listening to the data: why there’s room for improvement in mi care heartscape® consultants...

Listening to the Data: Why There’s Room for Improvement

in MI Care

Listening to the Data: Why There’s Room for Improvement

in MI Care

Heartscape® Consultants MeetingHeartscape® Consultants Meeting

Charles V. Pollack, Jr, MA, MD, FACEP, FAAEM, FAHACharles V. Pollack, Jr, MA, MD, FACEP, FAAEM, FAHAChairman, Department of Emergency MedicineChairman, Department of Emergency Medicine

Pennsylvania HospitalPennsylvania HospitalProfessor of Emergency MedicineProfessor of Emergency Medicine

University of PennsylvaniaUniversity of Pennsylvania School of MedicineSchool of MedicinePhiladelphia, PAPhiladelphia, PA

Charles V. Pollack, Jr, MA, MD, FACEP, FAAEM, FAHACharles V. Pollack, Jr, MA, MD, FACEP, FAAEM, FAHAChairman, Department of Emergency MedicineChairman, Department of Emergency Medicine

Pennsylvania HospitalPennsylvania HospitalProfessor of Emergency MedicineProfessor of Emergency Medicine

University of PennsylvaniaUniversity of Pennsylvania School of MedicineSchool of MedicinePhiladelphia, PAPhiladelphia, PA

• 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.

• Pollack CV, Antman EA, Hollander JE: 2007 Focused Pollack CV, Antman EA, Hollander JE: 2007 Focused update to the ACC/AHA guidelines for the management of update to the ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction: patients with ST-elevation myocardial infarction: Implications for emergency department practice. Implications for emergency department practice. Ann Ann Emerg MedEmerg Med 2008, in press. 2008, in press.

STEMI: Optimal Therapy, 12/12/07STEMI: Optimal Therapy, 12/12/07

• 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.

• Pollack CV, Braunwald E: 2007 Update to the ACC/AHA Pollack CV, Braunwald E: 2007 Update to the ACC/AHA guidelines for the management of patients with unstable guidelines for the management of patients with unstable angina and non-ST-segment elevation myocardial angina and non-ST-segment elevation myocardial infarction: Implications for emergency department practice. infarction: Implications for emergency department practice. Ann Emerg MedAnn Emerg Med 2008;51:591-606. 2008;51:591-606.

NSTE ACS: Optimal Therapy, 8/6/07NSTE ACS: Optimal Therapy, 8/6/07

• 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 ACSSTEMI vs NSTE ACS

• 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


• 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


• clinical recognition• reliance on ECG (as a rule-in or as a rule-out)• timely evaluation and treatment• consistent care

STEMI vs NSTE ACS: CommonalitySTEMI vs NSTE ACS: Commonality

We Must Risk Stratify Patients with Chest PainWe Must Risk Stratify Patients with Chest Pain

Three levels of risk strat are pertinent to the ED:Three levels of risk strat are pertinent to the ED:

lowlow, , intermediate, or highintermediate, or high risk that ischemic risk that ischemic symptoms are a result of CADsymptoms are a result of CAD

low, intermediatelow, intermediate, or , or high riskhigh risk of short-term death or of short-term death or nonfatal MI from ACSnonfatal MI from ACS

dynamic, ongoing risk-oriented evaluation of low- or dynamic, ongoing risk-oriented evaluation of low- or intermediate-risk patients for “conversion” to high-intermediate-risk patients for “conversion” to high-risk status risk status that is linked to intensity of treatmentthat is linked to intensity of treatment

Three levels of risk strat are pertinent to the ED:Three levels of risk strat are pertinent to the ED:

lowlow, , intermediate, or highintermediate, or high risk that ischemic risk that ischemic symptoms are a result of CADsymptoms are a result of CAD

low, intermediatelow, intermediate, or , or high riskhigh risk of short-term death or of short-term death or nonfatal MI from ACSnonfatal MI from ACS

dynamic, ongoing risk-oriented evaluation of low- or dynamic, ongoing risk-oriented evaluation of low- or intermediate-risk patients for “conversion” to high-intermediate-risk patients for “conversion” to high-risk status risk status that is linked to intensity of treatmentthat is linked to intensity of treatment

Pollack CV. Ann Emerg Med 2001;38:229

• 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 ACSClinical Recognition of ACS

