La tecnologia al servizio della Medicina d’Urgenza:

dal Presente al Futuro Pisa 7, 8 e 9 novembre 2018

Auditorium Consiglio Nazionale Delle Ricerche, Pisa

Fondazione Toscana "Gabriele Monasterio"

SCA-NSTEMI: i ritardi evitabili

Alberto Conti (Massa)

Alberto Conti

Dipartimento Emergenza

ASL NordOvest Toscana Via Cocchi 7 Ospedaletto, Pisa

Ospedale Apuane Massa

& Università di Pisa,

alberto.conti@uslnordovest.toscana.it

La tecnologia al servizio della Medicina d’Urgenza:

dal Presente al Futuro Pisa 7, 8 e 9 novembre 2018

Auditorium Consiglio Nazionale Delle Ricerche, Pisa

Fondazione Toscana "Gabriele Monasterio"

SCA-NSTEMI: i ritardi evitabili

Alberto Conti (Massa)

1- Awareness of general population

2- Transportation

3- Diagnosis

4- Hospital System Delay

Lo Stato dell’Arte

Conclusioni

• Necessaria campagna per sensibilizzare popolazione alla chiamata del 118 in presenza di dolore toracico

• La Rete STE & NSTE ACS trasferisce il pz. in cath lab entro 120 min.

• Fuori Rete rischio di non raggiungere cath lab entro 120 min.

2018

2012 ESC Guidelines for the Management of STEACS Eur Heart J 2012, 33, 2569-26

Anyway, within 120 min from FMC

“La RETE” e “IL CATH LAB” per NSTE e STE-ACS

UA NSTEMI ESC guidelines. Eur Heart J 2015

Agenzia Regionale Sanità,

Toscana

STE-MI nel 2005

60% autopresentazione

40% via 118

STE-MI nel 2015

54% via 118

Pre-Hospital Delay

Delay:

almeno così veniva riportato

fino a pochi anni fa…

Pre-Hospital Delay

- dalla consapevolezza malattia,

- dalla chiamata ed arrivo

all’ospedale

- dalla diagnosi

In-Hospital Delay

circa 50% (40-60%)

autopresentazione al PS

senza 118:

-quindi diagnosi in DEA

Delay hospital-cath lab:

enfasi…

Trattamento ritardato

Insorgenza e

riconoscimento

dei sintomi

Allertamento

Sistema 118

Ospedale Cath Lab Trasporto

...incremento area necrosi

in STE-ACS

Reasons for Delayed “Door”-to-Balloon

Time in Primary PCI

S. Atique 1,∗, P. Marley2, R. Tan2

1 Liverpool Hospital, Sydney, Australia

2 The Canberra Hospital, Canberra, Australia

Source of activation was emergency department (57.5%), other hospitals (19.8%), ambulance ECG

transmission (19.2%) and inpatient (3.5%). D2BT was more than 90 minutes for 23 patients.

Reasons for delay are outlined in the attached figure.

Conclusion: Avoidable delays in D2BT can be targeted to further improve the performance of a

primary PCI service.

Reason for delay of door-to-balloon > 90 min key performance indicator for primary PCI

Heart, Lung and Circulation 2016 25, S193-S194DOI: (10.1016/j.hlc.2016.06.454)

Sxystem VF arrest Cath-lab Late > 12 h Others

delay or shock busy presentation

SCA-NSTEMI: i ritardi evitabili

Molto è stato fatto per

-Transportation (118)

-In-hospital diagnosis

(protocols, guidelines, cardiology consultation on time)

-cath lab 24 hrs with skilled team

Lo Stato dell’Arte

Chronological Distribution of Deaths

~ 1 in 4 ACS patients DIE during FIRST month (27%)

3 / 4 pf DEATHS, PRIOR TO HOSPITALISATION

French MONICA Registries:Vervueren PL. Arch Cardiovasc Dis 2012;105:478

Hrs

Month

Year Out-of-hospitadeathl Survivors

82 Mortality

up to 1 year: 8.7%

3% 3.2% 2.5%

Symptom onset FMC Diagnosis Reperfusion therapy

Patient delay

System delay

Wire passage in

culprit vessel if

primary PCI

Bolus or infusion

start if lysis

Time to reperfusion therapy

Components of delay in STE-ACS and ideal time intervals for intervention.

