1. Door 2 door MANAGEMENT OF STEMI

2. Disclosure Amgen FOURNIER Clinical Trial-Lipitor
Janssen MARINER Clinical Trial- Xarelto

3. In the event of a heart attack, time immediately starts working against you. For those unlucky enough to endure a ST elevation myocardial infarction (STEMI), wherein the complete closure of a major coronary artery occurs, this diminishing window of one’s survival is particularly short. The deadliest form of heart attack, STEMI requires immediate reperfusion therapy, either through primary percutaneous coronary intervention (PCI) or the use of thrombolytic drugs. Performing PCI within 90 minutes of medical contact is regarded as the optimal threshold for successfully saving someone’s life. How were these conclusions made?

4. The ACC and AHA task force have jointly produced guidelines in the area of CVD since The task force evaluates evidence related to drugs, devices and procedures for the management of disease, thus improving quality of care, patient outcomes and costs. The current 2013 guidelines are available online..they are 90 printed pages, 53 of those pages are references used to put the recommendations together.

5. Acute Myocardial Infarction remains a leading cause of morbidity and mortality world wide.
450,000 die in the U. S. yearly
95% survival rate in the U. S. for hospitalized patients.
This is related to the EMS response times and in field treatment.
Advanced treatment strategies like the D2B initiative.

6. Myocardial Infarction Categories
Trans mural
Ischemic necrosis of the full thickness of the heart muscle distal to the obstruction.
Endocardium
Myocardium
Epicardium

7. Myocardial Infarction Categories
Non Trans mural
Ischemia usually limited to the endocardium

8. Universal Definition of Myocardial Infarction
Type 1- spontaneous MI related to ischemia from a primary plaque rupture.
Type 2- ischemia from supply/demand mismatch.
Ao stenosis Anemia
Vasospasm Low Cardiac Output States
Type 3- MI resulting in sudden cardiac death
Type 4a- MI associated with PCI
Type 4b- MI associated with stent thrombosis
Type 5 – MI associated with CABG

9. EKG Classification of MI
STEMI
NSTEMI
Although 12 lead EKG interpretation is not within the scope of this presentation, I will review them shortly.

10. TIME
In the event of a STEMI, time immediately starts working against you.

11. STEMI PCI Immediate reperfusion Thrombolytic therapy
30% of the patients in the U.S. with STEMI never receive treatment!

12. 90 minutes
40%
Performing PCI therapy within 90 min, of medical contact is the optimum threshold in an effort to save myocardium and life. 40% of patients who do get to a lab to undergo pci get there in the recommended 90 min time frame.

13. “You can not know where you are going, until you know where you have been.” Unknown

15. Antonio Egas Moniz
Portuguese physician who developed the technique of angiography
1927 –first cerebral angiogram
Won the Nobel Prize for physiology and medicine

16. Werner Forssman
German physician inserted a rubber catheter into his own antecubital vein, walked to the xray machine and guided it into his right heart.
1929 – first heart catheterization
Nobel Prize for physiology and medicine.

17. Mason Sones
The most important contributor to modern invasive cardiology.

18. Coronary angiography is born!
1958 in the angiography lab at CCF
Dr. Sones unintentionally engaged the RCA while doing an aortic angiogram. The RCA was injected before the cath could be pulled back……
Sones Smoking story

19. Vae Lucile Van Derwyst RN present during the first coronary angiogram.
World’s first cath lab nurse.
She was in charge of a 40 nurse staff that traveled the world to speak and teach.

20. Rene Favaloro 1923-2000 Pioneer in Cardiothoracic Surgery
1967- first CABG at CCF
Saphenous Vein Graft

21. Heart Catheterization Lab
Before the 1970’s coronary angiography was diagnostic
1977 balloon angioplasty
1986 angioplasty with stents
Treatment of MI
D2B is born
Starting in the late 1970’s left heart cath was extended to therapeutic use

22. In analysing the data, the task force uses class of recommendations (COR) and level of evidence(LOE). The COR is an estimate of the size of the treatment effect considering risks vs benefits in addition to evidence that a given treatment or procedure is or is not useful/ effective or may cause harm. Listed as class 1 ,2 or 3 The LOE is an estimate of the certainty of the treatment effect. This is listed as A, B , C.

23. Door to Balloon Initiative
Time is muscle. D2B is a Class 1b

24. Launched November 2006
ACC/AHA guidelines recommend a D2B of 90 min. (JCAHO core quality measurement)
Time starts when an EKG showing STEMI is obtained and analyzed.
Time ends when the catheter crosses the lesion and the balloon is inflated.

