WHAT IS PEER TO PEER?
Med-IQ's new complimentary, certified continuing medical education (CME) activity,
Peer to Peer: A New Model for Improving Guideline- and Evidence-Based ACS Care, is connecting healthcare professionals from across the country. This exciting, first-of-its-kind CME series provides participants with access to acute coronary syndrome (ACS) faculty experts during personalized sessions focusing on improving ACS patient care in their practices. This real-time exchange of ideas has helped address some of the major challenges that clinical practices face in managing ACS cases.

WHAT ARE E-BRIEFS?
Each month, Med-IQ will publish a short e-brief to highlight real-world questions, opportunities for improvement, and front-line perspectives gained from these ACS Peer to Peer teleconferences. Below, you'll find the ninth of these e-briefs; in this installment, our expert faculty answer questions about reperfusion strategies and patient transport times.

Although ACC/AHA guidelines indicate when fibrinolysis may be preferable over percutaneous coronary intervention (PCI) as treatment for STEMI, in reality, numerous factors may need to be considered when deciding upon therapy. Below, our faculty explore some of these complexities and answer questions on time-to-treatment, improving patient transport times, and contraindications to fibrinolysis.

Selecting a Reperfusion Strategy
Question: If the door-to-balloon time for a patient with STEMI is projected to be 120 minutes or longer, should that patient undergo fibrinolysis instead?

Answer: ACC/AHA guidelines emphasize the importance of performing primary PCI, if available, in patients with STEMI within 90 minutes of presenting to the hospital (door-to-balloon time) to minimize mortality risk.¹ However, if a STEMI patient presents to a non–PCI-capable hospital (and cannot be transferred to a PCI center and undergo PCI within 90 minutes of first medical contact), guidelines recommend fibrinolysis with a door-to-needle time of 30 minutes or less, unless fibrinolytic therapy is contraindicated.

There has been some debate about whether the recommended door-to-balloon time should be greater than 90 minutes; in certain patients, the mortality advantage of primary PCI compared with fibrinolytic therapy is maintained with more prolonged door-to-balloon times—up to 120 minutes or even longer in some circumstances.^2,3 An observational study based on National Registry for Myocardial Infarction (NRMI) data found that in a cohort of more than 192,500 patients, the adjusted odds of death were identical with either PCI or fibrinolytic therapy when the PCI-related delay (door-to-balloon time minus door-to-needle time, or DB-DN) was approximately 114 minutes.² Thus, the mortality benefit of PCI over fibrinolysis did not begin to wane until around a DB-DN of almost 2 hours. Hence, on the basis of this study, if the door-to-balloon time would exceed 2 hours, fibrinolysis would appear to be the therapeutic choice.

It should be emphasized, however, that the analysis of the NRMI data also revealed that any delay at all in reperfusion times results in increased mortality rates, suggesting that door-to-balloon times of less than 90 minutes, if possible, could result in even fewer deaths than reaching the benchmark of 90 minutes.³

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Improving Transport Times for STEMI Patients
Question: In some regional hospital systems with no PCI capabilities, transfer/transport times of a patient with STEMI to a PCI lab can take an hour or longer, making it difficult to achieve door-to-balloon times of less than 90 minutes. What are some strategies that can help reduce transfer times?

Answer: Few patients with STEMI who are transferred from a hospital to a PCI-capable facility undergo PCI within the recommended 90 minutes. In fact, the median door-to-balloon time in such patients is 180 minutes.⁴ Certain strategies may help shorten transfer times to a PCI facility in patients with ACS. The use of prehospital ECGs by emergency medical services (EMS) to determine a STEMI diagnosis and expedite transport to an appropriate facility is one such strategy.¹ Another option is to limit the "door-in/door-out" time by keeping patients on the EMS stretcher at the emergency room while the ECG is obtained and interpreted. The ambulance should be instructed to wait. This avoids a time delay associated with having the patient physically admitted, moved to a bed, and then moved back to an ambulance. However, coordinating these changes with EMS, other regional hospitals, and the PCI facility will require collaboration with representatives from each institution to create an agreed-upon protocol to reduce transport times.

One example of a regional systems model aimed at reducing transfer and transport times in ACS patients is the RACE project (reperfusion of acute myocardial infarction in North Carolina emergency departments). Information about this initiative is available on the American College of Cardiology’s North Carolina Chapter Web site at www.nccacc.org/news/news1.html.

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Contraindications to Fibrinolysis
Question: Is fibrinolysis always contraindicated in a STEMI patient who has a history of structural central nervous system (CNS) disease?

Answer: Antiplatelet therapies may be safely given in a STEMI patient with CNS disease, but whether or not fibrinolytic therapy is contraindicated will depend, in many instances, on when the CNS lesion occurred. Structural cerebral vascular lesions, ischemic stroke within 3 months (except ischemic stroke within 3 hours of symptom onset), significant head trauma within 3 months, and intracranial malignant neoplasm are absolute contraindications for fibrinolysis.⁵ Thus, a patient who had a stroke several years earlier would be eligible to undergo treatment with fibrinolytic agents.

Other conditions that predispose to intracranial hemorrhage may also rule out the use of fibrinolytics in the STEMI patient. For example, severe hypertension that cannot be controlled with medication would preclude fibrinolysis.⁵

It is important to keep in mind that, even in the absence of contraindications, the use of fibrinolytics is associated with approximately a 1% risk of intracranial hemorrhage.⁶ Thus, in patients who have a substantial risk of intracranial hemorrhage—such as older patients—primary PCI is preferred over fibrinolysis if it is available.⁵ In either situation, however, the contraindications to fibrinolysis must be considered when making treatment decisions.

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REFERENCES

1. Antman EM, Hand M, Armstrong PW, et al. 2007 focused update of the ACC/AHA 2004 guidelines for the management of patients with ST-elevation myocardial infarction: J Am Coll Cardiol. 2008;51(2):210-247.

2. Pinto DS, Kirtane AJ, Nallamothu BK, et al. Hospital delays in reperfusion for ST-elevation myocardial infarction: implications when selecting a reperfusion strategy. Circulation. 2006;114(19):2019-2025.

3. Kushner FG, Hand M, Smith SC Jr, et al. 2009 focused updates: ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction and ACC/AHA/SCAI guidelines on percutaneous coronary intervention. Circulation. 2009;120(22):2271-2306.

4. Nallamothu BK, Bates ER, Herrin J, et al. Times to treatment in transfer patients undergoing primary percutaneous coronary intervention in the United States: National Registry of Myocardial Infarction (NRMI)-3/4 analysis. Circulation. 2005;111(6):761-767.

5. Antman EM, Anbe DT, Armstrong PW, et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction--executive summary. J Am Coll Cardiol. 2004;44(3):671-719.

6. De Jaegere PP, Arnold AA, Balk AH, et al. Intracranial hemorrhage in association with thrombolytic therapy: incidence and clinical predictive factors. J Am Coll Cardiol. 1992;19:289-294.

Educational Strategies in Atrial Fibrillation: Improving Guideline-Based Care at the Practice Level Register today for your personalized, certified CME teleconference in atrial fibrillation (AF). This exciting new CME series allows you to discuss guideline- and evidence-based care regarding rate and rhythm control in AF with a faculty expert. For more information, call (toll-free) 866 858 7434 or e-mail concierge@med-iq.com, or you can register today by completing this brief online form.   This activity has been approved for AMA PRA Category 1 Credit™. This activity is supported by an educational grant from sanofi-aventis U.S.

This activity is supported by an educational grant from sanofi-aventis U.S.

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