1. Listening to the Data: Why There’s Room for Improvement in MI Care Heartscape® Consultants Meeting Charles V. Pollack, Jr, MA, MD, FACEP, FAAEM, FAHA Chairman, Department of Emergency Medicine Pennsylvania Hospital Professor of Emergency Medicine University of PennsylvaniaSchool of Medicine University of Pennsylvania School of Medicine Philadelphia, PA Charles V. Pollack, Jr, MA, MD, FACEP, FAAEM, FAHA Chairman, Department of Emergency Medicine Pennsylvania Hospital Professor of Emergency Medicine University of PennsylvaniaSchool of Medicine University of Pennsylvania School of Medicine Philadelphia, PA

2. Antman EM, Hand M, Armstrong PW, et al. 2007 Focused update of the ACC/AHA 2004 guidelines for the management of patients ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol and Circulation; at www.acc.org and www.americanheart.org.www.acc.org www.americanheart.org Pollack CV, Antman EA, Hollander JE: 2007 Focused update to the ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction: Implications for emergency department practice. Ann Emerg Med 2008, in press. STEMI: Optimal Therapy, 12/12/07

3. Anderson JL, Adams CD, Antman EM, et al. 2007 guidelines for the management of patients with unstable angina/non-ST-segment-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2007;50:e1-e157, and Circulation 2007;116:e148-e304, and at www.acc.org and at www.americanheart.org.www.acc.org www.americanheart.org Pollack CV, Braunwald E: 2007 Update to the ACC/AHA guidelines for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction: Implications for emergency department practice. Ann Emerg Med 2008;51:591-606. NSTE ACS: Optimal Therapy, 8/6/07

4. STEMI diagnosis is clinical + ECG; markers not necessary there is risk stratification within STEMI, but in general, STEMI is high-risk treatment focus is on opening the IRA as soon as possible Necessary components: clinical recognition accurate ECG interpretation rapid treatment response STEMI vs NSTE ACS

5. NSTEMI diagnosis is clinical + markers; ECG Δs not necessary and often irrelevant risk stratification driven by biomarkers: elevated troponin = elevated risk treatment focus is on medical stabilization and early (24-48h) intervention Necessary components: clinical recognition accurate ECG interpretation (exclude STEMI) consistent treatment response STEMI vs NSTE ACS

6. Unstable angina diagnosis is clinical; ECG Δs not necessary and markers are negative by definition ST-segment depression confers somewhat higher risk and more likely to benefit from more aggressive therapy treatment focus is on medical stabilization and further evaluation Necessary components: clinical recognition consistent care and treatment STEMI vs NSTE ACS

7. clinical recognition reliance on ECG (as a rule-in or as a rule-out) timely evaluation and treatment consistent care STEMI vs NSTE ACS: Commonality

8. clinical recognition reliance on ECG (as a rule-in or as a rule-out) timely evaluation and treatment consistent care STEMI vs NSTE ACS: Commonality

9. We Must Risk Stratify Patients with Chest Pain Three levels of risk strat are pertinent to the ED: low, intermediate, or high risk that ischemic symptoms are a result of CAD low, intermediate, or high risk of short-term death or nonfatal MI from ACS dynamic, ongoing risk-oriented evaluation of low- or intermediate-risk patients for “conversion” to high- risk status that is linked to intensity of treatment Three levels of risk strat are pertinent to the ED: low, intermediate, or high risk that ischemic symptoms are a result of CAD low, intermediate, or high risk of short-term death or nonfatal MI from ACS dynamic, ongoing risk-oriented evaluation of low- or intermediate-risk patients for “conversion” to high- risk status that is linked to intensity of treatment Pollack CV. Ann Emerg Med 2001;38:229

10. up to one-third of ACS patients present without chest pain of these, 2/3 are NSTE ACS and 1/3 are STEMI particularly prevalent in women, diabetics, and patients with a history of heart failure “atypical is the new typical” as we see older and older patients, but atypical presentations are classically associated with delayed diagnosis and treatment Clinical Recognition of ACS Canto J et al, JAMA 2000; 283:3223

11. Clinical Recognition of ACS Drives Tx Canto J et al, JAMA 2000; 283:3223 Each comparison p < 0.001

12. Risk Scores TIMI GRACE PURSUIT ACI-TIPI Goldman best used to supplement—not replace—clinical judgment less useful in atypical presentations, but indeed validated in an ED population... Clinical Recognition of ACS

13. 0 10 20 30 40 50 0/123456/7 D/MI/Urg 14d (%) D/MI/Urg Revasc 14d (%) Risk Factors Risk Factors Risk Level LOW INTERMEDIATE HIGH UFH Group TIMI 11B (N= 1957) TIMI risk score for UA/NSTEMI Antman EM et al. JAMA 2000; 284:835 4.7 8.3 13.2 19.9 26.240.9

14. TIMI risk score for UA/NSTEMI Pollack CV et al. Acad Emerg Med 2006;13:13 0 10 20 30 40 50 0/123456/7 D/MI/Urg 30d (%) D/MI/Urg Revasc 30d (%) Risk Factors Risk Factors 7.1 10.1 19.5 22.1 39.2 45 Risk Level LOW INTERMEDIATE HIGH

15. Validation and treatment interaction for enoxaparin (ESSENCE data) 19.8 16.6 Risk factors % Triple endpoint (14d) UFH Enoxaparin 0 10 20 30 40 50 60 Total0/123456/7 population p=0.02  2 for trend p<0.001  2 for trend Antman EM at al, JAMA 2000;284:835

