Canadian Cardiovascular Society/Canadian …...Pre-hospital Interpretation of STEMI on ECG...

CCS Guideline/Position Statement Workshop as Presented at CCC 2018

Canadian Cardiovascular Society/Canadian Association of Interventional Cardiology

Guidelines on the Management of ST Elevation Myocardial Infarction: Focused Update on

Regionalization and Reperfusion

Warren J. Cantor, MD, FRCPC, FSCAISouthlake Regional Health Centre, Newmarket

Professor of Medicine, Univ. of Toronto


Committee Co-Chairs

Warren Cantor MD, FRCPC, FSCAIUniversity of Toronto

Southlake Regional Health Centre

Graham Wong MD, MPH, FRCPC, FACC, FCCS, FAHA

University of British ColumbiaVancouver General Hospital

“the greatest thingthat a Wong has ever done”


Presented in Oct 2018Published in Feb 2019Endorsed by the CAEP

21 PICO Questions, 34 Recommendations


CCS-CAIC STEMI Guideline Authors

Graham C. Wong MD MPH (Co-Chair), Michelle Welsford MD, Craig

Ainsworth MD, Wael Abuzeid MD MSc, Christopher B. Fordyce MDCM MHS

MSc, Jennifer Greene BSc ACP, Thao Huynh MD MSc PhD, Laurie Lambert

PhD, Michel Le May MD, Sohrab Lutchmedial MDCM, Shamir Mehta MD

MSc, Madhu Natarajan MD MSc, Colleen Norris RN, MN, PhD, Christopher

Overgaard MD MSc, Michele Perry Arnesen MHA, BSN, RN, Ata Quraishi

MBBS, Jean François Tanguay MD, Mouheiddin Traboulsi MD, Sean van

Diepen MD MSc, Robert Welsh MD, David Wood MD, Warren J Cantor MD

(Co-Chair)


The primary panel consisted of cardiologists, intensivists, emergency medicine physicians, nurses, health

care researchers and emergency health services personnel


Why do we need

Canadian STEMI Guidelines?


9.98 Million km2

2nd Largest Country in WorldPopulation: 35 Million25 million in large urban cities


Only 44 PCI Centres in Canada

5 provinces with only 1-2 PCI centres1 province & 3 territories with no PCI centre


Pre-Hospital STEMI Care Capability


Development and organization of Regional STEMI Centres (Hub and spoke) and

regional reperfusion strategies


• Evidence suggests that STEMI care is best performed using an

organized STEMI network with a primary PCI centre[s] (the ‘hub[s]’)

receiving referrals from surrounding hospitals (the ‘spokes’) and a

defined catchment area from the field via emergency medical

services (EMS).


ELEMENTS OF A REGIONAL STEMI NETWORK

A pre-planned default initial reperfusion strategy (PPCI or fibrinolysis) for each hospital within the

network based on geographic and transport considerations.

The ability to deliver appropriate adjunctive PCI following fibrinolysis.

The capability of EMS and emergency depts to rapidly diagnose and treat STEMI.

For PPCI, the ability for EMS and emergency depts to activate the STEMI team through a ‘single call’

mechanism immediately from the point of first medical contact

A “no-refusal” policy at PCI centres for STEMI patients appropriate for PPCI.

The ability for EMS teams to bypass non-PCI centres and transport patients directly to a PCI centre.

The ability for appropriately selected patients to bypass the emergency dept of a PCI centre and proceed

directly to the cardiac catheterization laboratory.


Patient identification and transportation


Ducas CJC 2016

Pre-Hospital ECG & Mortality


Models for Interpreting Prehospital ECG

Ting HH et al

Circulation 2008


Pre-hospital Interpretation of STEMI on ECG

• Advanced Care Paramedic Physician transmission• Feasible

• May incur additional costs, delays, and/or technical difficulties

• May reduce the number of false activations

LeMay CJEM 2006


Pre-hospital Interpretation of STEMI on ECG

• Advanced Care Paramedic Physician transmission• Feasible

• May incur additional costs, delays, and/or technical difficulties

• May reduce the number of false activations

LeMay CJEM 2006

“…..decisions related to how to best interpret the ECG and

who provides STEMI notification can be made at the

regional level.”


