1. Eddy Lang MD Attending Staff Emergency Department Jewish General Hospital Update in reperfusion therapy for acute myocardial infarction

2. Educational Process Objectives Use a problem-solving approach to address two controversial topics in MI reperfusion Review databases of research evidence Introduce the concept of the study synopsis

3. Clinical Scenario 52 year old male with chest pain x 2 hrs. No history of CAD, risk factors ++ Severe central C/P with radiation and diaphoresis and SOB No known bleeding No head trauma

4. Clinical Scenario Pale, diaphoretic BP 140/70 Pulse 115 RR 24 Chest: clear CVS: Normal HS; Ø JVD; Ø murmers Abdo: soft CNS: normal

8. Clinical Setting 4th year EM resident moonlighting at the Lakeshore Girlfriend/boyfriend working ED at JGH No formal transfer arrangement Arrange primary PTCA and transfer? (ignore the politics)

9. Clinical Question In patients with acute myocardial infarction who are candidates for reperfusion therapy but present to a center that doesn’t offer PCA does transport to a center with cath lab capabilities within a 3-hour window compared to early thrombolysis on-site reduce mortality?

10. Search Strategy Question type Resource: where would you look? –systematic review –shortcut reviews –primary RCTs –meta-search engines –cutting edge studies

11. Systematic Review

12. Shortcut Review 10 trials 2 600 pts.

13. Shortcut Review

16. Primary Studies

18. Meta-search engines

19. Cutting edge stuff

43. Clinical Scenario 52 year old male with chest pain x 2 hrs. No history of CAD, risk factors ++ Severe central C/P with radiation and diaphoresis and SOB No known bleeding No head trauma

44. Clinical Setting 4th year resident moonlighting on a rural rotation Extremely well-stocked ED pharmacy Ø IIb/IIIa inhibitors PCI unavailable In addition to ASA what anti-thrombin therapy should you give? UFH (most familiar)? LMWH? Does it matter?

45. Clinical Question In patients with acute myocardial infarction who are receiving thrombolytic therapy and ASA does adjuvant antithrombin therapy with LMWH in comparison with UFH reduce adverse cardiac events during the following 30 days without an unacceptable increase in bleeding?

46. Efficacy and safety of tenecteplase in combination with enoxaparin, abciximab, or unfractionated heparin: the ASSENT-3 randomised trial in acute myocardial infarction The ASSENT-3 Investigators Lancet 2001;358:605–13 ASSENT 3

47. Breakout tasks Develop a study synopsis 1. Maximum 5 sentences Appraise methodology 2. Prognosis before the start of the study 3. Prognosis after the start of the study Define the key issues in applicability 4. Why not use it

48. Aside from the experimental intervention, were groups treated equally?

49. Conclusions PCA: Even with 90 min additional delay PCA superior to lysis Evidence behooves the interventionist to come in at 2:00am Referral centers are coming Adjuvant anti-thrombotic therapy: Enoxaparin superior to UFH