Ebook Prehospital management of acute STEMI: Part 1

CARDIOVASCULAR TEAM APPROACH SERIES

PREHOSPITAL MANAGEMENT OF

ACUTE STEMI
PRACTICAL APPROACHES AND
INTERNATIONAL STRATEGIES
FOR EARLY INTERVENTION

Volume Editors:

Edgar do Es cobar , MD, FACC, FAHA
Alejandr o Bar bagelat a, MD, FAHA, FSCAI



Prehospital
Management of
Acute STEMI
Practical Approaches and
International Strategies for
Early Intervention


The Cardiovascular Team Approach
A book series focusing on the interprofessional team approach
for the management and prevention of cardiovascular diseases.
Editors-in-Chief:
Joseph S. Alpert, MD, FAHA, FACC, MACP, FESC
Lynne T. Braun, PhD, CNP, FAHA, FAAN
Barbara J. Fletcher, RN, MN, FAHA, FAAN

Gerald Fletcher, MD, FAHA, FACC, FACP

Look for these and other forthcoming series titles from
Cardiotext Publishing.
Volume 1 : Heart Failure: Strategies to Improve Outcomes
Ileana L. Piña, MD, MPH, FACC, FAHA, and
Elizabeth A. Madigan, PhD, RN, FAAN, editors
Volume 2 : Prehospital Management of Acute STEMI: Practical
Approaches and International Strategies for Early Intervention
Edgardo Escobar, MD, FACC, FAHA, and
Alejandro Barbagelata, MD, FAHA, FSCAI, editors
Volume 3 : Acute Coronary Syndrome: Urgent and Follow-up Care
Eileen Handberg, PhD, ARNP, BC, FAHA, FACC, and
R. David Anderson, MD, MS, FACC, FSCAI, editors
Volume 4 : Atrial Fibrillation: A Multidisciplinary Approach to
Improving Patient Outcomes
N.A. Mark Estes III MD, FACC, FHRS, FAHA, FESC, and
Albert L. Waldo, MD, PhD (Hon), FACC, FHRS, FAHA, FACCP, editors
Please visit www.cardiotextpublishing.com for more information about this series.


Prehospital
Management of
Acute STEMI
Practical Approaches and
International Strategies for
Early Intervention

The Cardiovascular
Team Approach Series

VOLUME 2
Edgardo Escobar, MD, FACC, FAHA
Alejandro Barbagelata, MD, FAHA, FSCAI
Volume Editors
Joseph S. Alpert, MD, FAHA, FACC, MACP, FESC
Lynne T. Braun, PHD, CNP, FAHA, FAAN
Barbara J. Fletcher, RN, MN, FAHA, FAAN
Gerald Fletcher, MD, FAHA, FACC, FACP
Editors-in-Chief

Minneapolis, Minnesota


© 2015 Joseph S. Alpert, Lynne T. Braun, Barbara J. Fletcher, Gerald Fletcher
Cardiotext Publishing, LLC
3405 W. 44th Street
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USA
www.cardiotextpublishing.com
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Library of Congress Control Number: 2015933408
ISBN: 978-1-935395-66-9
Printed in the United States of America


To my wife Josefina for her patience and to ITMS, Telemedicina
for giving me the inspiration
—Edgardo Escobar

To my beloved wife and 3 beautiful children
—Alejandro Barbagelata

Contents

About the Editors-in-Chief
About the Authors
Abbreviations

xiii
xv
xix

Introduction Increasing Importance of Prehospital Care of
ST-Segment Elevation Myocardial Infarction 1
Edgardo Escobar and Alejandro Barbagelata

