Prehospital NSTEMI Patient Assessment and Treatment Paul A. Berlin, MS, NRP

Presenter Disclosure Information Paul A. Berlin Prehospital Non-STEMI Assessment and Treatment FINANCIAL DISCLOSURE: None UNLABELED/UNAPPROVED USES DISCLOSURE:

82 YOM, Hx HTN, complain of chest pressure ECG: High Risk ACS? 82 YOM, Hx HTN, complain of chest pressure

68 YOF, Weakness, 132/88, 83, 24 Inversion of T’s in V1, V2 & V3 avl Ischemic T’s in Anterior & Septal

Acute Coronary Syndrome Myocardial Infarction Presentation Working Dx ECG No ST Elevation ST Elevation Non-ST ACS Cardiac Biomarker UA NSTEMI Unstable Angina Myocardial Infarction Final Dx NQMI Qw MI Libby P. Circulation 2001;104:365, Hamm CW, Bertrand M, Braunwald E, Lancet 2001; 358:1533-1538; Davies MJ. Heart 2000; 83:361-366. Anderson JL, et al. J Am Coll Cardiol. 2007;50:e1-e157,

Myocardial Infarction Non-ST – Segment Elevation (NSTEMI) (30% - 45%) ST – Segment Elevation (STEMI) (55% - 70%) How do we find the 30% - 45% of MI patients we are missing?

Prognosis of NSTEMI vs STEMI GUSTO IIb Cumulative mortality (%) 2 4 6 8 10 30 60 90 120 150 180 Days from randomization T-wave inversion ST  ACS STEMI with fibrinolytics Short-term (in-hospital or one month) mortality: NSTEMI (3-5%) compared to STEMI (10-15%). Re-infarction rate after hospital discharge NSTEMI (15-25%) to STEMI (5-8%). Long-term mortality is similar or higher in NSTEMI compared to STEMI (two year mortality is approximately 30% in both cases References Savonitto S, Ardissino D, Granger CB, et al. Prognostic value of the admission electrocardiogram in acute coronary syndromes. JAMA. 1999;281:707-713.

NSTEMI ECG Features Can Be: ST depression (70-80%) T wave inversion(10-20%) Symmetrical Both ST depression and T wave inversion Normal ECG

Assess Applicability for ACS Triage WA State EMS ≥ 21 years of age with symptoms lasting more than 10 minutes but less than 12 hours suspected to be caused by coronary artery disease: Chest discomfort, pressure, crushing pain, tightness, heaviness, cramping, burning, aching sensation, usually in the center of the chest lasting more than a few minutes, or that goes away and comes back. Epigastric (stomach) discomfort, such as unexplained indigestion, belching, or pain. Shortness of breath with or without chest discomfort. Radiating pain or discomfort in 1 or both arms, neck, jaws, shoulders, or back. Other symptoms may include sweating, nausea, vomiting. Women, diabetics, and geriatric patients might not have chest discomfort or pain. Instead they might have nausea/vomiting, back or jaw pain, fatigue/weakness, or generalized complaints.

Assess High Risk Criteria Based on TIMI (Three or more checked, High risk for NSTEMI) Age ≥ 55* 3 or more CAD risk factors: Family history of CAD High BP High cholesterol Diabetes Current smoker Aspirin use in last 7 days Angina in last 24 hours ST-segment deviation on ECG Known coronary disease Elevated cardiac biomarkers

Reporting Times for Cardiac Markers for the ED Bedside Test (mean=15 mins) Laboratory Test (mean=128 mins) 20 40 60 80 100 120 140 160 180 Test Type Reporting Times (mins) POC Point-of-care testing reduces ED length of stay (Annals of EM, June 2005)

High-sensitivity cardiac troponin I at presentation in patients with suspected ACS Low plasma troponin concentrations identify two–thirds of patients at very low risk of cardiac events who could be discharged from hospital. Implementation of this approach could substantially reduce hospital admissions and have major benefits for both patients and health–care providers. The Lancet, 10/27/2015 Shah ASV, et al.

NSTEMI MORTALITY RATES: EARLY vs LATER CATH Bhatt, D. L. et al. JAMA 2004;292:2096-2104.

Treatment Options Limit scene time Transport patient to the right facility Follow AHA or local protocols Communicate with receiving facility Transmit ECG if available Fibrinolytic check sheet PRN

Challenges ECG quality Acceptance of POC Risk Assessment Training Establishing POC Risk Assessment Training Acceptance by Receiving Centers

Questions? NSTEMI recognition programs are the next step in ACS care following the implementation of strong Prehospital STEMI care programs. Early recognition of NSTEMI using ECG findings, risk stratification and early biomarkers by prehospital care providers can direct patients to appropriate receiving facilities and reduce morbidity and mortality.

Paul A. Berlin Irondoc.paul@gmail.com Contact Info: Paul A. Berlin Irondoc.paul@gmail.com

Reference Cannon CP. J Thromb Thrombolysis. 1995;2:205-218. Journal of the American College of Cardiology, 2007; 50:1-157, doi:10.1016/j.jacc.2007.02.013 Anderson JL, et al. J Am Coll Cardiol 2007;50:e1–e157, Bhatt, D. L. et al. JAMA 2004;292:2096-2104 European Heart Journal. 2007;28(12):1409-1417. Christenson R: Md Med 2001 Spring:Suppl:98-103 Galvani M, et al. Circulation 2004;110:128–34. Antman EM. N Engl J Med 1996; 335: 12342-1349 Antman et al, JAMA, 284:835 de Lemos JA, et al. N Engl J Med. 2001;345:1014-1021 Savonitto S, et al. JAMA. 1999;281:707-713 Shah ASV, et al. The Lancet, 10/27/2015 The Lancet, 10/27/2015 Shah ASV, et al. Abdul Wadud NSTEMI.ORG, NSTEMI vs STEMI, September 12, 2013 update 5/25/14 http://www.americanheart.org/presenter.jhtml?identifier=251