1. EXPERTS WORKSHOP ON EARLY TREATMENT STRATEGIES FOR ACUTE MYOCARDIAL INFARCTION FOR THE MIDDLE EAST COUNTRIES
FEBRUARY 26TH -28TH 2005 / DUBAI, UAE
SPONSORED BY BOEHRINGER INGELHEIM
SUNDAY, 27th FEBRUARY – SESSION 2
Acute myocardial infarction and pre-hospital selection Who ? When ? Where ?
Patrick Goldstein

2. We want to save minutes to taking important decisions
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

3. There is not a single triage point but a
succession of different points of triage
to achieve a successful reperfusion
strategy

4. The initial selection:
the patient
the family
the environment
70% of patients are primary AMI
In case of chest pain call immediately

5. The French Strategy Acute chest pain is an emergency CALL 18 GP
Cardiologist 15
Analysis
Ambulance +/- MD
Medical assessment
Admission

6. Flyers Distributed by GP
AV 2002

7. Results Prehospital thrombolysis 41 40 55 48 96 1997 1998 1999 2000
500
450
400
350
300
chest pain
250
STEMI
200
non STEMI ACS
150
100 50
Okt 97
Okt 99
Nov 00
Jan 01
Mrz 01
Mai 01
Jul 01
Sep 01
Nov 01
Prehospital thrombolysis 41 40 55 48 96 25 50 75
100
1997
1998
1999
2000
2001

8. ESTIM - Results Calls to SAMU - 1915 Primary Interventions
According to time interval pain - first call 60 50 40
<2h
2-6h 30
6-12h
12-24h 20 10
Patient GP
Cardio. SP
Others

9. The Second Step: Role of the Emergency Dispatching Center
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

10. A True Medical Decision
Receiving the Call
A True Medical Decision

11. The good elements of decision = clinic + risk factor assessment
pain characteristics
personal and family history
cardiac history
age
risk factors
current treatment
in case of any doubt
send the most competent team

12. IF…
Physical signs
Risk factors
age
etc…. M I C U

13. M.I.C.U.

14. 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

15. 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 +/

16. 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
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.

18. Telemedicine and decision support in emergency ambulances in UPPSALA
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 UPPSALA
From R. Karlsten and BA Sjöquvist Journal of telemedicine and telecare 2000;6: 1-7

19. 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 ?

20. 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

21. Diagnosis
Clinical
Electrical
Biochemical ?

22. Medicalized Pre Hospital System
more patients
more complicated patient
added value
may be 17 lead ECG
Probably not
A place for biomarkers ?

23. Time to Treatment French experience GI G3 A2 A3 A3+ CAPTIM STIM
ESTIM IdF
ESTIM
SAMU
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
French experience

24. 180-Day Survival Curves For 79 and 98 Emergency Ambulance Users with Acute MI
1.0
0.8
0.6
0.4
1997
1996
0.2
0.0 20 40 60 80
100
120
140
160
180
1 September – 30 November 1996 and 1 September – 30 November 1997, respectively, in Aachus, Denmark.
Christenszen EF, Acta Anaesthesiol Scand, 2003; 47:

25. Results A3 UHF A3 Enox A3 + UHF A3+ Enox A3+ Fr UHH A3+Fr Endpoint
efficacy
15.3
11.3
17.1
14.2
12.15
7.14
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

27. Diagnosis of Acute MI in Daily Practice
Troponin 50
CPK-MB 20
Myoglobin 10 5 2
AMI decision level
La cinétique enzymatique est résumée sur cette figure en sachant que seule la troponine (I ou T) est spécifique de la nécrose myocardique. Dans un délai de 4 à 6 heures après le début des symptômes, les dosages enzymatiques seront le plus souvent dans les limites de la normale. La répétition des dosages à 2 ou 4 heures d’intervalle est indispensable avant de confirmer la normalité des valeurs. L’intérêt supplémentaire de la troponine, par sa présence retardée dans le sérum, est qu’elle permettra de faire un diagnostic rétrospectif à distance de l’épisode initial. L’élévation de la troponine peut également être observée au cours de l’insuffisance rénale chronique et de l’embolie pulmonaire aiguë. 1
Superior limit 1 2 3 4 5 6 7
In days
Wu AH et al. Clin Chem 1999;45:1104.

28. Directing the patients
ER CICU Cath lab without cath lab
not easy
a place for risk stratification on scene

29. TIMI Risk Score for STEMI
Odds of death by 30D* 1 2 3 4 5 6 7 8
>8
( )
( )
( )
( )
( )
( )
( )
( )
( )
(6.3-12)
Historical
Age 65-74
 75
2 points
3 points
DM/HTN or angina
1 point
Exam
SBP < 100
3 points
HR >100
2 points
Killip II-IV
2 points
Weight < 67 kg
1 point
Presentation
Anterior STE or LBBB
1 point
Time to rx > 4 hrs
1 point
Risk Score = Total (0 -14)
*referenced to average mortality
(95% confidence intervals)
(FRONT)
(BACK)

30. TIMI Risk Score for STEMI 30-Day and 1-Year Mortalities
30 days
1 year 40
35.9 35 30
26.8 25
23.4
Mortality (%) 20
17.2
16.1
16.3 15
12.4
12.1 10
7.3
6.7
7.7
4.4
4.2 5
2.2 3
0.8 1
1.6 1
1.8 1 2 3 4 5 6 7 8
>8
TIMI score

31. A «More» Simple Index For Initial Triage of 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:

32. (Heart rate x [age/10]²) / systolic blood pressure
A New TIMI Risk Score
24 hours
In-hospital
30 days
Calculated Risk Index
(Heart rate x [age/10]²) / systolic blood pressure 20
17.4
15.8 15
Mortality (%) 10
7.3
6.5
6.9 5
3.1
3.3
2.4
1.5
1.9
0.6
0.8 1
0.2
0.4
≤12.5
>
>
>
>30
Calculated Risk Index
D.Morrow. Lancet 2001;358:

33. Key Issue: Regional Development of Cardiology Departments
The best chance for the patient, depends on:
time
location
possibilities

34. 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

35. with reperfusion therapy
USIC 2000
671 patients
with reperfusion therapy
MICU MICU
+ ER
Death p = 0.007
Admission through the ER is an independent risk factor for short-term mortality.
OR = p = 0.006

36. 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

37. WHY? Decision yes no 100 90 80 70 60 50 40 30 59.4 20 29.6 10 ED on
ED on
ED in the
scene ER
yes no

38. In-hospital thrombolysis represents a failure
of pre-hospital thrombolysis
pre-CICU thrombolysis

39. 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

40. Good Orientation Never an improvisation
Following local and national guidelines
But
Who makes the guidelines ?