Department of Human Services
Improving Care of Patients with Improving Care of Patients with potentially potentially IschaemicIschaemic Chest PainChest Pain
Engaging stakeholders outside ED (eg Cardiology, Pathology, Radiology)
Richard Harper, Clinical Lead,Cardiac Clinical Network
The Cardiologist and the ED Physician should be like Abbot and Costello…… in harmony with each other and working for the same team!
• Treating STEMI’s with the maximum possible urgency – saving minutes spares myocardium and improves outcomes.
• Ensuring patients with other high risk ACS (viz nonSTEMI, unstable angina) are not inadvertently discharged home.
• Ensuring low risk patients have early and adequate cardiology follow up after discharge.
Chest Pain in the ED Chest Pain in the ED –– the the CardiologistCardiologist’’s concerns.s concerns.
Apart from chest pain evaluation the Apart from chest pain evaluation the cardiologist has other roles in the ED.cardiologist has other roles in the ED.
• Helping sort out other serious but non ischaemic causes of chest pain eg Aortic dissection, Pulmonary embolism.
• Helping manage acute arrhythmias eg VT, SVT, AF.
• Helping sort out pacemaker, AICD problems.
• Helping manage cardiac tamponade.
The Cardiologist / ED Physician The Cardiologist / ED Physician InteractionInteraction
• ED Physician’s responsibility: call the cardiologist early especially for suspected STEMI.
• The Cardiologist’s responsibility:respond immediately to the ED Physician’s call.
How is this achieved?How is this achieved?
• In hours: A Cardiology Registrar (trainee) whose prime responsibilty is to the ED.
• After hours: Cardiologist on call has a FAX machine (decisions are often made on the basis of the ECG findings)
The Ideal set up.The Ideal set up.
• The Cardiology Department (and in particular the cath lab) and ED are on the same level and adjacent to each other.
• The ED has ready access to echocardiography.
Chest Pain in the ED Chest Pain in the ED –– the the CardiologistCardiologist’’s concerns. s concerns.
• Treating STEMI’s with the maximum possible urgency.
• Ensuring patients with other high risk ACS (viz nonSTEMI, unstable angina) are not inadvertently discharged home.
• Ensuring low risk patients have early and adequate cardiology follow up after discharge.
Chest Pain Chest Pain –– General Principles General Principles
• Always assume chest pain is cardiac ischaemic in origin until proven otherwise.
• An ECG should be done within minutes of arrival in ED
A STEMI!A STEMI!
Treatment of STreatment of S--T Elevation Acute T Elevation Acute Myocardial Infarction (STEMI)Myocardial Infarction (STEMI)
• Early reperfusion is essential for patients who have STEMI
• Historically thrombolysis has been an accepted treatment modality for STEMI
• In most circumstances primary PCI is now acknowledged as a superiortreatment option in reducing morbidity and mortality
To save myocardium the artery must To save myocardium the artery must be opened ASAP!be opened ASAP!
Pre PCIPre PCI Post PCIPost PCI
Primary PCI vs Thrombolytic TherapyPrimary PCI vs Thrombolytic Therapy
5.3
7.4
2.5
6.8
12
8.2
14.3
0
2
4
6
8
10
12
14
16
Death Reinfarction Stroke Composite
PPCIThrombolysis
5.3
7.4
2.5
6.8
12
8.2
14.3
0
2
4
6
8
10
12
14
16
Death Reinfarction Stroke Composite
PPCIThrombolysis
Summary of 23 Randomised TrialsSummary of 23 Summary of 23 RandomisedRandomised TrialsTrials
Inci
denc
e%
KeeleyKeeley et al Lancet 2003 Jan 4;361(9351): 13et al Lancet 2003 Jan 4;361(9351): 13--2020
P=0.0003 P<0.0001
P=0.0004
P<0.0001Primary PCI was better than Thrombolysis at reducing
1. Non-fatal reinfarction.
2. Stroke.
3. Composite end point of death,non-fatal reinfarction and stroke
Primary PCI was better than Thrombolysis at reducing
1. Non-fatal reinfarction.
2. Stroke.
3. Composite end point of death,non-fatal reinfarction and stroke
Symptom onset < 1 hourbefore presentation
PCI available within 1 hour†
YES NO
PCI Fibrinolysis‡
Symptom onset 1–3 hoursbefore presentation
PCI available within 90 minutes†
YES NO
PCI Fibrinolysis‡
Symptom onset 3–12 hours before presentation
PCI available within 90 minutes(onsite) or 2 hours
(offsite, including transport)†
YES NO
PCI Fibrinolysis‡
* Assuming no contraindications to fibrinolytic therapy; † Time delay refers to time from first medical contact to balloon; ‡ Patients with ongoing symptoms or instability should be transferred for PCI.PCI = percutaneous coronary intervention
Acute Coronary Syndrome Guidelines Working Group Acute Coronary Syndrome Guidelines Working Group Med J AustMed J Aust 2006;184(8 Suppl):S92006;184(8 Suppl):S9--2929..