8.We recommend that EMS personnel acquire an ECG in the

field to identify STEMI and alert STEMI care teams of an

imminent patient arrival.

(Strong Recommendation, Low Quality Evidence)


Adjunctive STEMI prehospital therapiesOxygen

Opioids

P2Y12 inhibitors


Question: Adjunctive Prehospital Therapies

• Which of the following statements is true?a) All STEMI patients should receive adjunctive oxygen

b) All STEMI patients should receive morphine

c) All STEMI patients should receive P2Y12 inhibitors in the ambulance

d) All of the above

e) None of the above


Eur Heart J 2013; 34:1630-5

Management of the STEMI Patient in the Prehospital setting: Supplemental Oxygen Administration


Circulation 2015; 131:2143-50


N Engl J Med 2017; 377:1240-9


11.We suggest avoiding routine prehospital administration of

supplemental oxygen to STEMI patients with oxygen saturation

≥ 90%.

(Weak Recommendation, Low Quality Evidence)


Values and Preferences:

This recommendation is based on the concern of potential harm from

hyperoxemia. Furthermore, supplemental oxygen may cause anxiety

or impair communication and does not appear to have any benefit in

the absence of hypoxia.

Practical Tips:

If SaO2 monitoring is not available or not reliable (poor waveform),

prehospital providers may provide oxygen supplementation during

initial care to those patients exhibiting signs of respiratory distress.


Am Heart J 2005; 149:1043-9

NSTEMI population


Eur Heart J 2016;37:245-52


12.We suggest avoidance of routine intravenous opioid analgesic

(e.g., morphine or fentanyl) administration for STEMI-related

discomfort. However, selective use of opioid analgesic medications

may be considered for severe pain with the goal of relieving pain

and reducing anxiety.



N Engl J Med 2014;371:1016-27


13.We suggest that prehospital (in-ambulance) P2Y12 receptor

antagonist medications not routinely be added to ASA in patients

with STEMI transported for PPCI. The P2Y12 receptor antagonist

should be administered in the emergency department or cardiac

catheterization laboratory as early as possible prior to coronary

angiography.



Values and Preferences:

Administration of any medication to a critically ill patient may add

complexity in the prehospital environment. Based on the currently

available evidence, the writing group concluded that routine

prehospital administration of a P2Y12 receptor antagonist could not

be recommended for transport times less than 60 minutes.

Practical Tip:

Prehospital administration of P2Y12 receptor antagonist medications

may be considered in systems or subsets of patients that have

prolonged transport times (those greater than 60 minutes) for PPCI.

Similarly, administration may be considered for those systems that

administer prehospital fibrinolysis.


Choice of Reperfusion Strategy


Relationship between PCI-related delay and in hospital mortality in STEMI

Pinto, Circulation 2011


Mortality in patients randomized to primary PCI when compared with fibrinolysis according to PCI-related delay

• Pooled analysis of 25 RCTs

• Adjusted for patient, hospital and study-level covariates

Boersma, EHJ 2006


9. If primary PCI is used as a default reperfusion strategy for

suspected STEMI patients in the field, we recommend that

patients should bypass non-PCI capable centres and instead be

transported to the nearest PPCI centre with the goal of achieving

a maximum FMC-to-device time of ≤ 120 minutes (ideal FMC-to-

device time ≤ 90 minutes in urban settings). Fibrinolytic therapy

should be considered if this timeline cannot be achieved.

