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type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/advagg_css\/css__ce2QY63WIanKyr8eSq7eavr1XQRRmFD6ZSmwpyJi8lM__zXwFqpqmxrZOXXcd_TpBQpjuELbmIP9wBR5UuTDWAO4__YJWWMMdfCJuAFm5cUEp88OsodhO3ZA-2lzRfoBsSlk4.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\n            \u003Cp id=\u0022p-1\u0022\u003EIt has been well established that primary percutaneous coronary intervention (PCI) is superior to fibrinolytic therapy for ST-segment elevation myocardial infarction (STEMI) but only if coronary reperfusion can be established in a timely manner (\u0026lt;90 minutes) by skilled operators. Achieving that goal has been a challenge, however, because of delays in diagnosis as well as in treatment. Two particular areas of concern are the effective use of prehospital electrocardiograms and the appropriate treatment strategy for patients who must be transferred a long distance for PCI.\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003EMyocardial Infarction\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EImaging Modalities\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EInterventional Techniques \u0026amp; Devices\u003C\/li\u003E\u003C\/ul\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-1\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EAppropriate STEMI Care Depends on Timing\u003C\/h2\u003E\n         \u003Cp id=\u0022p-2\u0022\u003EIt has been well established that primary percutaneous coronary intervention (PCI) is superior to fibrinolytic therapy for ST\u2013segment elevation myocardial infarction (STEMI) but only if coronary reperfusion can be established in a timely manner (\u0026lt;90 minutes) by skilled operators. Achieving that goal has been a challenge, however, because of delays in diagnosis as well as in treatment. Two particular areas of concern are the effective use of prehospital electrocardiograms (PH\u2013ECGs) and the appropriate treatment strategy for patients who must be transferred a long distance for PCI.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-2\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EPrehospital ECGs\u003C\/h2\u003E\n         \u003Cp id=\u0022p-3\u0022\u003EIvan Rokos, MD, FACEP, FAHA, FACC, an emergency physician in Los Angeles, California, USA, emphasized that patients with STEMI identified on a PH\u2013ECG consistently have the fastest door\u2013to\u2013balloon (D2B) times. For example, in a Canadian study of 344 STEMI patients, the median D2B time was much shorter for patients who were referred directly to a PCI center by emergency medical services (EMS) personnel who were trained in ECG interpretation than for patients who were referred via interhospital transfer (69 minutes vs 123 minutes) [Le May MR et al. \u003Cem\u003EN Engl J Med\u003C\/em\u003E 2008]. The ACTION Registry - Get with the Guidelines (ARG) study of 7098 STEMI patients who were transported by paramedics to the hospital, showed that the use of a PH\u2013ECG was also associated with a shorter D2B time (median of 61 minutes vs 75 minutes; p\u0026lt;0.001) [Diercks DB et al. \u003Cem\u003EJACC\u003C\/em\u003E 2009]. In addition, a 2053\u2013patient study that evaluated the integration of PH\u2013ECGs across 10 independent STEMI receiving center networks demonstrated that 86% of patients had a D2B time of \u226490 minutes, 50% were treated with a D2B time of \u226460 minutes, and 25% were treated with a D2B time of \u226430 minutes [Rokos IC. \u003Cem\u003EJ Am Coll Card CV Interv\u003C\/em\u003E 2009]. The study also evaluated EMS providers by using the date\/time that was autostamped on the PH\u2013ECG as Time 0 (rather than the hospital\u0027s door time) and found that 68% of patients had a rate of EMS\u2013to\u2013balloon time of \u0026lt;90 minutes in these organized STEMI networks.\u003C\/p\u003E\n         \u003Cp id=\u0022p-4\u0022\u003EThe greatest challenge with PH\u2013ECGs is a higher rate of inappropriate activation of the cardiac catheterization laboratory. Various activation studies have shown rates of false\u2013positive activation of the catheterization laboratory 5% to 10% for ECGs that are interpreted by emergency department (ED) physicians and of 10% to 25% for ECGs that are interpreted by EMS personnel. However, studies have also demonstrated that PH\u2013ECG transmission systems can reduce the rate of false\u2013positive activations, because another set of \u201ccritical eyes\u201d can review the ECG (usually the on\u2013duty ED physician) before the 4 to 5 member catheterization laboratory team is activated. Various proprietary PH\u2013ECG transmission options currently exist, but their use is by no means universal, because of various technical, financial, and administrative issues.