“This is a CME program where tomorrow you can go back and make a change that affects a patient population.” — Josen Thomas, RN, MBA, Director of Cardiovascular Services, Palmetto General Hospital, Hialeah, FL The acute myocardial infarction-focused 2010 LUMEN meeting, set amidst the palm trees and beaches of Miami, reflected the spirit of what course director Sameer Mehta, MD, FACC, MBA,1 called “a call to conscience.” In the U.S. alone, nearly 400,000 people experience a ST-elevation myocardial infarction (STEMI) each year, with an estimated 1,330 cath labs nationwide able to perform percutaneous coronary intervention (PCI). Considered the most rewarding and the most urgent procedure in interventional cardiology, the outcome of primary PCI touches every segment of the global population, whether directly or “The joy you have in saving these lives is incredible,” noted Dr. Mehta. Yet this joy comes with challenges to all who work to save the STEMI patient. As an example, data from the single-operator 565-patient SINCERE database showed 67% of interventions took place between 1-5 am. Thirty-two percent of SINCERE patients have no insurance. It is because of these and many other hurdles caregivers face that over 235 LUMEN attendees spent three days focusing on STEMI — easily, as Dr. Mehta has said, “the finest indication for PCI.” Andreas Gruentzig, the father of balloon angioplasty, was actually opposed to its use in acute MI, pointed out William O’Neill, MD, FACC,2 recipient of the LUMEN achievement award. “Think how far we have come,” he encouraged attendees, who were presented with some sobering data over the course of the meeting. Ivan Rokos, MD, FACEP, 3 noted that each 15-minute delay to revascularization beyond 90 minutes increases mortality. Samin Sharma, MD, 4 later echoed this focus, emphasizing that with every 30-minute delay, there is an additional 1-1.5% mortality. Both within the U.S. and globally, there are regions meeting and exceeding the 5 emphasized, only 25% of the hospitals in the U.S. can actually do primary PCI and 82% of transferred patients have D2B times ≥120 minutes. With the release in November 2009 of updated American Heart Association (AHA)/ACC/Society of Cardiovascular Angiography & Interventions (SCAI) guidelines, it is now a class Ic recommendation that each community develop a STEMI system of care that follows standards at least as stringent as those for the AHA’s Mission: Lifeline, said Alice Jacobs, MD, FACC, 6 chair of the Mission: Lifeline Advisory Working Group. AHA’s Mission: Lifeline is a community-based national initiative to improve quality of care and outcomes for STEMI, addressing the STEMI patient throughout the continuum of care. New for the initiative are an online social networking community (launched in March) and recognition criteria (at “bronze,” “silver” and “gold” levels) focused on achievement measures. An outside body will certify centers. Fifty percent of the U.S. population is now covered by systems registered with Mission: Lifeline. If your system is not yet registered, it can be done in less than 20 minutes at www.americanheart. org/missionlifeline. Opening the STEMI critical nursing issues workshop was Mission: Lifeline’s National Director, Mayme Lou Roettig, RN, MSN.7 She cited several reasons why nurses are excellent leaders in creating STEMI regional and local care systems: • Patient advocates • Disease state experts • Liaisons for multi-disciplinary teams • Coordinators of care pathways and protocol development • Quality improvement specialists • Trainers and educators Ms. Roettig also discussed steps to regionalization, including establishing a neutral party (the “Switzerland”) in areas where competing STEMI centers exist, and utilizing a quality database. LUMEN co-director Barbara T. Unger, RN, BS, FAACVPR, 8 Director, Cardiac Level One Services at the Minneapolis Heart Institute (MHI) at Abbott Northwestern Hospital, shared valuable advice from her experience working in both rural and urban settings. She seconded Ms. Roettig’s advice for a strong database, noting that how you collect data is very important. A streamlined process of care occurs within MHI’s regional network, and Ms. Unger shared suggestions to shave off minutes from D2B times: • Security guards meet and escort EMS (hold the elevator as well) • Drug box for STEMIs • Poster/checklist in the ER bays for RNs, as well as pocket cards • For transfers/handoffs, establish critically needed information (standardized forms among centers) and limit time on the phone. Fax all clinical information. • Under EMTALA, a bed is