Part 1:  Pro g ram De ve lo pme nt fo r Pre ho spital STEMI 
Care  Syste ms:  Fo cus o n the  Unite d State s 
Expe rie nce
Chapter 1 Delays and Decision Points in Prehospital
STEMI Management Systems: A Framework for
Reducing the Gap Between the Scientific
Guidelines and the Real-World Experience
Qiangjun Cai and Alejandro Barbagelata
Introduction
Patient Delay—Early Symptom Recognition
System Delay—First Medical Contact,
Door-to-Balloon, and Door-in Door-out
Prehospital ECG
False Activation—The “Collateral Damage” of
Reducing Time to Reperfusion
Systems of Care—The AHA Mission: Lifeline®

Program STEMI Networks
Cardiac Arrest in STEMI—Time Is Life: Extending
the Chain of Survival

 

7
7
8
10
14
17
20
23

 

vii


viii 

Co nte nts
Prehospital Fibrinolysis or Pharmacoinvasive
Therapy in the Real World—Why It Does
Not Work in the United States
Conclusion
References
Chapter 2 The Time Dilemma and Decision Making for
Prehospital Fibrinolysis, Hospital Fibrinolysis,

and/or Transfer to a Percutaneous Coronary
Intervention Center
Freij Gobal, Abdul Hakeem, Zubair Ahmed,
and Barry F. Uretsky
Introduction
“Time is Muscle” and the “Golden Hour”
for Reperfusion
Therapeutic Options with Anticipated Delay
to PPCI of > 90 to 120 Minutes
Adjunctive Prehospital Pharmacotherapy
Conclusion
References
Chapter 3 Prehospital ECG Acquisition/Interpretation:
Emerging Technology Applied to STEMI Care
Michael J. Pompliano and George L. Adams
Introduction
Advancements in Technology
ECG Acquisition
Interpretation Accuracy
Benefits of ECG Telemedicine for Triage and
Mobilization of Resources
Future of the Prehospital ECG and Telemedicine
Conclusion
References
Chapter 4 ECG Pitfalls in Early Recognition of STEMI:
Ischemic Versus Nonischemic ST Elevation
Henry D. Huang, Waleed T. Kayani, Salman J. Bandeali,
and Yochai Birnbaum
Introduction

25
28
28

37

37
38
45
54
61
62
69
69
70
71
72
76
80
82
82
87

87


 Co nte nts
Prevalence of Benign NISTE
“Concave” Versus “Convex” Pattern of STE
A “Normal Variant” Pattern of NISTE

Early Repolarization
Acute Pericarditis
STE Secondary to LVH
STE Secondary to IVCD and/or Altered
Depolarization
The Brugada Pattern
Takotsubo Syndrome (Apical Ballooning Syndrome)
Left Ventricular Aneurysm
Spontaneously Reperfused STEMI
Conclusion
References
Chapter 5 Triage Models for ST-Elevation Myocardial
Infarction Systems of Prehospital Care
and the Challenge of Inappropriate Cardiac
Catheterization Laboratory Activation
David A. Hildebrandt, David M. Larson,
and Timothy D. Henry
Introduction
Systems of Care Approach: Ideal Features
Role of EMS
Non-PCI Hospitals within STEMI Systems
“False Positive” and “Inappropriate Activation”
of the Cardiac Cath Lab
Strategies to Reduce Inappropriate CCL
Activations
Conclusion
References
Chapter 6 Prehospital STEMI Management in the
Setting of Out-of-Hospital Cardiac Arrest
Eric Wiel and Patrick Goldstein

Introduction
STEMI–OHCA-Specific Population Characteristics
and Predictors of Mortality

 
90
91
91
93
94
95
97
99
101
102
103
104
105

111

111
113
114
115
118
124
127
128
131

131
132

ix


x 

Co nte nts
Thrombolysis in the OHCA Setting
Angiography and Percutaneous Coronary
Intervention in OHCA Patients
Adjuvant Therapies for OHCA Patients
Conclusion
References
Chapter 7 Role of Nurses and Paramedics in
the Prehospital Care of Acute
Myocardial Infarction
Denise Greci Robinson
Introduction
Guidelines for Achieving Optimal Outcomes
Barriers to Treatment
Role of the Paramedic in Reducing the
Prehospital Delay to Treatment of ACS
Role of Prehospital ECG Performed by
Paramedics
Prehospital Thrombolytic Therapy
Role of Nurses in Prehospital Management of ACS
Conclusion
References