25. Evidence Based Strategies to Reduce D2B Times
ED or Prehospital EKG is obtained within 10 minutes of patient encounter (1B)
ED Physician activates the Cath Lab
Single-call activation system activates the cath lab team.
Cath lab team arrives within min.
Prompt data feedback
Senior Management commitment
Team Approach/Community Leaders
The d2b alliance advocates key evidence based strategies to reduce d2b times.

26. Team Effort
All communities should create and maintain a regional system of STEMI care. (1B)
Door to EKG time
EKG to Lab time
Lab to Device time
Constant review and evaluation of the components to reduce time to treatment.

27. EMS >98% of the US population is covered by 9-1-1 service
2011 ACTION Registry
60% of 37K STEMI patients used EMS
Older surveys
EMS activation 23-53% with substantial geographic variability
1 in 300 pts transported to ED by private vehicle suffer cardiac arrest en route.

28. EKG
Remember this..beyond the scope of this presentation…..however

29. EKG
Good
Bad

30. EKG
good
bad

31. EKG

32. STEMI Location

33. One More

34. Primary PCI in STEMI. Primary PCI in STEMI
WRITING COMMITTEE MEMBERS* et al. Circulation. 2013;127:e362-e425
Copyright © American Heart Association, Inc. All rights reserved.

35. PCI vs Fibrinolytic Therapy
Higher rates of infarct artery patency
Lower rates of
Recurrent ischemia
Re-infarction
Emergency repeat revascularization procedures
Intracranial hemorrhage
death
PCI is preferred to fibrinolytic therapy when time to treatment delays are short and a PCI center is available.

36. ED to CATH LAB
The level of evidence is clear that the sooner we get to the lab the better, sometimes the ED is bypassed if there is a Pre hospital EKG that activates the STEMI system. Part of stopping the myocardial damage after coronary artery occlusion as an adjunct to angioplasty are medications used to interrupt the platelet clotting cascade.

37. Platelet Clotting Cascade
Aspirin, UFH, Direct thrombin inhibitors like Angiomax and P2Y12 receptor inhibitors like Plavix, Effient and Brillinta all act on the platelet cascade. This is important because the thrombus seen at plaque rupture is initially primarily a platelet mediated process. The activation of the coagulation cascade occurs later in the process.

38. BMS or DES
Coronary stents are used at the time of angioplasty, compared to just balloon angioplasty, BMS decreases the risk of re-occlusion and re-infarction but does not decrease mortality. DES decreases restenosis rates and the need for re-intervention but does not definitively reduce rates of death or re-infraction. The most important challenge is deciding in an emergency situation whether the patient is a candidate for dual antiplatelet therapy for one year.

39. Class 1 Stent Recommendations
Placement of a DES or BMS in STEMI (1A)
BMS (1C)
High bleeding risk
Inability to comply with 1 year of dual antiplatelet therapy (DAPT)
Anticipated surgery within one year

40. Stent Class 3:Harm
DES should not be used if the patient can not comply with one year of dual antiplatelet therapy because of increased risk of stent thrombosis. (3B)

41. Stent Delivery

43. Antiplatelet Therapy
Aspirin 162 to 325mg should be given before PCI (1B)
After PCI should be continued indefinitely (1A)
81mg maintenance does is preferred after PCI (2aB)
Although the minimum effective asa dose in the setting of PCI for STEMI has not been established, prospectively the task force recommends 325mg be given as early as possible before PCI and a maint dose continued indefinitely afterward. It is the consensus of the task force that the 81mg maintenance dose is preferred. This recommendation is based on evidence of an increased risk of bleeding in most studies comparing higher with lower dose asa as well as the absence of data from RCT’s demonstrating superior efficacy of higher asa doses in this setting.

44. P2Y12 Receptor Inhibitors
A loading dose should be given as early as possible or at the time of PCI to patients with STEMI (1B)
DAPT should be given for one year for patients with STEMI who receive DES or BMS (1B)
Effient (Prasugrel) should not be given to patients with a history of prior stroke or TIA (3B)

45. P2Y12 Receptor Inhibitors
Here are our players Plavix (Clopidogrel), the first and the one that subsequent antiplatelet meds were compared to. Effient (Prasugrel) and Brilinta (Ticagrelor)

46. For those who need a visual on where in the platelet these drugs work.

47. Reversible means that the drug binds with the platelet receptor site and stays there until the platelet leaves the circulation which is about 7-10 days

48. Problems with Plavix

49. Depending on how an individual metabolizes plavix you could be normal or a hyperesponder leading to bleeding or a hyporesponder leading to stent thrombosis. This then lead to the development of the other antiplatelet meds. There is a lab test to determine if you are genetically resistant cyp2c19 metabolizer of plavix.. $ About 25-30% may harbor a reduced function cyp2c19 allele. There have been further studies that have not confirmed the association of cyp2c19 metabolism deficiencies to adverse outcomes in plavix treated patients. The ACC has rec. future studies to clarify the risk.

