SUNDAY, 27th FEBRUARY – SESSION 2

Acute myocardial infarctionand pre-hospital selection

Who ? When ? Where ?

Patrick Goldstein

EXPERTS WORKSHOP ON EARLY TREATMENT STRATEGIES FOR ACUTE MYOCARDIAL INFARCTIONFOR THE MIDDLE EAST COUNTRIES

FEBRUARY 26TH -28TH 2005 / DUBAI, UAESPONSORED BY BOEHRINGER INGELHEIM

We want to save time

We want to save minutes to taking important decisions

but

where is the correct decision point

• emergency room

• CICU

• on scene

• at home

• at the dispatching center

There is not a single triage point but a

succession of different points of triage

to achieve a successful reperfusion

strategy

The initial selection:

• the patient

• the family

• the environment

70% of patients are primary AMI

In case of chest pain call immediately

15 - 999 - 911 - 112

15

Acute chest pain is an emergency

CALL

CardiologistGP 18

AnalysisAmbulance +/- MDMedical assessmentAdmission

The French Strategy

AV 2002

Flyers Distributed by GP

Prehospital thrombolysis

41 40

5548

96

0

25

50

75

100

1997

1998

1999

2000

2001

Results

050

100150200250300350400450500

Okt

97

Okt

99

Nov

00

Jan

01

Mrz

01

Mai

01

Jul 0

1

Sep

01

Nov

01

chest pain

STEMI

non STEMI ACS

ESTIM - ResultsCalls to SAMU - 1915 Primary Interventions

According to time interval pain - first call

0

10

20

30

40

50

60

Patient GP Cardio. SP Others

<2h

2-6h

6-12h

12-24h

No more than 90 sec to make a correct decision

• do nothing

• give medical advice

• send a standard ambulance

• send a competent team

decision algorithm

The Second Step: Role of the Emergency Dispatching Center

Receiving the Call

A True Medical Decision

• pain characteristics• personal and family history• cardiac history• age• risk factors• current treatment

in case of any doubt

send the most competent team

The good elements of decision=

clinic + risk factor assessment

IF…

• Physical signs

• Risk factors

• age

• etc…. M I C U

M.I.C.U.

Management of AMI in the Field

DIAGNOSTIC CRITERIA

TYPICAL (80%)

• Typical chest pain

• ECG: ST elevation > 1mm in 2 or more limb leads or >2 mm in 2 or more chest leads

• Nonrelief of pain and ECG alterations by sublingual nitrates

ATYPICAL (20%)

• Atypical pain

• ECG: ST depression, non Q-waves or quite normal, LBBB ...

=> unstable angina or AMI, pericarditis...

=> medical transportation

=> CPK, Echocardio, Angiography

Triage on Scene

Paramedics organization

• Clinical examination

• Characteristics of the chest pain

• Check for contraindications to thrombolytic therapy

ECG – 12 or 17 leads

- analysis of ECG - clinical examination - medical- clinical check list - analysis by the validation- no medical validation internal software

+/- + +++

Pre-hospital identification of patients with AMI by 12-lead ECG using cellular telephone transmission has decreased the time to treatment; its use should be encouraged. Development and strategies for transmitting the 12-lead ECG from the field to the ED should be encouraged.

Staffing and equipping emergency medical services systems.

Rapid identification and treatment of AMI

National heart attack alert program coordinating committee

Am J Emerg med 1995;13:58-86

The GPS help the EMD in assigning the closest available resource to a case

a 12-lead ECG is transmitted to the CICU for consultation

PHT is performed by GP on scene

Telemedicine and decision support in emergency ambulances in UPPSALAFrom R. Karlsten and BA Sjöquvist

Journal of telemedicine and telecare 2000;6: 1-7

Telemedicine and decision support in emergency ambulances in UPPSALAFrom R. Karlsten and BA Sjöquvist

Journal of telemedicine and telecare 2000;6: 1-7

What is Behind Medical Validation

• Transmission of the ECG by modem rather than by fax

• Sending in all data on the patient simultaneously (PDA)

• Storing ECG in a precious data bank

Who to receive ?

EASY !!

The doctor must be available 24 h / 24 h for analysis and validation on line

dispatching center

doctor ER

CICU

Transmission must not be an indirect factor prolonging the delay to reperfusion

Diagnosis

• Clinical

• Electrical

• Biochemical ?

Medicalized Pre Hospital System

more patients

more complicated patient

added value

may be 17 lead ECG

Probably not

A place for biomarkers ?