133
135
137
137
137

141
141
142
142
143
144
145
146
150
150

Part 2:  Syste ms o f Pre ho spital STEMI Care  fro m 
Aro und the  Wo rld
Chapter 8 Canada: Integrated Systems of
Prehospital STEMI Care
Darren Knapp and Robert C. Welsh
Epidemiology and Geographic Realities in Canada
Tertiary Healthcare Access in Canada
Prehospital STEMI Management Systems
in Canada
Levels of Prehospital EMS Care-Providers
Strategies for Prehospital STEMI Care: A Graduated
Approach

Conclusion
References

155
155
156
156
157
158
166
167


 Co nte nts
Chapter 9 Denmark: Prehospital STEMI
Management Systems
Maria Sejersten and Peter Clemmensen
A National Treatment Strategy for Acute
Myocardial Infarction (AMI) Patients
Demographics and the Prehospital Strategy
Involving the General Public in the STEMI
Management Team through Cardiopulmonary
Resuscitation (CPR) Training
Shortening Prehospital Delays to EMS Arrival
Ambulance Service Uniformity in Denmark
Prehospital ECG Recording and Transmission
Required by Law
Prehospital Triage by Cardiology Fellows and
Interventional Cardiologists
Prehospital Antithrombotic Therapy and

Transportation Protocols in Denmark
Expanded Helicopter Service
Conclusion
References
Chapter 10 Argentina: Prehospital Management
of STEMI
Liliana Grinfeld and Florencia Rolandi
Argentina: Demographics and Healthcare
System Resources
Estimations of Incidence and Mortality of
Myocardial Infarction in Argentina
Local Therapeutic Strategies
Components of Prehospital STEMI
Management in Argentina
Recommendations for Improvement
Conclusion
References
Chapter 11 Brazil: Prehospital Management of STEMI
Roberto Vieira Botelho and Thais Waisman
Demographics and Healthcare Delivery
Systems in Brazil

 

169

169
171

172

173
174
177
179
181
181
183
183
187

187
188
188
190
191
193
194
197

197

xi


xii 

Co nte nts
Particular Considerations for the Prehospital
Situation in Brazil
Current Programs—SAMU

Conclusion
References

199
201
203
204

Chapter 12 Chile: Prehospital Management of STEMI
Edgardo Escobar
Demographics and Epidemiology
Access to Medical Assistance
National ECG Call Center
Cardiology Consultant Contact with
Primary Physicians
National Protocol for Thrombolysis
The AUGE Law and Patient Outcomes for AMI
Conclusion
References

207

Chapter 13 France: Prehospital Management of STEMI
Nicolas Danchin, Etienne Puymirat, Eric Durand,
and Patrick Goldstein
Introduction
General Scheme of Prehospital Management
of Suspected AMI
Evaluation and Progress of Prehospital
AMI Management in France

Early Outcomes According to Prehospital
Use of Medications and Procedures
Conclusion
References

215

Index

227

207
208
208
209
210
211
212
212

215
216
216
222
224
225


About the
Editors-in-Chief

Editors-in-Chief
Joseph S. Alpert, MD, FAHA, FACC, MACP, FESC
Professor of Medicine, University of Arizona Health Science
Network; Editor-in-Chief, The American Journal of Medicine,
Tucson, Arizona
Lynne T. Braun, PhD, CNP, FAHA, FAAN
Professor, Department of Adult Health and Gerontological
Nursing, Rush University College of Nursing; Nurse Practitioner,
Section of Cardiology, Rush University Medical Center, Chicago,
Illinois
Barbara J. Fletcher, RN, MN, FAHA, FAAN
Clinical Associate Professor, Brooks College of Health, School of
Nursing, University of North Florida, Jacksonville, Florida
Gerald Fletcher, MD, FAHA, FACC, FACP
Professor in Medicine (Cardiovascular Diseases), Mayo Clinic
College of Medicine, Mayo Clinic Florida, Jacksonville, Florida