- 2010

- 2010

Insorgenza e

riconoscimento

dei sintomi

Allertamento

Sistema 118

Svezia (Ostersund Umea University)

SCA-NSTEMI: i ritardi evitabili

Molto resta da fare per

-Awareness in general population

regarding

Chest Pain, and Risk Factors ...

STE & NSTE-ACS

Il dolore toracico

Inghilterra (Birmingham)

mean and SD: 2.2 ± 1.3

Awareness of cardiovascular disease,its risk factors, and its association

with attendance at outpatient clinics in ACS

...awareness of CVD risk factors plays an important role in the prevention of CVD and its complications.

A number of studies surveyed patients’ awareness of CVD risk factors–dyslipidemia, arterial hypertension,

diabetes mellitus, and demonstrated that patients’ awareness of these CVD risk factors is not always high.

There also are some studies on factors associated with patients’ lower awareness of CVD risk factors.

The most common factors affecting awareness were age, family history of a specific risk factor,

physical activity, smoking, and alcohol.

Conclusion:

In patients with CVD: differences between data from patients and data from objective examination

All patients were aware of their diabetes mellitus, and of arterial hypertension; few patients with

dyslipidemia. All patients knew of previous myocardial infarction.

Awareness of dyslipidemia increased with increasing attendance level; there was only a

slight increase in awareness of arterial hypertension.

Marsevich SY. Integr Med Res. 2017 Sep; 6(3): 240–244.

Clinical characteristics

from patients

or obtained from

objective examination .

Russia (Mosca)

Awareness of dyslipidemia, arterial hypertension, and diabetes mellitus prior to

reference acute coronary syndrome (ACS) in patients attendance at outpatient

clinics.

Marsevich SY. Integr Med Res. 2017 Sep; 6(3): 240–244.

Dublin (Ireland) & Kentucky (USA)

Educational Intervention

Dublin and Belfast (Ireland) & Kentucky (USA)

Educational Intervention in the context of RCT

International results of public campaign:

Reduction delay (Europe) Incresed call to 911 (USA)

Emerg Med 2017 Australia

Trasporto

.

Italy

Symptom onset FMC Diagnosis Reperfusion therapy

Patient delay

System delay

Wire passage in

culprit vessel if

primary PCI

Bolus or infusion

start if lysis

Time to reperfusion therapy

Components of delay in STE-ACS and ideal time intervals for intervention.

...sindrome esofagea & heartburn

Kontos MC. Mayo Clin Proc. 2010;85(3):284-299

Incidence of ACS in patients with normal or nonspecific ECG is 5% to 28%.

New ECG abnormalities increases the UA risk of 14-43% and AMI risk of 25-73%

State-of-the-Art Evaluation of ED patients with potential ACS

State-of-the-Art Evaluation of ED patients with potential ACS

JE Hollander Circulation 2016; 134: 547-564

Indagini

Markers danno miocardico: Troponina I e T diventano rilevabili nel siero 3-6 ore da IMA, . picco prevedibile a 12-24 ore, possono rimanere elevate fino a 14 giorni.

Le Troponine sono quindi solitamente testate a 6 e 9 ore dopo l'insorgenza del dolore. Il test può essere ripetuto nel caso di sospetto clinico suggestivo fino a 12-24 ore

Possibile un rapido rule-out con Troponina ad alta sensitività ( 2 soli prelievi a distanza di 3 ore: base-ingresso e 3 ore dopo).

Peters. Acute coronary syndromes without ST segment elevation. BMJ. 2007 Jun 16;334(7606):1265-9.

Management of Acute Coronary Syndromes (ACS) in patients presenting without persistent ST-segment elevation, ESC (2011).

Chest pain of recent onset, NICE Clinical Guideline (March 2010).

JAMA. 1998;280:913-920.

ECG

imaging

Exercise-MPI Imaging and Exercise-Echocardiography ?