(Strong Recommendation, Low Quality Evidence)

Pre-Hospital- PPCI vs. Fibrinolysis


FMC-to-Device Goals in STEMI Guidelines

CCS-CAIC ACC-AHA ESC

Pre-Hospital ≤ 120 minutes* ≤ 90 minutes ≤ 120 minutes*

Non-PCI Hospital ≤ 120 minutes ≤ 120 minutes ≤ 120 minutes

PCI Hospital ≤ 90 minutes ≤ 90 minutes ≤ 90 minutes

* Aim for ≤ 90 minutes but allow for ≤ 120 minutes when deciding PPCI vs. Fibrinolysis


METRIC GOAL (Regional goal: >75% of cases to achieve each metric)

First Medical Contact (FMC) to Diagnosis (ECG acquisition

& interpretation)<10 Minutes

Diagnosis to Catheterization Lab Activation<10 Minutes

Door-in to Door-out Time for Emergency Departments <30 Minutes

Transport Times for Inter-Hospital Transfers or STEMI

patients diagnosed in the field

<60 Minutes

Time from arrival at catheterization lab to first balloon

activation

<30 Minutes

Total time from FMC to first device activation (for primary

PCI)- for non-PCI centres or patients diagnosed in the field

<120 Minutes

Total time from FMC to first device activation (for primary

PCI) - for patients presenting to PCI centres

<90 Minutes

REPERFUSION TREATMENT GOALS


Summary of Reperfusion Strategies


Pharmacoinvasive PCI


Pharmacoinvasive Strategy: Definition

A reperfusion strategy utilizing adjunctive PCI following initial pharmacological reperfusion with fibrinolysis.

Consists of:

1. Routine immediate transfer to PCI centres after fibrinolysis

2. Immediate PCI for patients with failed fibrinolysis

3. Routine angiography +/- PCI within 24 hours after successful fibrinolysis


Randomized Trials of the Pharmacoinvasive Strategy

Pharmacoinvasive Strategy versus Fibrinolysis and Standard of Care

GRACIA-1, CAPITAL-AMI,

SIAM-III, WEST,

TRANSFER-AMI, CARESS-

IN-AMI, NORDISTEMI

Pharmacoinvasive Strategy was associated with reduced

ischemic complications compared to fibrinolysis standard of care.

Reduced death/re-MI at 30 days with an HR of 0.65 (95% CI 0.50

to 0.86, p=0.0024).

Pharmacoinvasive Strategy versus Primary PCI

WEST, GRACIA-2, STREAM,

STEPP-AMI, EARLY-MYO

Pharmacoinvasive Strategy provided similar clinical outcomes to

Primary PCI.


Routine Early PCI after LysisMeta-Analysis of Contemporary Trials

Piscione F et al, Eur Heart J 2010

OR 0.71 (95% C.I. 0.52-0.97)


Meta-Analysis Contemporary Trials

Piscione F et al, Eur Heart J 2010


19.We recommend routine immediate transfer to PCI centres after

fibrinolysis, immediate PCI for patients with failed reperfusion,

and routine angiography +/- PCI within 24 hours after successful

fibrinolysis.

(Strong recommendation, Moderate Quality Evidence)


STREAM Trial- Primary Endpoint

TNK 12.4%

PPCI 14.3%

p=0.24

De

ath

/Sh

ock

/CH

F/R

e-M

I (%

)

The 95% CI of the observed incidence in the pharmaco-invasive arm would exclude a 9%

relative excess compared with PPCI

TNK vs PPCI

Relative Risk 0.86, 95%CI (0.68-1.09)

Armstrong PW et al, N Engl J Med 2013


Pharmacoinvasive Strategy as an Alternative to PPCI

17.We suggest that timely fibrinolysis (prehospital or in a hospital

without PCI capability) followed by a pharmacoinvasive strategy could

be considered as an alternative to primary PCI for patients who are

early presenters (symptom onset <3 hours), who are at low risk of

bleeding and who cannot undergo rapid primary PCI.

(Weak recommendation, Moderate quality evidence)


Practical aspects of PCI


Practical Aspects of Primary PCI


CONCLUSIONS:

• systematic appraisal of sex and gender considerations into guidelinedevelopment was feasible

• Barriers include:

• inadequate enrollment of women in randomized trials

• lack of publication of main outcomes stratified by sex

• lack of inclusion of gender as a study variable

CCS Pilot Project- Proof of Concept

Incorporating Sex and Gender into Guidelines

Norris C- JAHA 2019. In Press

Canadian Cardiovascular Society/Canadian …...Pre-hospital Interpretation of STEMI on ECG...

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