2013 AHA STEMI Guideline Review

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Natalie M. -

You mentioned considering giving thrombolytics in pts with STEMI w/ ROSC in rural area who cannot get to cath lab in 120 minutes..
but what about after prolonged CPR? Obviously a moderate risk..should it possibly be on case-by-case basis?

Natalie M. -

that is, post arrest patients w ROSC after STEMi

Amal M. -

Tough question. Yes, case by case basis, and not specifically addressed in the guidelines. It's tough to define what "prolonged" CPR is, though that's always listed as a relative (not absolute) contraindication. Very much a judgment call, and this would truly be a time to discuss with family (informed consent) and/or cardiology or intensivist on-call if available. I don't know what the mortality of a post-arrest patient with ROSC after prolonged CPR + STEMI is WITH vs. WITHOUT lytics, so I don't know NNT vs. NNH. I don't think it's been defined. Group decision.

BIg T -

4 days ago a pt arrived with sharp chest pain, jaw pain, left arm pain for 16 + hours (no diaphoresis and very comfortable in the stretcher). initial ekg was sinus brady (47bpm) with boderline elevations in III and aVF (was just under 1mm). No reciprical changes. One flipped T in lead III. Repeat EKG after 0.5mg Atropine (HR= 70's) showed not even boderline elevation of III and aVF with still flipped T's and one Q wave in lead III. Pt became pain free with ASA, plavix, lovenox, and morphine (held nitro due to no right side ekg and didn't want to bottom the BP- and gave plavix due to NSTEMI (TPN=5) not expecting pt to go to Cath due to current guidlines.
Cardiology decided to call a stat cath for the pt. ???? Do they need to be updated to these new 2013 guidelines. Pt ultimately needed a cath- but emergently after 16 hours and pain free. I don't get it.

Benjamin M. S., M.D. -

The guidelines say either heparin or LMWH for patients getting lytics, but only heparin for patients going to cath. Wouldn't the possibility of needing to go for rescue cath in lytics treated patients suggest simplifying to heparin for all?

Sean G., M.D. -

Amal why do u assume one "continues to infarct" the entire time one is awaiting cath, and you'd clearly opt for systemic lytics if your AMI is dx in the first 5 minutes? Docs treated ACS pretty well with 02, heparin asa and rest for decades before lytics. Seems the point of the article was to individualize the decision process and not to cook book things. I think if my pain resolved completely with asa, heparin 02 and nitro I might chose to wait for cath rather then get a systemic lytic that may cause me to hemorrhage in my brain.

Amal M. -

Big T,
Your case actually brings up a few issues.
1. EKG indications for reperfusion: Technically, with STE < 1 full mm, the EKG itself doesn't meet the guidelines for acute reperfusion. However, you bring up a great discussion point regarding the magnitude of STE--when you see < 1 full mm of STE but nevertheless the morphology of the STE is concerning and the patient has concerning Sx's you still need to worry. Some might activate the cath lab or give lytics for this, and others might simply call cardiology and let them weigh in. I've seen many cases (and I'm sure others have also) where cardiology does the PCI on a patient with < 1 mm STE but based on the morphology of STE (e.g. straightening of the initial part of the T wave + very tall Ts) + concerning symptoms. The 1 mm "cutoff" is a bit arbitrary.
2. Spontaneous reperfusion: What do you do if you see a STEMI on the first EKG but then the STE and symptoms spontaneously resolve, or resolve with the usual anti-anginal Tx's such as O2, NTG, etc. In that scenario, I think most cardiologists would want to still do the cath...although that's not well-addressed in the literature or guidelines. In that scenario, I think the best thing to do is to call the cardiologist and give them the choice. I don't think lytics would be mandated if Sx's and STE resolved though....but would still discuss with cardiologist.
3. Duration of Sx's: The 12 hour "cut-off" that is used in the guidelines is a bit arbitrary. In your scenario, if I see STE + concerning symptoms, it means to me that there is still viable myocardium that is actively ischemic and dying (totally dead tissue shouldn't produce persistent STE and symptoms), and so I'd still try to use aggressive reperfusion therapy. I'd call cards, tell them the timeframe, and push for cath or even get them on-board potentially with lytics if there's no way cath is an option. The latter point might be a bit controversial, and that's why I'd get cards on-board. The argument could also be made that although the Sx's have been present for 16 hours, maybe the patient was simply intermittently ischemic for the first 15 hours but only began to infarct 1 hour ago.