20%

Background

The HEART Pathway is a decision aid designed to identify emergency department patients with acute chest pain for early

discharge. No randomized trials have compared the HEART Pathway with usual care.

Methods and Results

Adult emergency department patients with symptoms related to acute coronary syndrome without ST-elevation on ECG

(n=282) were randomized to the HEART Pathway or usual care. In the HEART Pathway arm, emergency department

providers used the HEART score, a validated decision aid, and troponin measures at 0 and 3 hours to identify patients for

early discharge. Usual care was based on American College of Cardiology/American Heart Association guidelines. The

primary outcome, objective cardiac testing (stress testing or angiography), and secondary outcomes, index length of stay,

early discharge, and major adverse cardiac events (death, myocardial infarction, or coronary revascularization), were

assessed at 30 days by phone interview and record review. Participants had a mean age of 53 years, 16% had previous

myocardial infarction, and 6% (95% confidence interval, 3.6%–9.5%) had major adverse cardiac events within 30 days of

randomization. Compared with usual care, use of the HEART Pathway decreased objective cardiac testing at 30 days by

12.1% (68.8% versus 56.7%; P=0.048) and length of stay by 12 hours (9.9 versus 21.9 hours; P=0.013) and increased early

discharges by 21.3% (39.7% versus 18.4%;P<0.001). No patients identified for early discharge had major adverse cardiac

events within 30 days.

Conclusions

The HEART Pathway reduces objective cardiac testing during 30 days, shortens length of stay, and increases early

discharges. These important efficiency gains occurred without any patients identified for early discharge suffering MACE at 30

days.

Mahler SA. The HEART Pathway RCT. Circ Cardiovasc Qual Outcomes 2015.

Chest pain in the ER: a multicenter validation of the HEART Score (2010)

The HEART score for patients with CP in the ED: a multinational validation study (2013)

Backus BE. Crit Pathw Cardiol. 2010;9:164–169. Six AJ. Crit Pathw Cardiol. 2013;12:121–126.

The HEART score for Chest Pain Patients in the ED

History Highly Suspicious Moderately Suspicious Slightly or Non-Suspicious

2 ponits 1 point 0 points

ECG Significant ST-Depression Nonspecific repolarization Normal

2 ponits 1 point 0 points

Age ≥ 65 years > 45 - <65 years ≤ 45 years

2 ponits 1 point 0 points

Risk Factors ≥ 3 or istory of CAD 1 or 2 RF No RF

2 ponits 1 point 0 points

Troponin ≥ 3 x Normal Limit > 1 - < 3 x Normal Limit ≤ Normal Limit

2 ponits 1 point 0 points

Risk factors: DM, current or recent (< 1 month) smoker, HTN, HLP, family history of CAD, & obesity

Score 0-3: 2.5% MACE over next 6 weeks ―> Discharge Home Score 4-6: 20.3% MACE over next 6 weeks ―> Admit for Clinical Observation Score 7-10: 72.7% MACE over next 6 weeks ―> Early invasive Strategies

Chest pain in the ER: a multicenter validation of the HEART Score (2010)

The HEART score for patients with CP in the ED: a multinational validation study (2013)

Backus BE. Crit Pathw Cardiol. 2010;9:164–169. Six AJ. Crit Pathw Cardiol. 2013;12:121–126.

The HEART score for Chest Pain Patients in the ED

History Highly Suspicious Moderately Suspicious Slightly or Non-Suspicious

2 ponits 1 point 0 points

ECG Significant ST-Depression Nonspecific repolarization Normal

2 ponits 1 point 0 points

Age ≥ 65 years > 45 - <65 years ≤ 45 years

2 ponits 1 point 0 points

Risk Factors ≥ 3 or istory of CAD 1 or 2 RF No RF

2 ponits 1 point 0 points

Troponin ≥ 3 x Normal Limit > 1 - < 3 x Normal Limit ≤ Normal Limit

2 ponits 1 point 0 points

Risk factors: DM, current or recent (< 1 month) smoker, HTN, HLP, family history of CAD, & obesity

Score 0-3: 2.5% MACE over next 6 weeks ―> Discharge Home Score 4-6: 20.3% MACE over next 6 weeks ―> Admit for Clinical Observation Score 7-10: 72.7% MACE over next 6 weeks ―> Early invasive Strategies

Chest pain in the ER: a multicenter validation of the HEART Score (2010)

The HEART score for patients with CP in the ED: a multinational validation study (2013)

Backus BE. Crit Pathw Cardiol. 2010;9:164–169. Six AJ. Crit Pathw Cardiol. 2013;12:121–126.