\u003C\/p\u003E\n         \u003Cp id=\u0022p-5\u0022\u003EDr. Rokos cautioned that bringing patients with STEMI based on an ECG interpreted by paramedics directly from the field to the catheterization laboratory during the regular work day may be \u201cgreat\u201d for D2B times, but the cardiology team should also understand that significant potential exists for receiving a patient that did not have a STEMI. Thus, the role of the ED remains critical in filtering out inappropriate patients, especially if PH\u2013ECG transmission is not available. The goal for efficient STEMI systems should be a \u0026lt;5% rate of inappropriate activation (red zone), as summarized in \u003Ca id=\u0022xref-table-wrap-1-1\u0022 class=\u0022xref-table\u0022 href=\u0022#T1\u0022\u003ETable 1\u003C\/a\u003E [Rokos et al. \u003Cem\u003EAm Heart J\u003C\/em\u003E 2010].\u003C\/p\u003E\n         \u003Cdiv id=\u0022T1\u0022 class=\u0022table pos-float\u0022\u003E\u003Cdiv class=\u0022table-inline\u0022\u003E\u003Cdiv class=\u0022callout\u0022\u003E\u003Cspan\u003EView this table:\u003C\/span\u003E\u003Cul class=\u0022callout-links\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022\/\u0022 class=\u0022table-expand-inline\u0022 data-table-url=\u0022\/highwire\/markup\/14006\/expansion?postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed\u0026amp;table-expand-inline=1\u0022 html=\u00221\u0022 fragment=\u0022#\u0022 external=\u00221\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView inline\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022\/highwire\/markup\/14006\/expansion?width=1000\u0026amp;height=500\u0026amp;iframe=true\u0026amp;postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media\u0022 class=\u0022colorbox colorbox-load table-expand-popup\u0022 rel=\u0022gallery-fragment-tables\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView popup\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/14006\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cdiv class=\u0022table-caption\u0022\u003E\u003Cspan class=\u0022table-label\u0022\u003ETable 1.\u003C\/span\u003E \n               \u003Cp id=\u0022p-6\u0022 class=\u0022first-child\u0022\u003EClassification of Appropriate vs Inappropriate Cath Lab Activation.\u003C\/p\u003E\n            \u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n         \u003Cp id=\u0022p-12\u0022\u003ELastly, Dr. Rokos stated that the ECG criteria that are used to identify patients who require primary PCI need updating. According to the 2004 American College of Cardiology\/American Heart Association (ACC\/AHA) guidelines, STEMI is defined as ST elevation of \u22651 mm in 2 contiguous leads, new (or presumed new) left bundle branch block, or isolated posterior MI. He proposed that the criteria for STEMI should be broadened to include \u201csemi\u2013STEMI\u201d\u2014ST elevation \u0026lt;1 mm but with associated reciprocal changes\u2014and \u201cSTEMI\u2013equivalent\u201d\u2014any ECG pattern that lacks classic ST elevation but is associated with an acute coronary occlusion that requires primary PCI (eg, true posterior MI, diffuse inferolateral ST\u2013depression with concomitant ST\u2013elevation in lead aVR, de Winter T\u2013waves [de Winter et al. \u003Cem\u003EN Engl J Med\u003C\/em\u003E 2008], and certain cardiac arrest patients who have been resuscitated from a shockable rhythm). Importantly, Dr. Rokos emphasized that all frontline providers should be familiar with various ST\u2013elevation mimics that cause inappropriate activations, including narrow QRS complex (eg, normal early repolarization, pericarditis) and wide\/tall QRS complex (eg, ventricularly paced rhythms, left ventricular hypertrophy) rhythms.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-3\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EOptimal Reperfusion Strategies with Expected Delays\u003C\/h2\u003E\n         \u003Cp id=\u0022p-13\u0022\u003EAccording to the current standard of care for patients with STEMI, fibrinolysis is recommended when transferring the patient will mean a D2B time of \u0026gt;90 minutes (ACC\/AHA guidelines) and \u0026gt;120 minutes (European Society of Cardiology guidelines). Even among the best\u2013performing hospitals, the D2B time is not optimal in most cases, said Timothy D. Henry, MD, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota, USA. According to data from the ARG Registry, the D2B time was \u0026lt;90 minutes for only 18% of patients. Overall in the United States, only an estimated 15% to 20% of patients with STEMI who are transferred for primary PCI have a D2B time of \u0026lt;2 hours.