50. PPI and Plavix
Interferes with Plavix metabolism diminishing the antiplatelet effect.
At this time it does not appear this effect has lead to worse clinical outcomes
Most prominently omeprazole

52. Take Home
DO NOT STOP antiplatelet medication unless cleared by patient’s interventional cardiologist.
Monitor your patient’s compliance with DAPT

53. Medical Management
Prescribed courses of treatment are effective only if followed. Lack of understanding, lack of adherence adversely affect outcomes. Healthcare providers have to make every effort to encourage patient participation in medical regimes and life style changes.

54. Beta Blockers B B I IIa IIb III
Oral beta blockers should be initiated in the first 24 hours in patients with STEMI who do not have any of the following: signs of HF, evidence of a low output state, increased risk for cardiogenic shock,* or other contraindications to use of oral beta blockers (PR interval >0.24 seconds, second- or third-degree heart block, active asthma, or reactive airways disease). I
IIa
IIb
III B
Beta blockers should be continued during and after hospitalization for all patients with STEMI and with no contraindications to their use.
*Risk factors for cardiogenic shock (the greater the number of risk factors present, the higher the risk of developing cardiogenic shock) are age >70 years, systolic BP <120 mm Hg, sinus tachycardia >110 bpm or heart rate <60 bpm, and increased time since onset of symptoms of STEMI.

55. Beta Blockers B I IIa IIb III
Patients with initial contraindications to the use of beta blockers in the first 24 hours after STEMI should be reevaluated to determine their subsequent eligibility. I
IIa
IIb
III B
It is reasonable to administer intravenous beta blockers at the time of presentation to patients with STEMI and no contraindications to their use who are hypertensive or have ongoing ischemia.

56. Renin-Angiotensin-Aldosterone System Inhibitors
IIa
IIb
III A
An ACE inhibitor should be administered within the first 24 hours to all patients with STEMI with anterior location, HF, or EF less than or equal to 0.40, unless contraindicated. I
IIa
IIb
III B
An ARB should be given to patients with STEMI who have indications for but are intolerant of ACE inhibitors.

57. Renin-Angiotensin-Aldosterone System Inhibitors
IIa
IIb
III B
An aldosterone antagonist should be given to patients with STEMI and no contraindications who are already receiving an ACE inhibitor and beta blocker and who have an EF less than or equal to 0.40 and either symptomatic HF or diabetes mellitus. I
IIa
IIb
III A
ACE inhibitors are reasonable for all patients with STEMI and no contraindications to their use.

58. 9.6% increase in caloric and fat intake among statin users evaluated between and This did not hold true for non-users.

59. Lipid Management B I IIa IIb III
High-intensity statin therapy should be initiated or continued in all patients with STEMI and no contraindications to its use. I
IIa
IIb
III
It is reasonable to obtain a fasting lipid profile in patients with STEMI, preferably within 24 hours of presentation.
Among currently available statins, only high dose atorvastatin, 80mg qd, has been shown to reduce death and ischemic events among patients with ACS

60. Risk Assessment Delays to treatment Shorter treatment time Women
African Americans
Elderly
Medicaid-only
Medicare, when compared to privately insured patients
Patients taken directly to the hospital by EMS
Most do not seek care for hours after the onset of symptoms. Despite education this interval has not changed in over the past 10 years.

61. Risk Management
This is the hard part, education of patients with STEMI and their families is critical and challenging, especially when transitions of care occur. Failure to understand and comply with a plan of care may account for the high rate of STEMI rehospitalization.

62. Post Hospitalization Plan of Care
IIa
IIb
III
A clear, detailed, and evidence-based plan of care that promotes medication adherence, timely follow-up with the healthcare team, appropriate dietary and physical activities, and compliance with interventions for secondary prevention should be provided to patients with STEMI. I
IIa
IIb
III A
Encouragement and advice to stop smoking and to avoid secondhand smoke should be provided to patients with STEMI.

63. Post Hospitalization Plan of Care
IIa
IIb
III B
Post hospital systems of care designed to prevent hospital readmissions should be used to facilitate the transition to effective, coordinated outpatient care for all patients with STEMI. I
IIa
IIb
III B
Exercise-based cardiac rehabilitation/secondary prevention programs are recommended for patients with STEMI.

64. Risk Management New Hypertensive Guidelines
>60 yrs., treat to goal <150/90
<60 yrs., treat to goal <140/80
Diabetes or CKD, treat to goal <140/80 (23% STEMI have DM, 75% of DM deaths are from CAD)
Report from Panel Members Appointed to Eighth Joint National Committee (JNC8)