 

  xiii



About the Authors

Editors
Edgardo Escobar, MD, FACC, FAHA
Professor of Medicine, University of Chile; Medical
Director, ITMS Telemedicine of Chile, Santiago, Chile
Alejandro Barbagelata, MD, FAHA, FSCAI

Associate Professor of Medicine, Division of Cardiology,
University of Texas Medical Branch, Galveston, Texas

Contributors
George L. Adams, MD, MHS, FACC
Director of Cardiovascular and Peripheral Vascular Research,
Rex Healthcare, Raleigh, North Carolina; Clinical Associate
Professor of Medicine, University of North Carolina Health
Systems, Chapel Hill, North Carolina
Zubair Ahmed, MD, FSCAI
Assistant Professor, Interventional Cardiology; Director, Cardiac
Catheterization Laboratories, University of Arkansas for Medical
Sciences, Little Rock, Arkansas
Salman J. Bandeali, MBBS
Cardiology Fellow, Texas Heart Institute, Houston, Texas
Yochai Birnbaum, MD
Professor of Medicine, Department of Medicine, Section of
Cardiology, Baylor College of Medicine, Houston, Texas
Roberto Vieira Botelho, MD, PhD
Director, Triangulo Heart Institute, Uberlandia, Brazil
xv


xvi 

Abo ut the  Autho rs
Qiangjun Cai, MD, FACC, FACP
Division of Cardiology, University of Texas Medical Branch,
Galveston, Texas
Peter Clemmensen, MD, DMSc, FESC, FSCAI

Chair, Professor of Cardiology, University of Copenhagen; Chief
Physician, Heart Centre, Rigshospitalet, Denmark, Copenhagen
Nicolas Danchin, MD, PhD, FESC
Department of Cardiology, Hôpital Européen Georges
Pompidou, Assistance Publique Hôpitaux de Paris, and
Université Paris Descartes, Paris, France
Eric Durand, MD, PhD
Department of Cardiology, University Hospital of Rouen,
Rouen, France
Freij Gobal, MD
Cardiology, NEA Baptist Clinic, Jonesboro, Arkansas
Patrick Goldstein, MD
Medical Director, Head of Department, Emergency Department
and SAMU, Lille University Hospital, Lille, France
Denise Greci Robinson, RN, MS, CNS
Clinical Nurse Specialist, Emergency Department, Stanford
University Medical Center, Stanford, California
Liliana Grinfeld, MD, PhD, FSCAI, FACC
Interventional Cardiologist, Docent and Investigator,
Cardiovascular Fisiopathology Institute, School of Medicine,
University of Buenos Aires, Buenos Aires, Argentina
Abdul Hakeem, MBBS
Assistant Professor, Division of Cardiovascular Medicine,
University of Arkansas, Little Rock, Arkansas


 Abo ut the  Autho rs
Timothy D. Henry, MD
Director, Division of Cardiology, Lee and Harold Kapelovitz
Chair in Research Cardiology, Cedars-Sinai Heart Institute;