This is all poorly addressed in the literature and in the guidelines, so there might not be a clearly right or wrong answer. Nothing I say above should be interpreted as dogmatic or standard of care. I would summarize by saying, however, that persistent STE in the presence of ongoing symptoms should be interpreted as ongoing ischemia and infarction, and that means there's still an opportunity to salvage viable myocardium....regardless of how long the symptoms have been present. I always recommend discussing with cardiology in these equivocal cases because they are the ones who will be the critics if something goes wrong.

Amal M. -

I agree with what you are saying.
LMWH still has support from many because it produces much less heparin-induced thrombocytopenia, and probably because it's still benefiting from strong marketing efforts.

If the lytics don't work and the patient needs rescue PCI, heparin would have been better.
Also, to add on to what you state, even if the lytics do work, often patient will get a non-emergent cath later during the hospitalization to define the anatomy, and it seems like UFH would be preferred in that scenario also.

But in the end, I think that when you factor in bleeding risk, cost, potential for HIT, etc. it's probably not actually a huge difference between UFH vs. LMWH regardless of how you treat the patient.

Amal M. -

If the patient has ongoing pain with the STEMI, the reasonable assumption is that the infarction is continuing, perhaps even at risk for progression. If you change the scenario by stating that the pain is resolved, then lytics are really no longer indicated, and the whole "time is muscle" contention is less of an issue. I'd still contact cardiol and see if the cardiol wants to take the patient emergently for cath. Some will, and some won't rush to cath a patient that has symptoms resolved. As noted above, the guidelines and most literature really doesn't address the patient with STEMI whose symptoms have resolved.

Regarding your other point, I don't really agree that treatment with ASA, O2, heparin, NTG and rest in previous decades was all that great. In fact, of those things ASA is the only one that was shown to decrease mortality. Emergent reperfusion with lytics or cath represents a huge advance over decades-past.

In contrast to what you've stated, I actually think that the Guidelines have dumbed things down by trying to promote a 1-size fits all approach. I believe EM as a specialty has come far enough that we should feel compelled to promote a tailored approach to the patient's presentation, based on age, location of infarct, and duration of symptoms. As an example, take a look at the following writeup, which provides a bit more elaboration on what I stated in the podcast: http://www.medscape.com/viewarticle/778279

Though not perfect, it's an example of how we should be tailoring our treatments rather than using a fixed 90 or 120 minute cutoff for everyone.

Matt B. -

I have a question about UFH dosing. According to the AHA/ACC guidelines if you are giving fibrinolytics then you give 60 U/Kg (max 4000 units) followed by a drip of 12 U/kg/hr (max 1000 units) titrated to aPTT.

Yet if they're going for primary PCI then the dose is 70-100 U/kg (no max) and no drip, targeted to a specified activated clotting time (ACT). Are we not supposed to have a max for the bolus? And no drip??

Amal M. -

Good pickup. I don't have an answer to that question. I don't think anyone really knows how effective heparin is, if at all, especially given all the other meds we throw at the patient. I don't think the strange dosing is based on any literature I've seen or heard. I'll see if I can find out, and if I do, post a response. For now, I'd suggest discussing with your cardiologists what heparin they want (since they are assuming care and bleeding risks). For now, I'm sticking with the bolus (max 4000) and drip (max 1000) when starting UFH in the ED.

Sean G., M.D. -

Amal, I definitely agree with the "dumbed down" statement and I think it applies for Tpa in Stroke as well. location, duration, size of infarct(in both cases) as well as age of pt and a myriad of co morbidities +/- not necessarily addressed with the standard contraindication check lists make the decision of the use of lytics (again in both AMI and CVA) a decision best made by treating the pt as an individual taking into account the pt and or family desires. I just had a case of a massive anterior lateral wall MI of about 20 min duration arrive the other day. We clearly could have made the new 2 hour window, but the pt was getting 0 relief from all other interventions. I explained to him options of flying now and delaying cath about an hour or assuming the potential bleeding risk of lytics now for a damn good shot at halting the infarct in a matter of minutes, the pt said "hell yeah lets go for it!" (He was 46). 10 minutes later after 50mg of Tnkase he was asymptomatic and his tombstones were resolved.

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Episode 139 Full episode audio for MD edition 238:04 min - 100 MB - M4AResumen en español Español 79:35 min - 32 MB - MP3EM:RAP 2013 April MP3 81 MB - ZIPEM:RAP April 2013 Written Summmary 847 KB - PDFNew Feature: EM:RAP April 2013 Board Review Questions 6 MB - PDFNew Feature: EM:RAP April 2013 Board Review Questions: Answer Sheet 637 KB - PDF