Appropriate Cardiac Cath Lab Activation: Optimizing ECG interpretation and clinical decision making for acute STEMI

An important and useful article has been published that deserves our attention.

Rokos IC, French WJ, Mattu A, Nichol G, Farkouh ME, Reiffel J, Stone GW (December 2010). “Appropriate Cardiac Cath Lab activation: Optimizing electrocardiogram interpretation and clinical decision-making for acute ST-elevation myocardial infarction“. Am Heart J 160 (6): 995–1003.e8

Here are some comments from the lead author Ivan Rokos, MD that I received in an email.

You may recall that I published an article with Dr. Rokos entitled “The emergency medical systems-to-balloon (E2B) challenge: building on the foundations of the D2B Alliance.”

Here’s what Dr. Rokos had to say in his email:

“A big issue for STEMI receiving centers is false positives or inappropriate Cath Lab activations and my goal is to prevent this from becoming the Achilles heel of STEMI systems. Thus we propose a benchmark of less than 5% rate of inappropriate Cath Lab activations in a STEMI system.

Other key points from our recent AHJ paper:

  • Perhaps of primary interest is our group’s efforts to provide a terminology outline that is comprehensive and precise….”classic” STEMI, STEMI-equivalents, STE-mimics, and semi-STEMI
  • Table 1 compares 2004 ACC/AHA guideline recommendations with our group’s proposed updates (note: topic not updated in 2007 or 2009 GL).
  • We have also raised concern regarding “new LBBB” as a Class I-A recommendation….and this manuscript provides the supporting rationale in detail.
  • Isolated Posterior MI is also reviewed….and highlights huge opportunities from improved diagnostic sensitivity.
  • We also describe some esoteric but real conditions….De Winter ST/T waves and STE in lead AVR for acute Left Main occlusion
  • We attempted to provide a strong supporting rationale to bridge STEMI and out-of-hospital cardiac arrest (OHCA) systems and regional networks.
  • Beyond the ECG, clinical decision making is emphasized for “appropriateness” before Cath lab activation.
  • Lastly, SPEED has been a key focus of STEMI systems and much has been accomplished regarding D2B and E2B times. However, I believe the next big challenge is EFFICIENCY and optimizing resource utilization, and that is a primary focus of our AHJ manuscript.”

3 Comments

  • Any mention of adding cardiac marker screening to the pre-hospital arena? If the MDs are basing their decisions to activate on history, EKG and enzymes, perhaps adding that ability pre-hospital can help speed up the proper decision, or in rural areas, be the deciding factor in destination selection?

    And especially for non-STEMI patients we know are having a cardiac event but isn’t on the 12-lead yet.

    Saw a neat product in Dallas that does this in 15 minutes in the same fashion we check a BGL. Won’t mention it’s name here, but wondered your thoughts on the idea of checking markers in the field.
    Thanks,
    Justin

  • Tom B says:

    Justin – If the ECG is suspicious but does not meet the bypass or STEMI Alert criteria then I don’t have a problem with POC biomarkers being used to triage the patient to a cardiac center (with the patient’s consent of course) but “early invasive strategy” for NSTEMI does not necessarily mean emergent cath measured to the minute like our STEMI patients. Sooner may end up being better for these patients but I think the jury is still out and STEMI is still the low hanging fruit. Tom

  • Ethan Camden says:

    Hello – can you please send me the link to the full article published on Ivan Rokos, M.D., relating to Indications for Cath Lab activation (from 2010, AJH) ?

    Thanks!
    Ethan

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EMS 12-Lead

Cardiac Rhythm Analysis, 12-Lead ECG Interpretation, Resuscitation
Comments
Jewel
53 Year Old Male: Severe Leg Pain
Hmm it appears like your site ate my first comment (it was extremely long) so I guess I'll just sum it up what I wrote and say, I'm thoroughly enjoying your blog. I as well am an aspiring blog writer but I'm still new to the whole thing. Do you have any helpful hints for…
2014-08-31 17:51:28
David Baumrind
All that wiggles isn’t Wellens’
@Gary, by all means, nitpick all you like. I agree with your assessment, and the post has been modified. Thank you for the feedback!
2014-08-30 17:28:16
Gary Huntress
All that wiggles isn’t Wellens’
Not to nitpick but is this really a "slightly leftward axis"? I and AVF are both positive. I put it at about +20 degrees, not leftward.
2014-08-30 11:49:35
Handsome Robb
87 YOM COMPLAINING OF CHEST DISCOMFORT AND DYSPNEA
CHF. 12-lead shows a sinus Tachycardia in the 120s with PACs, besides the anterior leads there's diffuse ST depression, the STE in the anterior leads can be explained by the LBBB, axis is good as well. I wish they posted the EtCO2 waveform so we could see but I'm assuming it's non-obstructive. The elevated EtCO2…
2014-08-30 08:08:22
Christopher Watford
“Bad heartburn” – 82 y.o. female without chest pain.
Brooks, Firstly, thank you for the warm welcome to the club. Secondly, the Glasgow algorithm's only published sens/spec for AMI is 51.6%/97.6% respectively (Tuscon STEMI Database). I've not been able to find any other publications. The GE Marquette 12SL algorithm has been widely studied, but is much older, and ranges in sensitivity from 48% to…
2014-08-29 16:50:14

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