Australian Guidelines for Hospital Management of STEMI*
Australian Guidelines for Hospital Management of STEMI*
Door to Balloon time affects in hospital mortality
Door to Balloon time affects Door to Balloon time affects in hospital mortalityin hospital mortality
US National registry of myocardial infarctionUS National registry of myocardial infarctionJ Am J Am CollColl CardiolCardiol, 2006 47:2180, 2006 47:2180--21862186
67%
7%
39%
0%
20%
40%
60%
80%
DTB <= 90 min -Non-Transfer In
DTB <= 90 min -Transfer In
DTN <= 30 min - All
ACTION DATA: January 1, 2007 – December 31. 2007 (n=19,523)
STEMI – Door to Balloon and Door to Needle Times:Cumulative 12 Month Data (301 cities)
DTB = 1st Door to Balloon for Primary PCIDTN = Door to Needle for Lytics
Median DTB 160 mins
Median DTB 78 mins
GuidelinesGuidelines
•• AHA / ACC / Aust Heart AHA / ACC / Aust Heart Foundation / ESC / SCAI Foundation / ESC / SCAI guidelines:guidelines:–– D2BT < 90 minutes in 75% of D2BT < 90 minutes in 75% of
patients.patients.
How are we doing in How are we doing in Australia?Australia?
• Median D2B time is 110 minutes.• Less than 50% patients achieve D2B
time of < 90 minutes.
Basic RequirementsBasic Requirements
• Ambulance officers trained to recognise STEMI on 12 lead ECG.
• ED physician prepared to interpret faxed ECG and summon the infarct team without delay.
• Ability to open the cath lab and start the procedure within 30 minutes.
• Receiving hospital must accept the patient even if a bed not immediately available.
What to do with the patient after the What to do with the patient after the cathcath lab procedure if no bed available?lab procedure if no bed available?
• Send the patient to ED?• Send the patient to recovery?• Transfer to another hospital?
MonAMI StudyMonAMI Study
ED stand downN = 58 (35%)
STEMIN = 0
ACS(excluding STEMI)
N = 22 (38%)
ECG Faxed to MMC ED: N = 166ECG ECG FaxedFaxed to MMC ED: N = to MMC ED: N = 166166
No ACSN = 36 (62%)
Primary PCIN = 96(89%)
Taken to Cath LabN = 108 (65%)
CAD no PCIN = 3*(2.7%)
No overt CADN = 9(8.3%)
* Severe Triple Vessel Disease (CABG)
102 100.5
56
0
20
40
60
80
100
120
Pre MonAMI Non MonAMI MonAMI
Tim
e (m
in)
Median D2B TimesMedian D2B Times
P < 0.001P < 0.001
37
59 60
0
20
40
60
80
100
120
In Hours (n=53) Out of Hours (n=29) Weekend (n=26)
Tim
e (m
in)
MonAMI Median D2B TimesMonAMI Median D2B Times
38%42%
47%
31%
44%
57%65%
33%
95% 95% 93% 96%
0%
20%
40%
60%
80%
100%
Southern Health MMC-PCI Capable In hours Out of hours
Pre MonAMI Non MonAMI MonAMI
Proportion of cases achieving D2B time under 90 minutes
Proportion of cases achieving D2B time under 90 minutes
75%*
*AHA /ACC /ESC/ SCAI guidelines
SUSPECTED ACSSUSPECTED ACS
Low Risk Low Risk ((troponintroponin ––veve))
High Risk (High Risk (troponintroponin ++veve or or high risk clinical features)high risk clinical features)
Troponin, Troponin, Clinical AssessmentClinical Assessment
No ST No ST ElevationElevationST ElevationST Elevation
Reperfusion (PCI or
Thrombolysis)
Medical Therapy and
Stratification
Intensive Medical Therapy plus Early Angiography with
view to PCI
ECG
High Risk FeaturesHigh Risk Features
• Elevated troponin level• Prolonged episodes of chest pain• ST depression or T wave inversion• Cardiac failure• Haemodynamic instability
Managing the (very) low risk patient – can we avoid keeping all of these patients in ED for 6 hours awaiting a 2nd troponin
level?
Managing the (very) low risk patient – can we avoid keeping all of these patients in ED for 6 hours awaiting a 2nd troponin
level? • Normal ECG.• Clinical features not suggestive of an ACS.• Features consistent with a musculoskeletal
or non cardiac cause.
Option: share the responsibility with a cardiologist!
Should all patients with a borderline elevated troponin
level be admitted?
Should all patients with a borderline elevated troponin
level be admitted?
Causes of Causes of TroponinTroponinelevation elevation notnot due to ACSdue to ACS
• Renal impairment • Congestive heart failure (severe)• Pulmonary embolus• Tachycardia (eg AF, SVT) with haemodynamic compromise• Direct injury to the heart (accidental trauma, ablation, cardiac
surgery)• Toxins (adriamycin, 5-fluorouracil)• Viral infection (myocarditis)• Pericarditis• Cerebrovascular accident• Sepsis• Prolonged strenuous endurance exercise• Any elderly patient who is severely ill !
ConclusionsConclusions
● Optimal management of chest pain requires efficient and timely communication between the ED physician and the cardiologist. ● Scope for improvement in the management of STEMI by reduction in D2B time.
