Transcript 6:45 PM The Best of Resuscitation 2012

6:45 PM The Best of Resuscitation 2012
The 30th Annual
Emergencies in Medicine Conference
March 4 - 8, 2012
Hyatt Escala Lodge
Park City, UT
Thursday, March 8, 2012
Background
Robert E. O'Connor, M.D., MPH
Professor and Chair
Department of Emergency Medicine
University of Virginia Health System
PO Box 800699
Charlottesville, VA 22908
ACEP Board 2010-2013
Immediate Past Chair 2009-2011
ECC Chair 2007-2009
ECC Vice-Chair 2005-2007
ACLS Chair 2003-2005
No COI to disclose relevant to this topic
Top Stories 2012
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Early Risk Stratification
Early Detection of NSTEMI
Rapid Reperfusion
Fibrinolysis vs. PCI vs. both
Impact of Crowding
STEMI Systems
Typical Angina vs. Atypical Symptoms
• The presenting symptoms were obtained from a
structured questionnaire administered before stress
testing.
• Patient chest pain was categorized according to the
presence of substernal chest pain or discomfort that
was provoked by exertion or emotional stress and
was relieved by rest and/or nitroglycerin.
• Chest pain was classified as “typical” angina if all 3
descriptors were present and “atypical” or
“nonanginal” if <3 descriptors were present.
Am J Cardiol 2010; 105:1561-1564
Typical Angina vs. Atypical Symptoms
• Presenting symptoms did not vary by age,
gender, or history of diabetes.
• Patients who presented with “typical” angina
were no more likely to have inducible
myocardial on stress testing than patients
with other presenting symptoms.
Am J Cardiol 2010; 105:1561-1564
Typical Angina vs. Atypical Symptoms
No Chest
Pain
Typical
Anginal
Pain
Atypical,
Nonanginal
Pain
Total
n
152
231
2136
2519
Ischemia
25 (8%)
33 (11)%
241 (81%)
299 (12%)
No
Ischemia 127 (6%)
198 (9%)
1895 (85%)
2220 (88%)
Am J Cardiol 2010; 105:1561-1564
Non-diagnostic ECG
• Prospective observational study of ED patients with an initial
complaint of chest pain with a normal initial ECG who were
admitted. Outcome measure – ACS.
• Normal ECG criteria were as follow:
1) normal sinus rhythm with heart rate of 55–105 beats/min,
2) normal QRS interval and ST segment, and
3) normal T-wave morphology or T-wave flattening.
• ACS was defined as follows:
1) elevation and characteristic evolution of troponin I level,
2) coronary angiography demonstrating >70% stenosis in a major
coronary artery, or
3) positive noninvasive cardiac stress test.
Acad Emerg Med 2009; 16:495-499
Non-diagnostic ECG
• A total of 261 (67%) patients experienced chest pain
during ECG; 126 (33%) patients experienced no chest
pain during ECG.
• There was no difference between the two groups in
age, sex, cardiac risk factors, or known CAD.
• The frequency of ACS for the total study group was
17% (67/387).
• There was no difference in prevalence of ACS based
on the presence or absence of chest pain (16% or
42/261 vs. 20% or 25/126; OR = 0.77, 95%
confidence interval = 0.45 to 1.33, p = 0.4).
Acad Emerg Med 2009; 16:495-499
Table 3. Clinical Outcomes of Patients With Suspected Acute Coronary Syndrome Before
(Validation Phase) and After (Implementation Phase) the Introduction of a Sensitive Troponin
Assays.
Mills, N. L. et al. JAMA 2011;305:1210-1216
Copyright restrictions may apply.
Figure. Survival Free From Death or Recurrent MI in Patients With Suspected Acute Coronary
Syndrome Before (Validation Phase) and After (Implementation Phase) the Introduction of a
Sensitive Troponin Assay
Mills, N. L. et al. JAMA 2011;305:1210-1216
Copyright restrictions may apply.
Serial troponin
• Using levels obtained at 3 hours after admission,
the sensitivity was 98.2% and the negative
predictive value was 99.4% for both hsTnI and
cTnI assays.
• Combining the 99th percentile cutoff at
admission with the serial change in troponin
concentration within 3 hours, the positive
predictive value (for ruling in AMI) for hsTnI
increased from 75.1% at admission to 95.8% after
3 hours, and for cTnI increased from 80.9% at
admission to 96.1% after 3 hours.
JAMA. 2011;306(24):2684-2693.
Delays From Symptom Onset to Primary Percutaneous Coronary
Intervention in Patients With ST-Segment Elevation Myocardial Infarction
Transported by the Emergency Medical Service
Terkelsen, C. J. et al. JAMA 2010;304:763-771.
