1. OHSU - BDMS Heart CoE ACS Program
3rd Video Conference
July 26, 2018

2. Agenda from OHSU Brief update on upcoming visit
Plan of OHSU visit to Thailand
Schedule and plan for remaining video conference
Standardization through cardiac CoE at a local level
Discussion on radial access, medication, same day discharge

3. Standardization STEMI Guidelines Reperfusion STEMI Equivalent
15 lead ECG
Non STE ACS
UA definition
NSTEMI, hs-cTn
Registry
ACTION Registry-GWTG Format
Definition

4. Guidelines
BDMS CoE Heart
Articles
STEMI
Practice Guidelines
2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction (Article)
2015 ACC/AHA/SCAI Focused Update on Primary Percutaneous Coronary Intervention for Patients With ST-Elevation Myocardial Infarction (Article)
2012 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation (Article)
2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation (Article)
2014 แนวทางเวชปฏิบัติในการดูแลผู้ป่วย โรคหัวใจขาดเลือดในประเทศไทย ฉบับปรับปรุง ปี (Article)
สถานการณผู้ป่วยกล้ามเนื้อหัวใจขำดเลือดหรือตายชนิดที่มี ST Elevation ในประเทศไทย (Article)
Performance measure
2006 ACC/AHA Clinical Performance Measures for Adults With ST-Elevation and Non-ST-Elevation Myocardial Infarction (Article)
2008 ACC/AHA Performance Measures for Adults With ST-Elevation and Non–ST-Elevation Myocardial Infarction (Article)
2017 AHA/ACC Clinical Performance and Quality Measures for Adults With ST-Elevation and Non- ST-Elevation Myocardial Infarction (Article)
2015 ACC/AHA/STS Statement on the Future of Registries and the Performance Measurement Enterprise (Article)

5. Guidelines NSTEMI Practice Guidelines
BDMS CoE Heart
NSTEMI
Practice Guidelines
2014 AHA/ACC Guideline for the Management of Patients with Non-ST-Elevation Acute Coronary Syndromes (Article)
2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation (Article)
Performance measure
2006 ACC/AHA Clinical Performance Measures for Adults With ST-Elevation and Non-ST-Elevation Myocardial Infarction (Article)
2008 ACC/AHA Performance Measures for Adults With ST-Elevation and Non–ST-Elevation Myocardial Infarction (Article)
2017 AHA/ACC Clinical Performance and Quality Measures for Adults With ST-Elevation and Non- ST-Elevation Myocardial Infarction (Article) UA
Practice Guidelines
See NSTEMI guidelines
2017 Classification of unstable angina and non-ST elevation myocardial infarction. UpToDate (Article)
Unstable Angina: Is It Time for a Requiem? (Braunwald and Morrow) (Article)
Performance measure
See NSTEMI Performance measure
Statement from ACC/AHA 2008 Performance Measures for Adults With ST-Elevation and Non–ST-Elevation Myocardial Infarction………… Unstable angina (UA) is not considered in this document, in part because of the difficulty in defining the population with certainty.

6. STEMI

7. Reperfusion Therapy for Patients with STEMI
BDMS CoE Heart
Reperfusion Therapy for Patients with STEMI
ACCF/AHA 2013
Anticipated D2B >120 min
Fibrinolysis within 30 min Transfer to PCI center
Angiogram/PCI in (2)3-24 h
Next slide

8. Reperfusion Therapy for Patients with STEMI
BDMS CoE Heart
Reperfusion Therapy for Patients with STEMI
BDMS CoE Heart
STEMI Rx
Rapid Reperfusion
ACCF/AHA 2013
Thrombolytic
PPCI
For Thailand
Pharm-invasive
The Differences
Culture/knowledge effecting patient decision
Payment system effecting patient decision and time delay
Non PCI capable knowledge and resource
EMS system
Transport system: One/two ways, traffic, helicopter myth for STEMI primary PCI
Solo practice? ….
Not for Thailand
IA (ESC 2012, 2017)
(For now)
IIA (ACC 2013)
(Rescue PCI)
(Pharmaco-invasive)

9. The Differences Culture/knowledge effecting patient decision
Payment system effecting patient decision and time delay
Non PCI capable knowledge and resource
EMS system
Transport system: One/two ways, traffic, helicopter myth for STEMI primary PCI
Solo practice ….