The HEART score for Chest Pain Patients in the ED

History Highly Suspicious Moderately Suspicious Slightly or Non-Suspicious

2 ponits 1 point 0 points

ECG Significant ST-Depression Nonspecific repolarization Normal

2 ponits 1 point 0 points

Age ≥ 65 years > 45 - <65 years ≤ 45 years

2 ponits 1 point 0 points

Risk Factors ≥ 3 or istory of CAD 1 or 2 RF No RF

2 ponits 1 point 0 points

Troponin ≥ 3 x Normal Limit > 1 - < 3 x Normal Limit ≤ Normal Limit

2 ponits 1 point 0 points

Risk factors: DM, current or recent (< 1 month) smoker, HTN, HLP, family history of CAD, & obesity

Score 0-3: 2.5% MACE over next 6 weeks ―> Discharge Home Score 4-6: 20.3% MACE over next 6 weeks ―> Admit for Clinical Observation Score 7-10: 72.7% MACE over next 6 weeks ―> Early invasive Strategies

Mahler SA. The HEART Pathway RCT. Circ Cardiovasc Qual Outcomes 2015.

Chest pain in the ER: a multicenter validation of the HEART Score (2010)

The HEART score for patients with CP in the ED: a multinational validation study (2013)

Backus BE. Crit Pathw Cardiol. 2010;9:164–169. Six AJ. Crit Pathw Cardiol. 2013;12:121–126.

The HEART score for Chest Pain Patients in the ED

History Highly Suspicious Moderately Suspicious Slightly or Non-Suspicious

2 ponits 1 point 0 points

ECG Significant ST-Depression Nonspecific repolarization Normal

2 ponits 1 point 0 points

Age ≥ 65 years > 45 - <65 years ≤ 45 years

2 ponits 1 point 0 points

Risk Factors ≥ 3 or istory of CAD 1 or 2 RF No RF

2 ponits 1 point 0 points

Troponin ≥ 3 x Normal Limit > 1 - < 3 x Normal Limit ≤ Normal Limit

2 ponits 1 point 0 points

Risk factors: DM, current or recent (< 1 month) smoker, HTN, HLP, family history of CAD, & obesity

Score 0-3: 2.5% MACE over next 6 weeks ―> Discharge Home Score 4-6: 20.3% MACE over next 6 weeks ―> Admit for Clinical Observation Score 7-10: 72.7% MACE over next 6 weeks ―> Early invasive Strategies

ECG: normale

o non diagnostico

alto rischio basso rischio

>70% <5-20%

probabilità bassa o intermedia

Lab. Emodinamica o UCIC Osservazione Breve in DEA

ECG: chiave della stratificazione del rischio

ST

STEACS: ECG criteria

118 Elisoccorso ASL Nordovest Toscana

NSTEACS: ECG criteria

Sempre rivalutazione in PS se ST sottoslivellato

Coordinamento con cardiologia referente

(attenzione ai criteri per alto rischio per angiografia “immediate or early or late…)

Processo-percorso tempo-dipendente?

Se autopresentazione in PS: ECG entro 10 min, angiografia entro 30 min

Coordinamento con cardiologia referente

118 Elisoccorso ASL Nordovest Toscana

Savonitto JAMA 1999.

ST-elevation and depression

ST-depression

ST-elevation

Isolated T inversion

NSTE-ACS e mortalità: 1.5-4% (breve-termine); 5-11% (medio-termine: 6-mesi).

ACC/AHA stat. update 1999; PRAIS-UK, Eur Heart J 2000.