System Delay
• Patients (N = 6209) underwent primary PCI within 12
hours of symptom onset. The median follow-up time
was 3.4 (interquartile range, 1.8-5.2) years.
• In multivariable analysis adjusted for other predictors
of mortality, system delay was independently
associated with mortality (adjusted hazard ratio, 1.10
[95% confidence interval, 1.04-1.16] per 1-hour
delay), as was its components, prehospital system
delay and door-to-balloon delay.
JAMA. 2010;304(7):763-771.
Kaplan-Meier Cumulative Mortality Estimates for Patients With
ST-Segment Elevation Myocardial Infarction Treated With
Primary Percutaneous Coronary Intervention (N = 6209)
Terkelsen, C. J. et al. JAMA 2010;304:763-771.
Remote Ischemic Preconditioning
STEMI Treatment Group
• Four 10 minute cycles of
inflation/deflation (5/5) BP
cuff applied to one arm
• PCI Performed
• SPECT scan within 8 hours
of PCI (area at risk)
• SPECT scan at 30 days (final
infarct size)
• Salvage index determined
STEMI Control Group
• No preconditioning en route
– usual care only
• PCI Performed
• SPECT scan within 8 hours
of PCI (area at risk)
• SPECT scan at 30 days (final
infarct size)
• Salvage index determined
Primary and other end points in study arms
End point
PCI plus remote
conditioning,
median (IQR)
PCI alone,
median (IQR)
p
Salvage index*
0.75 (0.50–0.93)
0.55 (0.35–0.88)
0.033
Area at risk, % of left ventricle
26 (20–40)
28 (22–42)
0.97
Salvage, % of left ventricle
16 (10–25)
12 (5–23)
0.037
Final infarct size, % of left
ventricle
4 (1–14)
7 (1–21)
0.1
*Primary end point
IQR=interquartile range
Bøtker HE et al. Lancet 2010; 375:727-734.
Adverse Outcomes by Type of Treatment
Lambert, L. et al. JAMA 2010;303:2148-2155.
Lambert, L. et al. JAMA 2010;303:2148-2155.
Timeliness
• Fibrinolysis >30 minutes in 54%
• PPCI > 90 minutes in 68%
• Death at 30 days was 6.6% in (F>30; P>90)
delayed versus 3.3% in timely (F<30; P<90)
group.
• Each 10% increase in patients treated within
recommended time resulted in reduction of
30 day mortality (OR=0.80; CI 0.65,0.98)
Regional 30-Day Mortality of All STEMI Patients by Intraregional
Proportion of Patients Treated Within Recommended Delays
and Percentage of Patients Receiving Reperfusion With PPCI
Lambert, L. et al. JAMA 2010;303:2148-2155.
N. Engl. J. Med. 360 (26):2705-18
N. Engl. J. Med. 360 (26):2705-18
Chest Pain Waiting Room
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Monitored Bed vs. Waiting Room
3 stretchers
EM Physician evaluation
Labs, ECG, imaging, consultation
Line-of-sight monitoring by triage staff
33% of WR group never received a stretcher
before disposition
Safety of Assessment of Patients With Potential Ischemic Chest
Pain in an Emergency Department Waiting Room: A Prospective
Comparative Cohort Study
Utilization
Number
Diagnostic test at index visit, No. (%)
0-h ECG performed
6-h ECG performed
0-h cardiac biomarker performed
6-h cardiac biomarker performed
Provocative testing at index ED visit
Provocative testing within 30 days
ED cardiology consultation
Hospital utilization
Patients discharged within 3 h, No. (%)
Admission during index visit, No. (%)
Admission during 30-day follow-up
Monitored Bed
804
Waiting Room
303
Difference (95% CI)
798 (99.3)
327 (40.7)
691 (86.0)
368 (45.8)
10 (1.2)
188 (23.3)
215 (26.7)
293 (96.7)
91 (30.1)
223 (73.6)
118 (38.9)
2 (0.7)
64 (21.1)
54 (17.8)
2.5 (0.7 to 5.4)
10.6 (4.1 to 16.8)
12.3 (6.9 to 18.2)
6.8 (0.1 to 13.3)
0.6 (-1.4 to 1.8)
2.2 (-3.6 to 7.6)
8.9 (3.2 to 14.1)
138 (17.2)
158 (19.7)
200 (24.9)
85 (28.0)
36 (11.8)
39 (12.9)
10.9 (5.2 to 16.9)
7.8 (2.9 to 12.0)
12.0 (6.9 to 16.9)
Safety of Assessment of Patients With Potential Ischemic Chest
Pain in an Emergency Department Waiting Room: A Prospective
Comparative Cohort Study
Results
Number of patients
30-day diagnosis, No. (%, 95% CI)
Acute myocardial infarction
Definite unstable angina