10. [New or presumably new] LBBB have to meet Sgarbossa (-Smith) Criteria)
BDMS CoE Heart
Society of Cardiology/ACCF/AHA/World Heart Federation Task Force for the Universal Definition of Myocardial Infarction, 2012.
“STEMI equivalent”
ST depression in 2 precordial leads (V1–V4) may indicate transmural posterior injury (Should perform posterior lead ECG, V7-9)
Multilead ST depression with coexistent ST elevation in lead aVR has been described in patients with left main or proximal left anterior descending artery occlusion
Hyperacute T-wave changes may be observed in the very early phase of STEMI, before the development of ST elevation
[New or presumably new] LBBB have to meet Sgarbossa (-Smith) Criteria)
De Winter STT complex (Not include in current guidelines)

11. BDMS CoE Heart

12. BDMS CoE Heart

13. UA

14. BDMS CoE Heart A
Anginal pain characteristic (To be placed in the patient medical record / MD to fill in)
Ask
Yes No
Comment / Detail
Location 
Substernal, shoulder(s), arms (L), neck-throat, Jaw(s), teeth, epigastrium. *
Substernal
Others
Characteristic
Pain - Pressure, tightness, heaviness, squeezing, fullness, burning, sharp, stabbing, indigestion.
Pressure
Sharp
Radiation
(see “location”)
Exertional relate
Duration
Second …… /minute …… (>20 Min) →
Relieved by rest
1st episode
Recurrent
Hours , Days , Weeks , Months 
Crescendo angina
CCS angina class
(1, 2, 3, 4)
Pleuro-pericarditis
Physician opinion can overide
* for ACS (UA) diagnosis needs at least 3
It should be document on medical record.
Good for all patient with chest pain.

15. Proposal for using uniform UA definition for more uniform statistic
BDMS CoE Heart B
Proposal for using uniform UA definition for more uniform statistic
Anginal pain in NSTE-ACS (UA and NSTEMI).
Prolonged (> 20 min) anginal pain at rest.
New onset (de novo) angina (class II or III of the Canadian Cardiovascular Society classification).
Recent destabilization of previously stable angina with at least Canadian Cardiovascular Society Class III angina characteristics (crescendo angina)
Post-MI angina. (Angina that occurs from a few hours to 30 days after acute MI is defined as postinfarction angina. Cleveland Clinic)
NSTEMI 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation
Note that 1-3 criteria of “B” is in “A” too

16. NSTEMI and hs-cTn

17. NSTEMI Diagnosis with 0 hr / 1 hr algorithm NSTEMI 2015 ESC Guidelines
BDMS CoE Heart
NSTEMI Diagnosis with 0 hr / 1 hr algorithm NSTEMI 2015 ESC Guidelines
* Only applicable if chest pain onset >3 h
(For Roche Elecsys)
0 hr
0 – 1 hr
Rule-out
<5*
<12
<3
Rule-in
>52
>5
ng/L
ng/L

18. The first algorithm to rule-in or rule-out AMI within 0 to 1 hour
BDMS CoE Heart
The first algorithm to rule-in or rule-out AMI within 0 to 1 hour
2015 NSTE-ACS ESC Guidelines
Reccommend
cTnT-hs values in patients presenting to the emergency department with chest pain1
0h < 5ng/L*
0h < 12 ng/L and △1h < 3ng/L
Other
0h ≥ 52 ng/L or △1h ≥ 5 ng/L
Observational zone (retest later, e.g. 3h)
Rule-in
Rule-out
The troponin values have to be used in conjunction with full clinical assessment including clinical symptoms and 12-lead ECG
1 Roffi, M. et al.(2016). Eur Heart J 37(3),
AMI = acute myocardial infarction, ESC = European Society of Cardiology, ECG = electrocardiogram, NSTE-ACS = non-ST-segment elevation acute coronary syndrome
* Only applicable if chest pain onset > 3 h

19. Characteristics of the 0 h/3 h and the 0 h/1 h algorithms
BDMS CoE Heart
Characteristics of the 0 h/3 h and the 0 h/1 h algorithms
2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation – Web Addenda
Recommend 0h/1h algorithm
GRACE = Global Registry of Acute Coronary Events; MI = myocardial infarction. a = Effectiveness is quantified by the percentage of consecutive chest pain patients clearly classified as rule-out or rule-in of acute MI (i.e., approximately 60% for the 0 h/3 h algorithm and approximately 75% for the 0 h/1 h algorithm)

20. ACC/AHA 2014 Guidelines (Slide set)
BDMS CoE Heart
Factors Associated With Appropriate Selection of Invasive Strategy or Ischemia-Guided Strategy in Patients With NSTE-ACS
YES
Immediate invasive
(within 2 h)
1. Refractory angina □
2. Signs or symptoms of HF or new or worsening mitral regurgitation
3. Hemodynamic instability (and cardiogenic shock)
4. Recurrent angina or ischemia at rest or with low-level activities despite intensive medical therapy
5. Sustained VT or VF
Early invasive (within 24 h)
1. None of the above, but GRACE risk score >140
2. Temporal change in Tn
3. New or presumably new ST depression
Delayed invasive
(within 2572 h)
1. None of the above but diabetes mellitus
2. Renal insufficiency (GFR <60 mL/min/1.73 m²)
3. Reduced LV systolic function (EF <0.40)
4. Early post infarction angina
5. PCI within 6 mo
6. Prior CABG
7. GRACE risk score 109–140; TIMI score ≥2
Ischemia-guided strategy
1. Low-risk score (e.g., TIMI [0 or 1], GRACE [<109])
2. Low-risk Tn-negative female patients
3. Patient or clinician preference in the absence of high-risk features
ACC/AHA 2014 Guidelines (Slide set)

21. Registry / Radial Access

25. Thank you