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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\u003EAnother guideline-focused session brought together several experts to discuss the 2013 American College of Cardiology Foundation \/American Heart Association Guidelines for the management of ST-elevation myocardial infarction [O\u0027Gara PT et al. \u003Cem\u003EJ Am Coll Cardiol\u003C\/em\u003E 2013].\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\u003ECardiology Guidelines\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EThrombotic Disorders\u003C\/li\u003E\u003C\/ul\u003E\u003Cul class=\u0022kwd-group clinical-trial\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003EMyocardial Infarction\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ECardiology Guidelines\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EThrombotic Disorders\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ECardiology\u003C\/li\u003E\u003C\/ul\u003E\u003Cp id=\u0022p-2\u0022\u003EAnother guideline-focused session brought together several experts to discuss the 2013 American College of Cardiology Foundation (ACCF)\/American Heart Association (AHA) Guidelines for the management of ST-elevation myocardial infarction (STEMI) [O\u0027Gara PT et al. \u003Cem\u003EJ Am Coll Cardiol\u003C\/em\u003E 2013].\u003C\/p\u003E\u003Cp id=\u0022p-3\u0022\u003EPatrick T. O\u0027Gara, MD, Brigham and Women\u0027s Hospital, Boston, Massachusetts, USA, spoke about some of the changes in the new guidelines and some important recommendations that have been reaffirmed. In Dr. O\u0027Gara\u0027s opinion, the key take-home messages from these guidelines are in the algorithm for triage and treatment for patients with suspected STEMI (\u003Ca id=\u0022xref-fig-1-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F1\u0022\u003EFigure 1\u003C\/a\u003E). Using this algorithm,\u003C\/p\u003E\u003Cp\u003E\n         \u003C\/p\u003E\u003Cul class=\u0022list-simple \u0022 id=\u0022list-1\u0022\u003E\u003Cli id=\u0022list-item-1\u0022\u003E\n               \u003Cp id=\u0022p-5\u0022\u003E\u25aa STEMI patients who are candidates for reperfusion who are seen at a percutaneous coronary intervention (PCI)-capable hospital should be sent to the catheterization laboratory for primary PCI within 90 minutes of first medical contact (FMC; Class I, Level of Evidence [LOE] A).\u003C\/p\u003E\n            \u003C\/li\u003E\u003Cli id=\u0022list-item-2\u0022\u003E\n               \u003Cp id=\u0022p-6\u0022\u003E\u25aa Patients initially seen at a non-PCI-capable hospital should be transferred to a primary PCI-capable facility within 30 minutes provided that the FMC was \u2264120 minutes. When this is not possible, full-dose fibrinolytic therapy should be administered within 30 minutes of arrival at the non-PCI capable facility (Class I, LOE B).\u003C\/p\u003E\n            \u003C\/li\u003E\u003Cli id=\u0022list-item-3\u0022\u003E\n               \u003Cp id=\u0022p-7\u0022\u003E\u25aa In a departure from previous guidelines, the committee now recommends that it is reasonable to transfer patients to a PCI-capable facility after fibrinolytic therapy has been administered regardless of whether the fibrinolytic therapy was successful (Class IIa, LOE B).\u003C\/p\u003E\n            \u003C\/li\u003E\u003C\/ul\u003E\u003Cp\u003E\n      \u003C\/p\u003E\u003Cdiv id=\u0022F1\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/13\/2\/28\/F1.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Reperfusion Therapy for Patients With STEMI\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-631350921\u0022 data-figure-caption=\u0022Reperfusion Therapy for Patients With STEMI\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 1.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/13\/2\/28\/F1.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/13\/2\/28\/F1.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 1.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/13\/2\/28\/F1.