a PCI-capable facility and those presenting to a non–PCI-capable facility. Those seen at a PCI-capable facility should be moved expeditiously to the catheterization laboratory, with appropriate antithrombotic therapy for catheterization and PCI if appropriate. There has been discussion about whether the recommended door-to-balloon time (or first medical contact–to-balloon time) should be greater than 90 minutes, with the recognition that in certain patients, the mortality advantage of primary PCI compared with fibrinolytic therapy is maintained with more prolonged door-to-balloon times. However, the writing groups continue to believe that the focus should be on developing systems of care to increase the number of patients with timely access to primary PCI rather than extending the acceptable window for door-to-balloon time.
The update continues:
Those patients presenting to a non–PCI-capable facility should be triaged to fibrinolytic therapy or immediate transfer for PCI. This decision will depend on multiple clinical observations that allow judgment of the mortality risk of the STEMI, the risk of fibrinolytic therapy, the duration of the symptoms when first seen, and the time required for transport to a PCI-capable facility. If primary PCI is chosen, the patient will be transferred for PCI. If fibrinolytic therapy is chosen, the patient will receive the agent(s), and a judgment as to whether the patient is high risk or not will be made. If high risk, the patient should receive appropriate antithrombotic therapy and be moved immediately to a PCI-capable facility for diagnostic catheterization and consideration of PCI. If not high risk, the patient may be moved to a PCI-capable facility after receiving antithrombotic therapy or may be observed in the initial facility.
Patients best suited for transfer for PCI are those STEMI patients who present with high-risk features, those with high bleeding risk from fibrinolytic therapy, and patients presenting late, that is, more than 4 hours after onset of symptoms. The decision to transfer is a judgment made after consideration of the time required for transport and the capabilities of the receiving hospital. Patients best suited for fibrinolytic therapy are those who present early after symptom onset with low bleeding risk. After fibrinolytic therapy, if the patient is not at high risk, transfer to a PCI-capable facility may be considered, especially if symptoms persist and failure to reperfuse is suspected.
The duration of symptoms should continue to serve as a modulating factor in selecting a reperfusion strategy for STEMI patients. Although patients at high risk (e.g., those with congestive heart failure, shock, and contraindications to fibrinolytic therapy) are best served with timely PCI, “inordinate delays between the time from symptom onset and effective reperfusion with PCI may prove deleterious, especially among the majority of STEMI patients at relatively low risk”. Accordingly, each community and each facility in that community should have an agreed-upon plan for how STEMI patients are to be treated. This includes which hospitals should receive STEMI patients from emergency medical services units capable of obtaining diagnostic ECGs, management at the initial receiving hospital, and written criteria and agreements for expeditious transfer of patients from non–PCI-capable to PCI-capable facilities.
The development of regional systems of STEMI care is a matter of utmost importance. This includes encouraging the participation of key stakeholders in collaborative efforts to evaluate care using standardized performance and quality improvement measures, such as those endorsed by the ACC and the AHA for ACS. Standardized quality-of-care data registries designed to track and measure outcomes, complications, and adherence to evidence-based processes of care for ACS are also critical: programs such as the National Cardiovascular Data Registry ACTION Registry, the AHA’s “Get With The Guidelines” quality improvement program, and those performance-measurement systems required by the Joint Commission and the Centers for Medicare and Medicaid Services. More recently, the AHA has promoted its “Mission: Lifeline” initiative, which was developed to encourage closer cooperation and trust among prehospital emergency services, and cardiac care professionals. The evaluation of STEMI care delivery across traditional care-delivery boundaries with these tools and other resources is imperative to identify systems problems and to enable the application of modern quality improvement methods, such as Six Sigma, to make necessary improvements.
Let’s hear it for Mission: Lifeline!
*** Update 12/13/09 ***
You can download a slide set from the American Heart Association HERE (PDF).