Canto J et al, JAMA 2000; 283:3223

Clinical Recognition of ACS Drives TxClinical Recognition of ACS Drives Tx

Canto J et al, JAMA 2000; 283:3223

0

10

20

30

40

50

60

70

80

90

Heparin ASA/clopi Cath

CP

No CP

Each comparison p < 0.001

• 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 ACSClinical Recognition of ACS

0

10

20

30

40

50

0/1 2 3 4 5 6/7

D/M

I/Urg

D

/MI/U

rg R

evas

c 1

4d (

%)

14d

(%

)

Risk FactorsRisk Factors

Risk Level LOW INTERMEDIATE HIGHRisk Level LOW INTERMEDIATE HIGH

UFH Group TIMI 11B (N= 1957)UFH Group TIMI 11B (N= 1957)

TIMI risk score for UA/NSTEMI

Antman EM et al. JAMA 2000; 284:835

4.74.78.38.3

13.213.219.919.9

26.226.2

40.940.9

TIMI risk score for UA/NSTEMI

Pollack CV et al. Acad Emerg Med 2006;13:13

0

10

20

30

40

50

0/1 2 3 4 5 6/7

D/M

I/Urg

D

/MI/U

rg R

evas

c 3

0d (

%)

30d

(%

)

Risk FactorsRisk Factors

7.17.1 10.110.119.519.5

22.122.1

39.239.2

4545

Risk Level LOW INTERMEDIATE HIGHRisk Level LOW INTERMEDIATE HIGH

Validation and treatment interaction forenoxaparin (ESSENCE data)

19.816.6

Risk factors

% T

rip

le e

nd

po

int

(14d

)

UFH

Enoxaparin

0

10

20

30

40

50

60

Total 0/1 2 3 4 5 6/7population

p=0.022 for trend

p<0.0012 for trend

Antman EM at al, JAMA 2000;284:835

ECGECG

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

ECGECG

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

ECG: LimitationsECG: 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


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”


Difficulties in interpretation BBB LVH Early repolarization Pericarditis Inexperienced reader

Addressed with Computerized interpretations Consultation Training Risk management

• 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, TimeSTEMI vs NSTE ACS: Time, Time, Time

* Brener SJ et al, Eur Heart J 2008;29:1127

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)


• 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


UMass STEMI %DTB < 90 minutes vs MortalityUMass STEMI %DTB < 90 minutes vs Mortality

81.00%

43.50%

50%

72.00%

57.10%61.50%

89.50%

74.20%

84.60%

96.00%91.70%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Q1 05 Q2 05 Q3 05 Q4 05 Q1 06 Q2 06 Q3 06 Q4 06 Q1 07 Q2 07 Q3 07

0

0.5

1

1.5

2

2.5

3

3.5

DTB time < 90 minutes Mortality data

Courtesy of Greg Volturo, MD

Hospital Link Between Overall Guidelines Hospital Link Between Overall Guidelines Adherence and Mortality: NSTE-ACSAdherence and Mortality: NSTE-ACS

Hospital Link Between Overall Guidelines Hospital Link Between Overall Guidelines Adherence and Mortality: NSTE-ACSAdherence and Mortality: NSTE-ACS

Peterson ED et al, JAMA 2006;295:1863

5.95

5.16 4.97

4.16

5.064.63

4.15

6.31

0

1

2

3

4

5

6

7

<=25% 25 - 50% 50 - 75% >=75%

Hospital Composite Quality Quartiles

% I

n-H

osp

Mo

rtal

ity

Adjusted Unadjusted

5.95

5.16 4.97

4.16

5.064.63

4.15

6.31

0

1

2

3

4

5

6

7

<=25% 25 - 50% 50 - 75% >=75%

Hospital Composite Quality Quartiles

% I

n-H

osp

Mo

rtal

ity

Adjusted Unadjusted

Every 10% Every 10% in guidelines adherence in guidelines adherence 10% 10% in mortality (OR=0.90, 95% CI: 0.84-0.97) in mortality (OR=0.90, 95% CI: 0.84-0.97)

ConclusionsConclusions

► 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

listening to the data: why there’s room for improvement in mi care heartscape® consultants...

Documents

intermediaterisk patients

higher risk

acs patients

high risk status

elevated risk treatment

timi risk score

levels of risk strat

irrelevant risk stratification