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/13146\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\u003Cdiv class=\u0022fig-caption attrib\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 1.\u003C\/span\u003E \n            \u003Cp id=\u0022p-8\u0022 class=\u0022first-child\u0022\u003EReperfusion Therapy for Patients With STEMI\u003C\/p\u003E\n         \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-1\u0022\u003ECABG=coronary artery bypass grafting; DIDO=door-in to door-out; FMC=first medical contact; LOE=level of evidence; PCI=percutaneous coronary intervention; STEMI=ST-elevation myocardial infarction.\u003C\/q\u003E\u003Cq class=\u0022attrib\u0022 id=\u0022attrib-2\u0022\u003E\u2020Angiography and revascularization should not be performed within the first 2 to 3 hours after administration of fibrinolytic therapy.\u003C\/q\u003E\u003Cq class=\u0022attrib\u0022 id=\u0022attrib-3\u0022\u003EReproduced from O\u0027Gara PT et al. 2013 ACCF\/AHA Guideline for the Management of ST-Elevation Myocardial Infarction. \u003Cem\u003EJournal of the American College of Cardiology\u003C\/em\u003E 2013;61(4):e78\u2013104. With permission from Elsevier.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cp id=\u0022p-9\u0022\u003EOther changes in the new guidelines include the recommendation that emergency medical service (EMS) personnel perform a 12-lead electrocardiogram (ECG) at the site of FMC (Class I, LOE B). There is a strong recommendation against PCI of a noninfarct artery at the time of primary PCI in patients without hemodynamic compromise (Class III: Harm LOE B). However, PCI may be appropriate later in patients with spontaneous symptoms of myocardial ischemia (Class I, LOE C) and in patients with intermediate- or high-risk findings on noninvasive testing (Class IIa, LOE B).\u003C\/p\u003E\u003Cp id=\u0022p-10\u0022\u003EThe guideline also recommends institution of therapeutic hypothermia as soon as possible in comatose patients with STEMI and out-of-hospital cardiac arrest due to ventricular fibrillation or pulseless ventricular tachycardia. Patients who are resuscitated after out-of-hospital cardiac arrest whose initial ECG shows ST segment elevation should also undergo coronary angiography and primary PCI (both Class I, LOE B).\u003C\/p\u003E\u003Cp id=\u0022p-11\u0022\u003ELow-dose aspirin (81 mg QD) is now the preferred maintenance dose to support reperfusion with PCI (Class IIa, LOE B); prasugrel should not be used in patients with STEMI with a history of stroke (Class III: Harm LOE B). Given the current uncertainty about its routine use [Thiele H et al. \u003Cem\u003EN Engl J Med\u003C\/em\u003E 2012], the recommendation for the use of intra-aortic balloon pump counterpulsation in patients with cardiogenic shock after STEMI who do not quickly stabilize with pharmacological therapy has been downgraded to Class IIa, LOE B.\u003C\/p\u003E\u003Cp id=\u0022p-12\u0022\u003EAll patients with STEMI should receive high-intensity statin therapy (Class I, LOE B), unless there is a clear contraindication. Anticoagulant therapy with a vitamin K antagonist should be provided to patients with STEMI and atrial fibrillation with CHADS\u003Csub\u003E2\u003C\/sub\u003E score \u22652, mechanical heart valves, venous thromboembolism, or hypercoagulable disorder. The duration of triple-antithrombotic therapy with a vitamin K antagonist, aspirin, and a P2Y12 receptor inhibitor should be minimized to limit the risk of bleeding (both Class I, LOE C).\u003C\/p\u003E\u003Cp id=\u0022p-13\u0022\u003EPCI is clearly superior to fibrinolytics when performed in a timely manner by experienced operators, said Ivan Rokos, MD, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California, USA. Under the new guidelines, all communities should create and maintain a regional system of STEMI care that includes assessment and continuous quality improvement of EMS and hospital-based activities. The guidelines suggest the use of programs such as the AHA\u0027s Mission: Lifeline and the ACC\u0027s Door-to-Balloon (D2B): An Alliance for Quality to facilitate performance (Class I, LOE B).