required. Let the cath lab table be the guaranteed bed. • Add everyone to the single activation page, from the chaplain to admissions. • Helicopters need to move out to rural areas, and not wait at urban centers. • Do helicopter “hot loads” — keep the rotors going, as it can take 7 minutes to start up. (“We measured everything,” Ms. Unger said.) • Re-education should be done regularly. Consider rates of turnover among all involved parties along with the rate of system changes. • Put cardiologists and RNs in ambulances for ride-alongs to understand the EMS world (a frequent adage cited at LUMEN: “If you’ve seen one EMS system…you’ve seen one EMS system!”). • IV tubing: put in a saline lock so any tubing can be used • Put IV in the right side if you always shift from the left on the gurney • When working with transfer hospitals, share data and listen, rather than dictating solutions • Disseminate feedback on every patient The success of the Abbott Northwestern regionalization program has been such that similar programs are being created for aortic dissection, abdominal aortic aneurysms (AAAs), and acute critical limb ischemia. Already established is a cooling program for cardiac arrest patients (see CLD’s Nov 2009 issue, “Cooling in the Cath Lab: Miracle on Ice in Minnesota”). Workshop presenters and attendees also discussed adequate staffing for a STEMI — should there be 3 or 4 staff? Adequate staffing is a “big deal,” noted an attendee, and the workshop panel essentially concluded that while 4 is always preferable, in most uncomplicated STEMIs, an (experienced) staff of 3 is adequate. Ms. Unger noted that at her facility, the ED charge nurse is backup in case of multiple STEMIs, and there are two cardiologists in the room, one conducting a quick H&P and one doing the intervention. An advantage to regionalization is that you can coordinate with other programs to accept STEMI patients if you have too many. Josen Thomas, RN, MBA, 9 spoke eloquently of efforts to open a STEMI program at Palmetto General Hospital in Hialeah, Florida, located in northwest Miami Dade County. An area of 2.5 million people, heavily Hispanic with a very high uninsured population, had zero STEMI centers until the recent introduction of Palmetto’s STEMI program in January 2007. Palmetto is now meeting 10 in the STEMI administrators workshop. Dr. Henry shared the success of the Minneapolis regional STEMI network, which incorporates 3 “zones,” from urban to rural, with the longest transfer at 210 miles. One-year mortality is at 12 presented on the use of radial access in STEMI patients. “A causality strain has never been established” regarding bleeding complications and mortality, he argued. Ultimately, Dr. Nallamothu said, the success of a STEMI procedure is measured by lives and myocardium saved, not by the convenience or comfort offered by a radial approach. Unstable STEMI patients need femoral access regardless, since sheath sizes are limited to 7 French in men and 6 French in women. There is also a high crossover rate in acute MI patients, with a 7% crossover rate for radial versus 0.7% for femoral access. Real-world effectiveness trials are needed, a point echoed by Leif Thuesen, MD, 12 who noted that in STEMI, “adopting the radial route is still not evidence-based.” Cindy Grines, MD, FACC, 13 presented 9 “take-home” lessons from STEMI clinical trials: 1) PPCI is superior to thrombolytic therapy and should be done 24/7 in all STEMI patients. 2) Do not automatically give lytics if the anticipated D2B time will exceed 90 minutes, which Dr. Grines pointed out is against the current guidelines, but is her conclusion from an analysis of the PCAT-2 trial (Primary coronary angioplasty compared with intravenous thrombolytic therapy for acute myocardial infarction). 3) Attempt to decrease PCI-related bleeding. • Radial access offers an 80% decrease in bleeding complications • Proton pump inhibitors may decrease the effectiveness of clopidogrel • Dose antithrombins carefully, especially in the elderly • Bivalirudin use may be beneficial in high-risk patients 4) Be cautious using bivalirudin in those patients not adequately pretreated with clopidogrel or unfractionated heparin, especially with angiographic risk factors for stent thrombosis. 5) Perform thrombectomy only in infarct vessels with angiographic evidence of large thrombus. Older patients may have atherosclerosis and not benefit from thrombectomy. 