Possible unstable angina
No ACS but adverse event
No ACS and no adverse event
Number of ACS
Missed cases of ACS, No. (%, 95% CI)
Index visit outcome events, No. (%)
Death during index visit
PCI during index visit‡
CABG during index visit
30-day outcome events, No. (%)§
Death during 30-day follow-up
PCI during 30-day follow-up
CABG during 30-day follow-up
Monitored Bed
804
Waiting Room Difference (95% CI)
303
31 (3.9)
63 (7.8)
19 (2.4)
32 (4.0)
659 (82.0)
94 (11.7)
0 (0, 0.0 to 0.4)
9 (3.0)
14 (4.6)
4 (1.3)
2 (0.7)
274 (90.4)
23 (7.6)
0 (0.0 to 1.0)
0.9 (-1.9 to 3.0)
3.2 (0.2 to 6.0)
1.0 (-1.1 to 2.6)
3.3 (1.3 to 5.0)
8.5 (3.7 to 12.6)
4.1 (-0.2 to 7.6)
0.0 (-1.6 to 0.6)
4 (0.5)
30 (3.8)
15 (1.9)
0 (0.0)
12 (4.0)
1 (0.3)
0.5 (-1.1 to 1.4)
0.2 (-2.2 to 3.5)
1.5 (-0.4 to 2.8)
4 (0.5)
40 (5.0)
19 (2.4)
0
13 (4.3)
2 (0.6)
0.5 (-1.1 to 1.4)
0.7 (-2.7 to 3.3)
1.7 (-0.4 to 3.2)
Chest Pain Evaluation Unit of the Future?
Reperfusion time goals for patients with STsegment-elevation myocardial infarction
Ting, H. H. et al. Circulation 2008;118:1066-1079
Copyright ©2008 American Heart Association
Stenestrand, U. et al. JAMA 2006;296:1749-1756.
Short-term mortality comparison between those diverted to primary
Percutaneous coronary intervention (pPCI) and those transported to the
closest emergency department (ED).
CJEM 2009; 11:481-492
Short-term mortality outcomes by control group intervention type. The shortterm mortality (30 d or in-hospital) in patients diverted directly to primary
percutaneous coronary intervention (pPCI) by emergency medical services
personnel as compared with those transported to the closest hospital for initial
treatment grouped by type of control intervention is shown.
CJEM 2009; 11:481-492
PCI
vs. Lysis:
Importance
of PCI-related
Delay
Estimated
Treatment
Effect and 95%
Confidence Intervals
Data fromonNRMI
2,3 and
Registries
Conditional
PCI Related
Delay4(DB-DN)(min)
After Adjusting for Covariates
PCI Better
Estimated Treatment Effect
Fibrinolysis Better
Odds of Death with Fibrinolysis
2.0
1.5
1.25
1.0
0.8
0.5
60
75
90
105
114 120
135
PCI Related Delay (DB-DN) (min)
Pinto et al. Circulation, 2006
150
165
180
Adverse Outcomes by Type of Treatment
Lambert, L. et al. JAMA 2010;303:2148-2155.
Lambert, L. et al. JAMA 2010;303:2148-2155.
Timeliness
• Fibrinolysis >30 minutes in 54%
• PPCI > 90 minutes in 68%
• Death at 30 days was 6.6% in (F>30; P>90)
delayed versus 3.3% in timely (F<30; P<90)
group.
• Each 10% increase in patients treated within
recommended time resulted in reduction of
30 day mortality (OR=0.80; CI 0.65,0.98)
Regional 30-Day Mortality of All STEMI Patients by Intraregional
Proportion of Patients Treated Within Recommended Delays
and Percentage of Patients Receiving Reperfusion With PPCI
Lambert, L. et al. JAMA 2010;303:2148-2155.
STREAM Study
• The STREAM study will provide novel
information on whether prompt fibrinolysis at
first medical contact, followed by timely
catheterization or rescue coronary
intervention in STEMI patients presenting
within 3 hours of symptom onset, represents
an appropriate alternative strategy to primary
PCI.
STREAM Study
• Acute STEMI patients presenting early after symptom
onset are eligible if PCI is not feasible within 60
minutes of first medical contact. This is an openlabel, prospective, randomized, parallel,
comparative, international multicenter trial.
• Patients are randomized to fibrinolysis combined
with enoxaparin, clopidogrel, and aspirin, and cardiac
catheterization within 6 to 24 hours or rescue
coronary intervention if reperfusion fails within 90
minutes of fibrinolysis versus PCI performed
according to local guidelines.
Top Stories 2012
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Early Risk Stratification
Early Detection of NSTEMI
Rapid Reperfusion
Fibrinolysis vs. PCI vs. both
Impact of Crowding
STEMI Systems