\u003C\/p\u003E\u003Cp id=\u0022p-14\u0022\u003EThe goal of a STEMI system is to route patients to a PCI-capable hospital within guideline benchmarks, regardless of how or where they initially enter the system. Two new programs are making the implementation and management of these systems more efficient and effective. As of 2012, standardized high-quality regional reports are available from the ACC\/AHA\u0027s Acute Coronary Treatment and Intervention Outcomes Network registry-Get With the Guidelines (ACTION-GWTG) that show the performance of all ACTION-GWTG registry hospitals in a particular community as well as outcome measures (eg, risk-adjusted mortality) that can be used for benchmarking and quality improvement. In addition, Geospatial Information Systems maps available through the Mission: Lifeline website are increasingly making it possible to map regions and states to show the location of PCI- and non-PCI-capable hospitals and their referral hospitals, thus providing a mechanism to manage the flow of patients [Rokos I et al. \u003Cem\u003ECrit Pathw Cardiol\u003C\/em\u003E 2013].\u003C\/p\u003E\u003Cblockquote id=\u0022disp-quote-1\u0022 class=\u0022disp-quote\u0022\u003E\n         \u003Cp id=\u0022p-15\u0022\u003E\n            \u003Cstrong\u003EPCI is clearly superior to fibrinolytics when performed in a timely manner by experienced operators.\u003C\/strong\u003E\n         \u003C\/p\u003E\n      \u003C\/blockquote\u003E\u003Cp id=\u0022p-16\u0022\u003ETo-date, the existing STEMI systems have focused on quality, but Dr. Rokos believes that it is time to change the focus to value\u2014value that can be increased through faster reperfusion, and lower morbidity and hospitalization cost. He proposed creating Time-Critical Accountable Care Organizations that cover entire states or regions of \u0026gt;1 million people [Rokos IC. \u003Cem\u003ECirc Cardiovasc Qual Outcomes\u003C\/em\u003E 2011]. These organizations would operate much like their primary-care counterparts but they would focus on hyper-acute situations like STEMI, stroke, and resuscitation. Importantly, they would operate under a regional pay-for-performance system in that all hospitals in the system would benefit when goals are met (vs just the larger organizations).\u003C\/p\u003E\u003Cp id=\u0022p-17\u0022\u003EStephen D. Wiviott, MD, Brigham and Women\u0027s Hospital, Boston, Massachusetts, USA, discussed the use of adjunctive pharmacologic therapy in the setting of PCI. Although there are several options for anticoagulation with primary PCI, clinical data and the guidelines favor the use of bivalirudin (Class I, LOE B) as it has similar efficacy to heparin plus a glycoprotein IIb\/IIIa inhibitor with improved safety and ultimately improved survival [Stone G et al. \u003Cem\u003EN Engl J Med\u003C\/em\u003E 2008]. However, the very early occurrence of stent thrombosis in the HORIZONS AMI study underscored the need for early and potent antiplatelet therapy in the setting of primary PCI.\u003C\/p\u003E\u003Cp id=\u0022p-18\u0022\u003EAs to the best choice of antiplatelet, the guidelines offer providers the choice of using clopidogrel, prasugrel, or ticagrelor. Compared with clopidogrel, both prasugrel and ticagrelor have more rapid onset and offer more potent and consistent antiplatelet effect but at the expense of higher bleeding complications. [Montalescot G et al. \u003Cem\u003ELancet\u003C\/em\u003E 2009; Steg PG et al. \u003Cem\u003ECirculation\u003C\/em\u003E 2010]. With these new guidelines, clinicians have a comprehensive summary of the data driven approaches to pre-, peri-, and post-hospital care of patients with STEMI that have been demonstrated to lead to decreased patient morbidity and mortality.\u003C\/p\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2013 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\/13\/2\/28.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_figures.js?nzo09p\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_openurl.js?nzo09p\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}