Acute Myocardial Infarction – Evidence-Based Care for Optimum Outcome
Guruprasad Naik, MD, FACC, FSCAI, Marshfield Clinic Interventional Cardiologist on staff at Ministry Saint Clare’s Hospital
Dan Gavrila, MD, Marshfield Clinic Interventional Cardiologist on staff at Ministry Saint Clare’s Hospital
An 86-year-old gentleman with a history of hypertension and hyper-lipidemia presents to the local ER. He also has a history of dyspnea and shortness of breath.
The chest pain was with onset about 10 hours ago and was now completely relieved. An electrocardiogram showed inferior Q waves without ST elevation. He did not meet criteria for thrombolysis and was transferred to a PCI-capable hospital. He did not have indications for primary angioplasty for coronary reperfusion and was treated conservatively. His hospital course was marked by congestive heart failure, atrial flutter and acute on chronic renal failure. An echocardiogram demonstrated infero-posterior and lateral wall motion abnormalities, and a nuclear perfusion stress study demonstrated large transmural infarct in the same segments without ischemia. He was discharged after a nine-day stay on appropriate medical therapy with NYHA class III functional status.
Contrast this scenario with a 37-year-old male smoker with 45 minutes duration chest pain, found to have an inferior wall myocardial infarction on presentation to the emergency room. He underwent primary angioplasty with stenting to an occluded right coronary artery, with a door-to-balloon time of 57 minutes. He had an uncomplicated hospital course and was discharged home in two days. His left ventricular ejection fraction was normal with mild inferior hypokinesia.
Though anecdotal, these cases reflect what we know about natural history of acute myocardial infarction and the excellent outcomes that can be obtained with timely evidence-based interventions.
Acute ST elevation myocardial infarction guidelines recommend early reperfusion therapy. This refers to either early thrombolysis (door-to-needle time < 30 minutes) or early percutaneous coronary intervention (door-to-balloon time < 90 minutes). Many meta-analysis and randomized trials have demonstrated superiority of primary percutaneous coronary intervention (PPCI) in treatment of acute STEMI.
In 2006, the American College of Cardiology (ACC) launched the D2B (door to balloon) alliance initiative to save time and lives in the treatment of acute STEMI. Though the goal as stated appears very simple, many variables are involved and the organizational complexities of this task are very high. The Marshfield Clinic and Ministry Health Care Heart Team launched the Rescue 1 program in 2006 to provide “state of the art” diagnosis, transfer, and treatment of STEMI patients. This program has been remarkably successful in providing excellent patient care and saving lives and is a nationally recognized program.
The measures for a STEMI-receiving hospital are in tune with the ACC/AHA recommendations (reflected in the CMS and JCAHO core measures) and include:
- Percentage of STEMI patients with a door-to-balloon (first device used) time within 90 minutes, non-transfer
- Percentage of STEMI patients with first medical contact to balloon inflation (first device used) time within 90 minutes, non-transfer
- Percentage of reperfusion–eligible patients receiving any reperfusion (PCI or fibrinolysis) therapy
- Percentage of STEMI patients receiving aspirin within 24 hours
- Percentage of STEMI patients on aspirin at discharge
- Percentage of STEMI patients on beta blocker at discharge
- Percentage of STEMI patients with LDL>100 who receive statins or lipid-lowering drugs
- Percentage of STEMI patients with left ventricular systolic dysfunction on ACEI/ARB at discharge
- Percentage of STEMI patients that smoke with smoking cessation counseling at discharge
Ministry Saint Clare’s Hospital and Ministry Saint Joseph’s Hospital are the two hospitals in our health care system that are designated PCI-capable hospitals and act as STEMI-receiving hospitals. Patient outcome is improved by adherence to the above measures. Besides achieving short door-to-balloon time or door-to-needle times, the other modifiable variable is the rapidity with which patients seek medical care. This requires continuing public and patient education.
Providing evidence-based care in accordance with relevant guidelines can improve patient outcomes, optimize utilization of health care resources and decrease cost of care. We have been successful in doing this with the active cooperation and initiatives of all the team players involved.