In-Hospital STEMI Management

Levine GN, Dai X, Henry TD, et al.
In-Hospital ST-Segment Elevation Myocardial Infarction: Improving Diagnosis, Triage, and Treatment. JAMA Cardiol 2018;Feb 21:[Epub ahead of print].

The following are key points to remember from this article about the management of in-hospital ST-segment elevation myocardial infarction (STEMI):

  1. In-hospital STEMI is a unique clinical entity with epidemiology, incidence, and outcomes distinct from that of out-of-hospital STEMI.
  2. Patients with in-hospital STEMI are older, have more comorbidities, and more frequently have coagulopathies and contraindications for anticoagulation and fibrinolytic therapy.
  3. Patients with in-hospital STEMI less frequently present with typical angina symptoms, and an electrocardiogram (ECG) is often obtained owing to changes in clinical status, changes on telemetry, or a finding of elevated cardiac biomarkers.
  4. The frequent nontypical presentations often lead to substantial delays in the diagnosis of STEMI. Only 34-71% of patients with in-hospital STEMI undergo diagnostic catheterization, and only 22-56% undergo percutaneous coronary intervention.
  5. Three areas of delay in the treatment of patients with in-hospital STEMI that merit particular attention are:
    1. Delays in ECG acquisition,
    2. Delays in ECG interpretation, and
    3. Delays in activation of existing STEMI systems of care.
  6. A standardized definition of in-hospital STEMI is that of in-hospital development of new ST-segment elevation or ST-segment elevation equivalents in conjunction with at least one of the additional supportive criteria:
    1. Elevated cardiac biomarker, as defined by contemporaneous universal definition of MI criteria.
    2. Angiographic finding of coronary artery thrombus, coronary embolization, coronary spasm, spontaneous dissection, stent thrombosis, TIMI flow grade 1, or frank coronary artery occlusion that correlates with the territory of ST elevation.
    3. Temporal onset of symptoms consistent with severe ischemia (e.g., severe angina).
    4. Abrupt otherwise unexplained deterioration in hemodynamics (e.g., hypotension or new pulmonary edema).
    5. New wall motion abnormality on echocardiography that correlates with the territory of ST-segment elevation.
  7. Three areas of emphasis to improve patient care include:
    1. Hospital-wide low threshold to expeditiously obtain an ECG in those with hemodynamic decompensation or other signs that might suggest acute MI,
    2. A process for immediate review and interpretation of the ECG, and
    3. Formal in-hospital STEMI activation process.
  8. The process of STEMI team or catheterization laboratory activation for an in-hospital STEMI should as much as possible mirror that for patients who present to the emergency department and are diagnosed as having STEMI.
  9. Quality improvement projects and protocols can expedite patient care and improve outcomes in patients with in-hospital STEMI.
  10. Establishment of national systematic measures of performance may serve as an additional impetus for improvements in the care of patients with in-hospital STEMI.

Keywords: Acute Coronary Syndrome, Angina Pectoris, Anticoagulants, Biomarkers, Catheterization, Comorbidity, Echocardiography, Electrocardiography, Emergency Service, Hospital, Hemodynamics, Hypotension, Myocardial Infarction, Patient Care, Percutaneous Coronary Intervention, Pulmonary Edema, Quality Improvement, Stents, Telemetry, Thrombolytic Therapy, Thrombosis

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