6) PCI should not be performed in a non-infarct-related artery (Class III recommendation). Avoid multi-vessel PCI — bring patients back if you have to. 7) Late PCI of the infarct artery is not completely out of the question (despite Class III guidelines) if you think there is viable myocardium. (The OAT trial was negative, but a pooled analysis of clinical trials shows benefit to PCI in mortality. 8) Drug-eluting stents are safe during STEMI and reduce target vessel revascularization (TVR) (The COMPARE-AMI trial, with clinically driven TVR, showed less TVR with the Xience stent than the Taxus Liberte). 9) Unconscious adult patients resuscitated from cardiac arrest should be cooled to 32˚-34˚C for 12-24 hours. Roxana Mehran, MD, 14 presented on STEMI in women. “Gender biases exist,” she said. “We have to figure out a way to increase interest in this topic.” Dr. Mehran cited data (3.4% of women vs. 1.4% of men) showing a gender disparity in the failure to hospitalize acute MI patients. According to the AHA’s Get With the Guidelines (GWTG) database, women receive lower rates of early medical therapy and invasive therapy, and have higher D2B times. Since 1984, more women die annually from heart disease than men. Men have more prior MIs, but women present more with co-morbidities such as heart failure, diabetes and stroke. More than 75% of clinical trials today have 15). Similarly, Dr. Sharma cautioned that we should not be focusing only on the epicardial vessel (i.e., thrombus) but on microperfusion as well. The future of STEMI treatment, as predicted by Dr. O’Neill in his keynote address, will focus on reducing infarct size and the use of mesenchymal stem cells to heal damaged or dead myocardium. The attempt will be to improve left ventricular wall thickness and motion. “Rather than saving the myocardium,” he said, “we are going to be regrowing the myocardium.” The paradigm may change in as little as five years, with mesenchymal stem cells delivered either through an IV or injected directly into the myocardium. Read more about LUMEN at www.lumenami.com. A special thanks to Huay Cheem Tan, MD, who traveled 13 hours from Singapore only to be delayed for 2 days in a snowstorm at the Newark airport. We are especially grateful he was able to arrive and present on the state of STEMI care in Singapore on LUMEN’s final day.
Referenced LUMEN faculty(title, facility and location):
1. Sameer Mehta, MD, FACC, MBA, LUMEN Course Director, Voluntary Associate Professor of Medicine, University of Miami Miller School of Medicine, President, Indo-American Society of Interventional Cardiology, Author, Textbook of STEMI Interventions, Miami, FL 2. William O’Neill, MD, FACC, Executive Dean for Clinical Affairs, Miller School of Medicine, University of Miami, Miami, FL 3. Ivan Rokos, MD, FACEP, LUMEN Co-Director, Assistant Clinical Professor of Medicine, Geffen/ UCLA, School of Medicine, Director of Clinical Faculty, Department of Emergency Medicine, Olive View/ UCLA, Northridge, CA 4. Samin Sharma, MD, FACC, Director, Cardiac Catheterization Laboratory & Intervention, Zena & Michael A. Weiner Professor of Medicine, The Mount Sinai Medical Center, New York, NY 5. David Larson, MD, Chief, Emergency Medicine, Ridgeview Medical Center, Waconia, MN 6. Alice Jacobs, MD, FACC, Professor of Medicine, Boston University School of Medicine, Boston, MA 7. Mayme Lou Roettig, RN, MSN, National Director, Mission: Lifeline, Executive Director, RACE (Reperfusion of Acute Myocardial Infarction in Carolina Emergency Departments), Duke University Medical Center, American Heart Association, Durham, NC 8. Barbara T. Unger, RN, BS, FAACVPR, LUMEN Co-Director, Director, Cardiac Level One Services, Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, MN 9. Josen Thomas, RN, MBA, Director of Cardiovascular Services, Palmetto General Hospital, Hialeah, FL 10. Timothy Henry, MD, Director of Research, Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, MN 11. Charanjit Rihal, MD, BSc(Med), MBA, LUMEN Co-Director, Director, Cardiovascular Laboratory, Mayo Clinic, Rochester, MN 12. Brahmajee Nallamothu, MD, MPH, FACC, Assistant Professor of Medicine, University of Michigan School of Medicine, Ann Arbor, MI 13. Leif Thuesen, MD, Director Cardiac Catheterization Laboratory, Skejby Hospital, University of Aarhus, Skejby, Denmark 14. Cindy L. Grines, MD, FACC, Vice Chief of Academic Affairs, Division of Cardiology, William Beaumont Hospital, Royal Oak, MI 15. Roxana Mehran, MD, FACC, New York Presbyterian Hospital/ Columbia University Medical Center, New York, NY 16. John M. Lasala, MD, PhD, Medical Director, Cardiac Catheterization Laboratory, Barnes-Jewish Hospital, Professor of Medicine, Washington University School of Medicine, Director, Interventional Cardiology, St. Louis, MO