Time to Treatment

French experience

GI G3 A2 A3 A3+ CAPTIM STIM SAMU

ESTIM IdF ESTIM Nord

1990 1995 2000 2001 2002 2001 1997 2001 2002

3.03 2.50 3.03 3.03 2.35 2.10 2.10 1.59 1.60

0.0

0.2

0.4

0.6

0.8

1.0

0 20 120 140 160 18040 60 80 100

1997

1996

180-Day Survival Curves For 79 and 98 Emergency Ambulance Users with Acute MI

1 September – 30 November 1996 and 1 September – 30 November 1997, respectively, in Aachus, Denmark.

Christenszen EF, Acta Anaesthesiol Scand, 2003; 47: 146-152

Results

A3 UHF A3 Enox A3 + UHF

A3+ Enox

A3+ Fr UHH

A3+Fr Enox

Endpoint efficacy

15.3

11.3

17.1

14.2

12.15

7.14

Endpoint Efficacy + safety

16.8

13.6

20.2

18.2

15.97

10.04

Death D 30

5.9

5.3

5.8

7.2

5.2

4.29

In Hosp ICH

0.95

0.90

1.02

2.05

1.03

2.14

Wu AH et al. Clin Chem 1999;45:1104.

In days

AMI decision level

Superior limit

1

2

5

10

20

50

Diagnosis of Acute MI in Daily Practice

0 1 2 3 4 5 6 7

Troponin

CPK-MB

Myoglobin

Directing the patients

ER CICU Cath lab without cath lab

not easy

a place for risk stratification on scene

TIMI Risk Score for STEMITIMI Risk Score for STEMI

Age 65-74 75DM/HTN or angina

Weight < 67 kg

Time to rx > 4 hrsAnterior STE or LBBB

HR >100SBP < 100

Historical

Exam

Presentation

Killip II-IV

2 points3 points1 point

3 points

2 points1 point

1 point1 point

2 points

Risk Score = Total (0 -14)

012345678

>8

Risk Score Odds of death by 30D*

(FRONT) (BACK)

0.1 (0.1-0.2)

0.3 (0.2-0.3)

0.4 (0.3-0.5)

0.7 (0.6-0.9)

1.2 (1.0-1.5)

2.2 (1.9-2.6)

3.0 (2.5-3.6)

4.8 (3.8-6.1)

5.8 (4.2-7.8)

8.8 (6.3-12)

*referenced to average mortality(95% confidence intervals)

TIMI Risk Score for STEMI30-Day and 1-Year Mortalities

0.8 1.6 2.24.4

7.3

12.416.1

23.426.8

35.9

1 1 1.83 4.2

6.7 7.712.1

16.3 17.2

05

10152025303540

0 1 2 3 4 5 6 7 8 >8

TIMI score

Mo

rtal

ity

(%)

30 days 1 year

A «More» Simple Index For Initial Triageof Patients With STEMI

In Time II

• Not for higher risk patients :

• Heart rate < 50 beats / min

• Heart rate > 150 beats / min

• Calculate Risk Index :

Heart rate x [age/10]²

systolic blood pressure

D.Morrow. Lancet 2001;358:1571-75

A New TIMI Risk Score

D.Morrow. Lancet 2001;358:1571-75

0.2 0.4 12.4

6.9

0.61.5

3.1

6.5

15.8

0.81.9

3.3

7.3

17.4

0

5

10

15

20

≤12.5 >12.5-17.5 >17.5-22.5 >22.5-30 >30

Calculated Risk Index

Mo

rtal

ity

(%)

24 hours In-hospital 30 days

Calculated Risk Index

(Heart rate x [age/10]²) / systolic blood pressure

Key Issue: Regional Developmentof Cardiology Departments

The best chance for the patient, depends on:

• time

• location

• possibilities

The patient MUST arrive directly at the Cardiac Intensive Care Unit

Passing through the ER means losing time, losing myocardium

That’s again one of the SAMU functions:

Finding the best place for the patient:

SHORT TRACK

USIC 2000

671 patients

with reperfusion therapy

MICU MICU+ ER

Death 4 9.9 p = 0.007

Admission through the ER is an independent risk factor for short-term mortality.

OR = 1.67 p = 0.006

Pre-Hospital Selection - Is That All ?

NO

we have to move from the concept of pre-hospital thrombolytic therapy

to

pre-cardiologist treatment

but

according to evaluated protocols

59.4

29.6

0

10

20

30

40

50

60

70

80

90

100

ED onscene

ED in theER

yes no

WHY?

Decision

In-hospital thrombolysis

represents a failure

of pre-hospital thrombolysis

pre-CICU thrombolysis

Where Nowadays Is Our Common Responsibility

We have today evidence-based medicine favouring a structured

ACS network

_________

We cannot implement this network because of demographics and facilities

Never an improvisation

Following local and national guidelines

But

Who makes the guidelines ?

Good Orientation