Professor, Department of Medicine, Cedars-Sinai Medical
Center; Professor In Residence, Step 3, David Geffen School of
Medicine; Department of Medicine, University of California Los
Angeles, Los Angeles, California
David A. Hildebrandt, RN, NREMTP
Minneapolis Heart Institute Foundation at Abbott Northwestern
Hospital, Minneapolis, Minnesota
Henry D. Huang, MD
Clinical and Research Electrophysiology Fellow, Arrhythmia
Service, Division of Cardiology, Beth Israel Deaconess Medical
Center; Harvard Thorndike Electrophysiology Institute, Boston,
Massachusetts
Waleed T. Kayani, MD
Department of Medicine, Baylor College of Medicine, Houston,
Texas
Darren Knapp, EMT-P
Vital Heart Response, Cardiac Sciences, EDM Zone, Alberta
Health Services; Mazankowski Alberta Heart Institute,
Edmonton, Alberta, Canada
David M. Larson, MD, FACEP
Chairman, Department of Emergency Services, Ridgeview
Medical Center, Waconia, Minnesota; Associate Clinical
Professor, University of Minnesota Medical School Minneapolis,
Minnesota
Michael J. Pompliano, NREMT, BS Biological Sciences
University of South Carolina Honors College, Columbia,
South Carolina
Etienne Puymirat, MD
Department of Cardiology, Hôpital Européen Georges
Pompidou, Université Paris Descartes, Paris, France

  xvii


xviii 

Abo ut the  Autho rs
Florencia Rolandi, MD, MSc
Cardiology Department, Italian Hospital of Buenos Aires,
Buenos Aires, Argentina
Maria Sejersten, MD, DMSc
Department of Cardiology, Roskilde Hospital, Roskilde,
Denmark
Barry F. Uretsky, MD
Director, Interventional Cardiology, University of Arkansas for
Medical Sciences and the Central Arkansas Veterans Health
System, Little Rock, Arkansas
Thais Waisman, MD, PhD
Engineering School at University of São Paulo – Interlab-EPUSP,
São Paulo, Brazil
Robert C. Welsh, MD, FRCPC, FACC, FAHA, FESC
Professor of Medicine, Department of Medicine and Division of
Cardiology, Mazankowski Alberta Heart Institute and University
of Alberta, Edmonton, Alberta, Canada
Eric Wiel, MD, PhD
Professor, Anesthesiologist-Intensivist-Emergency Physician,
Deputy Head of the Emergency Department & Academic
Head of Emergency Medicine, Emergency Department, Lille
University Hospital; Public Health Laboratory (EA 2694),
Northern France University, Lille, France

Abbreviations

ACC
ACCF
ACEIs
ACLS
ACP
ACS
ACTION
ADMIRAL

AEDs
AHA
AHS
ALS
AMI
AMU
ARVD
ASSENT-3
BLS
BRAVE
CA
CABG
CACI
CAD
CAG

 

American College of Cardiology
American College of Cardiology Foundation
angiotensin converting enzyme inhibitors
advanced cardiac life support
advanced care paramedic
acute coronary syndrome
Acute Coronary Treatment and Intervention
Outcomes Network
Abciximab before Direct Angioplasty and
Stenting in Myocardial Infarction Regarding
Acute and Long-Term Follow-Up
automated external defibrillators
American Heart Association
Alberta Health Services
advanced life support
acute myocardial infarction
advanced emergency medical unit
arrhythmogenic right ventricular dysplasia
Assessment of the Safety and Efficacy of a
New Thrombolytic agent
basic life support
Bavarian Reperfusion AlternatiVes Evaluation
cardiac arrest
coronary artery bypass grafting
Argentine College of Interventional
Cardioangiologists
coronary artery disease
coronary angiography

  xix


xx  

Abbre viatio ns
CCL
CCP
CCT RN
CHD
CHF
CL
CLA
CMS
CNS
CPR
cTnI
CVDs
D2B
DANAMI-2
DDKM
DIDO
DTD
DTN
ECG
ED
EMR
EMS
EMT
ERC

ESC
FINESSE
FMC
FTT
GDP
GP
GUSTO
GWTG
ILCOR
INDEC

cardiac catheterization laboratory
critical care paramedic
critical care transport nurse
coronary heart disease
congestive heart failure
catheterization laboratory
catheterization laboratory activation
Centers for Medicare and Medicaid Services
clinical nurse specialists
cardiopulmonary resuscitation
cardiac troponin I
cardiovascular diseases
door-to-balloon
Danish trial in acute myocardial infarction-2
Danish Healthcare Quality Program
door-in to door-out
door-to-device
door-to-needle
electrocardiogram/electrocardiographic