16. clinical recognition reliance on ECG (as a rule-in or as a rule-out) timely evaluation and treatment consistent care STEMI vs NSTE ACS: Commonality

17. ECG   Carries diagnostic and prognostic value   Especially valuable if captured during pain   ST-segment depression or transient ST-segment elevation are primary ECG markers of UA/NSTEMI   up to 25% of patients with NSTEMI and +marker develop Q-wave MI; 75% have NSTEMI   only classifying differentiation between UA and NSTEMI is a positive biomarker   inverted T-waves suggestive of ischemia, particularly with good chest pain story   Carries diagnostic and prognostic value   Especially valuable if captured during pain   ST-segment depression or transient ST-segment elevation are primary ECG markers of UA/NSTEMI   up to 25% of patients with NSTEMI and +marker develop Q-wave MI; 75% have NSTEMI   only classifying differentiation between UA and NSTEMI is a positive biomarker   inverted T-waves suggestive of ischemia, particularly with good chest pain story

18. ECG   Generally more useful in identifying STEMI than UA/NSTEMI   GLs suggest that serial ECGs increase both sensitivity and specificity   GLs withhold recommendation on utility of continuous ST-segment monitoring   GLs recommend mathematical models based on ECG findings only for identification of patients at low risk and for prognosis in those with ischemia   Generally more useful in identifying STEMI than UA/NSTEMI   GLs suggest that serial ECGs increase both sensitivity and specificity   GLs withhold recommendation on utility of continuous ST-segment monitoring   GLs recommend mathematical models based on ECG findings only for identification of patients at low risk and for prognosis in those with ischemia

19. ECG: Limitations   Only a point-in-time sample  Most common ECG in NSTE ACS is NSSTTΔs  In i*trACS, more than half of initial ECGs in patients with evolving MIs were nondiagnostic

20. ECG: Limitations   Large portions of myocardium are missed or at best are indirectly seen   Posterior wall   RV   High lateral   Addressed with   Additional leads   Not often done... Not often done correctly... Not enough “coverage”   Large portions of myocardium are missed or at best are indirectly seen   Posterior wall   RV   High lateral   Addressed with   Additional leads   Not often done... Not often done correctly... Not enough “coverage”

21. ECG: Limitations   Difficulties in interpretation   BBB   LVH   Early repolarization   Pericarditis   Inexperienced reader   Addressed with   Computerized interpretations   Consultation   Training   Risk management   Difficulties in interpretation   BBB   LVH   Early repolarization   Pericarditis   Inexperienced reader   Addressed with   Computerized interpretations   Consultation   Training   Risk management

22. clinical recognition reliance on ECG (as a rule-in or as a rule-out) timely evaluation and treatment consistent care STEMI vs NSTE ACS: Commonality

23. STEMI D2B target 90 minutes new data suggest that the likelihood of achieving TIMI-3 flow after PPCI is decreased by 21% (95% CI, 10-31%) with every 60min ischemic time* likelihood of achieving optimal (TMPG 2/3) reperfusion after PPCI is decreased by 19% (4-31%) with every 60min ischemic time* TMPG 2/3 associated with reduced 90day mortality D2N target 30 minutes STEMI vs NSTE ACS: Time, Time, Time * Brener SJ et al, Eur Heart J 2008;29:1127

24. NSTE ACS (high risk) 2000 ACC/AHA GLs: inpatient evaluation recommended (I-C) 2002 ACC/AHA GLs: diagnostic cath recommended within 48h (I-A) 2007 ACC/AHA GLs: diagnostic cath recommended within 4-24h (I-A) STEMI vs NSTE ACS: Time, Time, Time

25. Time to treatment is dependent on time to diagnosis, and accuracy of diagnosis ECG within 10 minutes accuracy not addressed markers within 60 minutes proper patients for assay must first be identified Public reporting of times has increased pressure on providers (image, P4P, medicolegal risk) and led to unusual interpretations of efficiency of care STEMI vs NSTEMI PPCI vs lysis STEMI vs NSTE ACS: Time, Time, Time

26. clinical recognition reliance on ECG (as a rule-in or as a rule-out) timely evaluation and treatment consistent care STEMI vs NSTE ACS: Commonality

27. UMass STEMI %DTB < 90 minutes vs Mortality Courtesy of Greg Volturo, MD

28. Hospital Link Between Overall Guidelines Adherence and Mortality: NSTE-ACS Peterson ED et al, JAMA 2006;295:1863 Every 10%  in guidelines adherence  10%  in mortality (OR=0.90, 95% CI: 0.84-0.97)

29. Conclusions ► ► ACS evaluation is complicated by atypical presentations, concern over medicolegal risk, inadequate collaboration across disciplines, and public reporting/P4P issues ► ► Atypical presentations are increasingly common ► ► Electrocardiography, the traditional ED triage point for emergent vs urgent therapy, is limited by time, geography, and reading expertise ► ► Patient care and outcomes may be significantly hampered by these issues ► ► ACS evaluation is complicated by atypical presentations, concern over medicolegal risk, inadequate collaboration across disciplines, and public reporting/P4P issues ► ► Atypical presentations are increasingly common ► ► Electrocardiography, the traditional ED triage point for emergent vs urgent therapy, is limited by time, geography, and reading expertise ► ► Patient care and outcomes may be significantly hampered by these issues