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SUNDAY, 27 th FEBRUARY – SESSION 2 Acute myocardial infarction and pre-hospital selection Who ? When ? Where ? Patrick Goldstein EXPERTS WORKSHOP ON EARLY.

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Presentation on theme: "SUNDAY, 27 th FEBRUARY – SESSION 2 Acute myocardial infarction and pre-hospital selection Who ? When ? Where ? Patrick Goldstein EXPERTS WORKSHOP ON EARLY."— Presentation transcript:

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

2 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 15 Acute chest pain is an emergency CALL Cardiologist GP 18 Analysis Ambulance +/- MD Medical assessment Admission The French Strategy

6 AV 2002 Flyers Distributed by GP

7 Prehospital thrombolysis Results Okt 97 Okt 99 Nov 00 Jan 01 Mrz 01 Mai 01 Jul 01 Sep 01 Nov 01 chest pain STEMI non STEMI ACS

8 ESTIM - Results Calls to SAMU Primary Interventions According to time interval pain - first call PatientGPCardio.SPOthers <2h 2-6h 6-12h 12-24h

9 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

10 Receiving the Call A True Medical Decision

11 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

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 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

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18 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 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 SAMU ESTIM IdF ESTIM Nord

24 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:

25 Results

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27 Wu AH et al. Clin Chem 1999;45:1104. In days AMI decision level Superior limit Diagnosis of Acute MI in Daily Practice Troponin CPK-MB Myoglobin

28 Directing the patients ERCICUCath lab without cath lab not easy a place for risk stratification on scene

29 TIMI Risk Score for STEMI Age DM/HTN or angina Weight < 67 kg Time to rx > 4 hrs Anterior STE or LBBB HR >100 SBP < 100 Historical Exam Presentation Killip II-IV 2 points 3 points 1 point 3 points 2 points 1 point 2 points Risk Score = Total (0 -14) >8 Risk ScoreOdds of death by 30D* (FRONT)(BACK) 0.1 ( ) 0.3 ( ) 0.4 ( ) 0.7 ( ) 1.2 ( ) 2.2 ( ) 3.0 ( ) 4.8 ( ) 5.8 ( ) 8.8 (6.3-12) *referenced to average mortality (95% confidence intervals)

30 TIMI Risk Score for STEMI 30-Day and 1-Year Mortalities >8 TIMI score Mortality (%) 30 days1 year

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 A New TIMI Risk Score D.Morrow. Lancet 2001;358: > > > >30 Calculated Risk Index Mortality (%) 24 hoursIn-hospital30 days Calculated Risk Index (Heart rate x [age/10]²) / systolic blood pressure

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 Thats again one of the SAMU functions: Finding the best place for the patient: SHORT TRACK

35 USIC patients with reperfusion therapyMICU + ER Death49.9p = Admission through the ER is an independent risk factor for short-term mortality. OR = 1.67 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 ED on scene ED in the ER yesno WHY? Decision

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


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