Emergency Department
emergency medical responder
emergency medical service/systems
emergency medical technician
European Resuscitation Council
European Society of Cardiology
Facilitated Intervention with Enhanced
Reperfusion Speed to Stop Events
first medical contact
Fibrinolytic Therapy Trialists’
gross domestic product
glycoprotein
Global Use of Strategies to Open Occluded
Arteries in Acute Coronary Syndromes
Get With the Guidelines
International Liaison Committee on
Resuscitation
National Institute of Statistics and Census
[Argentina]


 Abbre viatio ns
ISIS-2
ITMS
IVCD
LBBB
LMWH
LVH
MHI/ANW
MI

MICUs
NCDR
NISTE
NP
NRMI
NSTE-ACS
NSTEMI
OHCA
PCI
PCP
PI
POC
PPCI
RBBB
RCTs
REACT
REACT
RIKS-HIA
ROSC
SAC
SAMU
SAR
SRC
STE
STEMI
STREAM

International Study of Infarct Survival
International Telemedical System SA
intraventricular conduction delay

left bundle branch block
low molecular weight heparin
left ventricular hypertrophy
Minneapolis Heart Institute at
Abbott Northwestern Hospital
myocardial infarction
mobile intensive care units
National Cardiovascular Data Registry
nonischemic STE
nurse practitioner
National Registry of Acute MI
non-ST elevation-acute coronary syndrome
non-ST-elevation myocardial infarction
out-of-hospital cardiac arrest
percutaneous coronary intervention
primary care paramedic
pharmacoinvasive
point-of-care
primary percutaneous coronary intervention
Right bundle branch block
randomized controlled trials
Rapid Early Action for Coronary Treatment
Rescue Angioplasty versus Conservative
Treatment or Repeat Thrombolysis
Register of Information and Knowledge About
Swedish Heart Intensive Care Admissions
return of spontaneous circulation
Argentine Cardiology Society
Service d’Aide Médicale Urgente
search and rescue

STEMI receiving center
ST-segment elevation
ST-elevation myocardial infarction
Strategic Reperfusion Early After Myocardial
Infarction

  xxi


xxii 

Abbre viatio ns
TIME-NE
TIMI
TXA2
UFH
USIC
VF
WEST
WPW

Timely Intervention in Myocardial Emergency,
North-East
Thrombolysis In Myocardial Infarction
thromboxane A2
unfractionated heparin
Unité de Soins Intensifs Coronaires
ventricular fibrillation
Which Early ST-elevation MI Therapy
Wolff-Parkinson-White

in t r o d u c t io n

Increasing Importance
of Prehospital Care of
ST-Segment Elevation
Myocardial Infarction
Edgardo Escobar, MD, and Alejandro Barbagelata, MD

Due to the emergent nature of acute myocardial infarction (AMI), few events in medicine require such a rapid
and coordinated response from our healthcare system.
Unfortunately it remains a leading cause of mortality and
disability.
Giant steps have been made to abort the ongoing wavefront of myocardial necrosis in AMI with therapies that have
dramatically improved clinical outcomes if delivered in a
timely manner. Particularly following hospital admission, well
established guidelines around the globe allow effective management of AMI.
However, compared to the enormous amount of data available after hospital admission, the prehospital phase of AMI has
been mostly overlooked and much less data has been collected
and analyzed to determine the optimal management strategy.
This results in significant variation of care across different
regions.
This is particularly relevant due to the well known
early hazard of ST-segment elevation myocardial infarction

Prehospital Management of Acute STEMI: Practical Approaches and
International Strategies for Early Intervention © 2015 Joseph S. Alpert,
Lynne T. Braun, Barbara J. Fletcher, Gerald Fletcher, Editors-in-Chief,
Cardiotext Publishing, ISBN: 978-1-935395-66-9

 

 

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