lV-92 Circulation December 13, 2005 CHEST PAIN CHECKLIST FOR STEMI FIBRINOLYTIC THERAPY Step One: Has patient experienced chest discomfort for greater than 15 minutes and less than 12 hours? Does ECG show STEM or presumably new LBBB? Step Two H ANT of the following is CHECKED YEs, fibrinolysis MAY be contraindicated Systolic BP greater than 180 mm Hg O YES Diastolic BP greater than11mm地 ○YEs Right vs. left arm systolic BP difference greater than 15 mm Hg History of structural central nervous system disease Significant closed headnfacial trauma within the previous 3 months oooo Recent (within 6 wks)major trauma, surgery (including Laser eye surgery), GI/GU bleed Bleeding or dotting problem or on blood thinners ○YEs CPR greater than 10 minutes ○YEs Pregnant female erminal cancer, severe liver or kidney dise Step Three: IfAw ef the following is CHECKED \Is, CONSIDER Transport/ Transfer to PCI Facility Heart rate greater than or equal to 100 bpm AND systolic BP less than 100 mm Hg ○YEs Pulmonary edema(rales Signs of shock (cool, dammy ○Y gure 2. Fibrinolytic Checklist. interpretation or direct transmission of ECG) instead of fibrinolysis when transport can be completed in <60 minutes out-of-hospital delivery of fibrinolysis with a physician in a mobile intensive care unit. There is no direct evidence, however, to suggest that these strategies are safe or effective. Patients judged to be at highest risk for a of-Hospital Triage complicated transfer were excluded from some of these ital and EMS protocols should clearly identify criteria studies for transfer of patients to specialty centers and conditions In summary, at this time there is inadequate evidence to under which fibrinolytics should be initiated before transfer recommend out-of-hospital triage to bypass non-PCI-capable When transfer is indicated, the ACC/AHA guidelines recom- hospitals to bring patients to a PCI center(Class Indetermi- mend a door-to-departure time <30 minutes. 2 It may be nate). Local protocols for EMS providers are appropriate to appropriate for the EMS medical director to institute a policy guide the destination of patients with suspected or confirmed therapy only, particularly for patients who provide medicalSTEMI of out-of-hospital bypass of hospitals that Interven- tional therapy. Patients who require interventional therapy Interfacility Transfer may include those with cardiogenic shock, pulmonary edema, All patients with STEMI and symptom duration of =12 hours large infarctions, and contraindications to fibrinolytic are candidates for reperfusion therapy with either fibrinolysis therapy or PCI(Class D). When patients present directly to a facility At present no randomized studies have directly compared capable of providing only fibrinolysis, 3 treatment options ar triage with an experienced percutaneous coronary interven- available: administering fibrinolytics with admission to that on(PCi) center with medical the local hospital, transferring the patient for primary PCI, or giving hospital.Extrapolation from several randomized trials on fibrinolytics and then transferring the patient to a specialized interfacility transfer78-80 suggests that STEMI patients tri- center. The decision is guided by a risk-benefit assessment aged directly to a primary PCI facility may have better that includes evaluation of duration of symptoms, complica outcomes related to the potential for earlier treatment. A ons, contraindications, and the time delay from patient cost-efficacy substudy of the Comparison of Angioplasty and contact to fibrinolysis versus potential delay to PCI balloon Prehospital Thrombolysis in Acute Myocardial Infarction (CAPTIM) trials suggests that direct transport to a primary In 2 prospective studies (LOE 2)78-80 and a meta-analy PCI facility may be more cost-effective than out-of-hospit is,2 patients with STEMI who presented 3 to 12 hours afterinterpretation or direct transmission of ECG) instead of out-of-hospital delivery of fibrinolysis. Triage and Transfer Out-of-Hospital Triage Hospital and EMS protocols should clearly identify criteria for transfer of patients to specialty centers and conditions under which fibrinolytics should be initiated before transfer. When transfer is indicated, the ACC/AHA guidelines recom￾mend a door-to-departure time
30 minutes.12 It may be appropriate for the EMS medical director to institute a policy of out-of-hospital bypass of hospitals that provide medical therapy only, particularly for patients who require interven￾tional therapy. Patients who require interventional therapy may include those with cardiogenic shock, pulmonary edema, large infarctions, and contraindications to fibrinolytic therapy. At present no randomized studies have directly compared triage with an experienced percutaneous coronary interven￾tion (PCI) center with medical management at the local hospital. Extrapolation from several randomized trials on interfacility transfer78 – 80 suggests that STEMI patients tri￾aged directly to a primary PCI facility may have better outcomes related to the potential for earlier treatment. A cost-efficacy substudy of the Comparison of Angioplasty and Prehospital Thrombolysis in Acute Myocardial Infarction (CAPTIM) trial81 suggests that direct transport to a primary PCI facility may be more cost-effective than out-of-hospital fibrinolysis when transport can be completed in
60 minutes with a physician in a mobile intensive care unit. There is no direct evidence, however, to suggest that these strategies are safe or effective. Patients judged to be at highest risk for a complicated transfer were excluded from some of these studies. In summary, at this time there is inadequate evidence to recommend out-of-hospital triage to bypass non–PCI-capable hospitals to bring patients to a PCI center (Class Indetermi￾nate). Local protocols for EMS providers are appropriate to guide the destination of patients with suspected or confirmed STEMI. Interfacility Transfer All patients with STEMI and symptom duration of
12 hours are candidates for reperfusion therapy with either fibrinolysis or PCI (Class I). When patients present directly to a facility capable of providing only fibrinolysis, 3 treatment options are available: administering fibrinolytics with admission to that hospital, transferring the patient for primary PCI, or giving fibrinolytics and then transferring the patient to a specialized center. The decision is guided by a risk-benefit assessment that includes evaluation of duration of symptoms, complica￾tions, contraindications, and the time delay from patient contact to fibrinolysis versus potential delay to PCI balloon inflation. In 2 prospective studies (LOE 2)78 – 80 and a meta-analy￾sis,82 patients with STEMI who presented 3 to 12 hours after Figure 2. Fibrinolytic Checklist. IV-92 Circulation December 13, 2005