\u003C\/p\u003E\n         \u003Cp id=\u0022p-14\u0022\u003EThe low rate of optimal time to PCI has a negative effect on outcomes, with the advantage of PCI over fibrinolysis decreasing as the PCI\u2013related delay increases, said Duane S. Pinto, MD, MPH, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA. For every 10\u2013minute delay to PCI, there is a significant reduction in the mortality difference between PCI and fibrinolysis [Nallamothu BK et al. \u003Cem\u003EAm J Cardiol\u003C\/em\u003E 2004].\u003C\/p\u003E\n         \u003Cp id=\u0022p-15\u0022\u003EThe standard of care for patients with STEMI is based on randomized trials, where D2B times are shorter than in real\u2013world practice. Dr. Pinto and his colleagues reviewed data from the National Registry of Myocardial Infarctions and found that overall, the outcomes were better for patients who were transferred for PCI compared with patients who had onsite fibrinolytic therapy. The differences were not as pronounced when the outcomes for matched patients were compared. When the results were stratified according to time, the patients who benefited the most from transfer\u2013PCI were those for whom the delay was shorter [Pinto DS et al. \u003Cem\u003ECirculation\u003C\/em\u003E 2011].\u003C\/p\u003E\n         \u003Cp id=\u0022p-16\u0022\u003EFacilitated PCI was developed in an attempt to improve outcomes for STEMI patients with an expected delay to treatment. Giving fibrinolytic therapy before planned PCI was an excellent idea, said Dr. Henry, but based on data from initial randomized clinical trials, the authors of a key meta\u2013analysis concluded that facilitated PCI provided no benefit [Keeley EC et al. \u003Cem\u003ELancet\u003C\/em\u003E 2006]. Dr. Henry suggested that the results of the meta\u2013analysis need to be reconsidered, based on the newer practice patterns that include earlier and more frequent use of potent thienopyridines and more recent clinical trial data, especially for patients with an expected delay \u0026gt;120 minutes. There was wide variation in the fibrinolytics that were given across the trials in the meta\u2013analysis; the patients were relatively low\u2013risk, treated in a PCI hospital, or transferred only a short distance; and the studies that were done in the era prior to the introduction and use of potent thienopyridines. In addition, the majority of patients were from the ASSENT 4 trial, which used full\u2013dose fibrinolytic, and \u201cearly generation antiplatelet and antithrombin regimens [Van de Werf F et al. \u003Cem\u003ELancet\u003C\/em\u003E 2006]. Furthermore, although 45% of patients were managed in a hospital with onsite PCI, none of us would give a fibrinolytic, without high potency thienopyridine, and go to the catheterization laboratory in a PCI hospital,\u201d said Dr. Henry. In addition, ASSENT 4 excluded patients with anticipated delays to PCI of \u0026gt;3 hours\u2013\u201cexactly the patients we\u0027re concerned about,\u201d he added.\u003C\/p\u003E\n         \u003Cp id=\u0022p-17\u0022\u003EMore recently, pharmacoinvasive PCI has been studied as an option for patients with an expected delay to PCI. The difference between facilitated PCI and pharmacoinvasive PCI strategies is primarily timing, with facilitated PCI referring to PCI done immediately after fibrinolytic therapy and pharmacoinvasive PCI referring to PCI done within a few hours after fibrinolytic therapy. Recent data support the pharmacoinvasive approach, including both randomized trials that have demonstrated that fibrinolysis, followed by immediate transfer for PCI, has outcomes that are superior to fibrinolysis with standard of care, and registry data that have shown that a pharmacoinvasive approach in patients with delays \u0026gt;120 minutes has outcomes that are similar to patients who present to a PCI center [Di Mario C et al. \u003Cem\u003ELancet\u003C\/em\u003E 2008; Cantor WJ et al. \u003Cem\u003EN Engl J Med\u003C\/em\u003E 2009; Bohmer E et al. \u003Cem\u003EJ Am Coll Card\u003C\/em\u003E 2009; Larson D et al. \u003Cem\u003EEur J Heart\u003C\/em\u003E 2011].\u003C\/p\u003E\n         \u003Cp id=\u0022p-18\u0022\u003EThe use of pharmacoinvasive PCI in regional STEMI systems in the United States and Canada has shown that half\u2013dose fibrinolysis, combined with immediate transfer for PCI, may be a safe and effective option for patients with STEMI who have expected delays due to transfer to a hospital with PCI facilities.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2012 MD Conference Express\u00ae\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/12\/4\/26.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nznhr1\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_tables.js?nznhr1\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}