Patients with ST: Likely to Have Higher-risk Medical Histories than Patients with ST

ST ST

Prior MI 20% 32%

Prior CABG Surgery 6% 13%

Prior PCI 6% 13%

Prior Angina 52% 78%

Hypertension 41% 51%

Diabetes 17% 20%

Hypercholesterolemia 36% 42%

Prior CHF 4% 8%

Savonitto. JAMA 1999

ST Depression increases Likelihood of multivessel disease

No. diseased vessels

ST

(n=1864)

ST

(n=2170)

0 10% 11%

1 45% 26%

2 27% 28%

3 18% 36%

Metà

Doppio

Savonitto. JAMA 1999

Classificazione basata su Troponina e Clinica

NSTEACS basso rischio

NSTEACS alto rischio *

* Management come STE-ACS

NSTEACS: risk criteria for invasive strategy

*

*

*

Peters RJ, Mehta S, Yusuf S; Acute coronary syndromes without ST segment elevation. BMJ. 2007 Jun 16;334(7606):1265-9.

Management of Acute Coronary Syndromes (ACS) in patients presenting without persistent ST-segment elevation, ESC (2011)

Treat like STEMI

angio < 2 hrs

Angio < 24 hrs

Angio < 72 hrs

Recommendations COR LOE

An urgent/immediate invasive strategy (diagnostic angiography with intent to perform revascularization if appropriate based on coronary anatomy) is indicated in patients (men and women) with NSTE-ACS who have refractory angina or hemodynamic or electrical instability (without serious comorbidities or contraindications to such procedures).

I A

An early invasive strategy (diagnostic angiography with intent to perform revascularization if appropriate based on coronary anatomy) is indicated in initially stabilized patients with NSTE-ACS (without serious comorbidities or contraindications to such procedures) who have an elevated risk for clinical events.

I B

Antman 2000, JAMA 2000;284:835-42

ACC/AHA Guidelines ESC Guidelines

La Realtà in ASL Nordovest, Toscana

Distretti entro USL Toscane

• Isole

• Zone collinari

• Zone costiere

• Residenti

• Turismo

PISA

FIRENZE

SIENA

H

H H

H H

H

H

H

H

H

H

H

H

H

H H H

H

H

H

H

H

H

H

H

H

H

H

H

H

H

H

H

H

H

Ospedali USL Toscana

H

PORTOFERRAIO

H

H

H

H

H

H

H

AO-Uni PISA

H

PIOMBINO

LIVORNO

CECINA

LUCCA

PONTEDERA

VOLTERRA

VERSILIA

BARGA

C.NUOVO G.FA

APUANE

PONTREMOLI FIVIZZANO

H

H

H H

H

Distretti e Ospedali

USL Toscana Nordovest

xvnz

Tempi minimi di percorrenza comune – ospedale più vicino

autorizzato per trombolisi endovenosa

+ + + + + + +

+

+

+

+

+

+

Tempi minimi di percorrenza tra:

territorio comunale e Az Osp Univ

Tempi minimi di percorrenza tra:

territorio comunale e Osp Cath Lab

Ospedali USL Toscana

Medico e Infermiere: equipe sanitaria

Infermiere: risorsa intermedia,

autonomia limitata con protocolli

specifici

Equipaggio BLSD: prima risposta

rapida e capillare sul territorio

Evoluzione organizzativa: sistema centrale

operativa

Life Map (geo-localizzazione)

STEMI 118 Nord 2016

STEMI da PS(autopresentazione) 55%

STEMI da Territorio via EMS 45%

STEMI 118 Sud 2016

STEMI da PS(autopresentazione) 50%

STEMI da Territorio via EMS 50%

Ospedali USL Toscana

37 min

74 min

30x2 min

10 min

118 autopresentazione

Conclusioni

• Necessaria campagna per sensibilizzare popolazione alla chiamata del 118 in presenza di dolore toracico

• La Rete STE & NSTE ACS trasferisce il pz. in cath lab entro 120 min.

• Fuori Rete rischio di non raggiungere cath lab entro 120 min.

2018

…via ringrazio per l’attenzione

Alberto Conti

Dipartimento Emergenza

ASL NordOvest Toscana

& Università di Pisa, Via Cocchi 7 Ospedaletto, Pisa

Ospedale Apuane Massa

alberto.conti@uslnordovest.toscana.it