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
Christopher Watford
59 year old male: chest pressure – Conclusion
Tony, From the initial ECG it appears that the pattern of ST-elevation is suggestive of a proximal RCA occlusion. However, at cath it was instead found to be an LCx lesion. Good question!
2014-09-18 13:20:09
Tony
59 year old male: chest pressure – Conclusion
Please explain why you suggest that the inferoposterior is caused by RCA but the Left Cx has been stented. Thank you.
2014-09-18 06:17:03
Keren Levi
The 360 Degree Heart – Part I
Lately, a few paramedic-students arrived at my station. So i tried to explain that basics at my best simpliest way. After readinv your perfectly coherent "article", i couldnt stop smily for knowing we both thought of same phrases and associatives words. For me it is a great compliment! Thanks for writing! Cant wait for part…
2014-09-17 19:34:44
Richard Kenkel
64 y.o. Female with CP – “And then I gave her a NTG…”
Cardiac arrest? Its a RELATIVE contraindication. You need to use clinical gestalt. Her blood pressure is quite high, and her heart rate is average, she would probably tolerate nitro quite well. Provided she's not on beta blockers or calcium channel blocker, orthostatic hypotension etc, from what I can tell she'd compensate just fine. While there…
2014-09-16 02:05:12
Stephen Smith, of Dr. Smith's ECG Blog
59 year old male: chest pressure
Inferolateral MI, not RV (T-wave down in V1)
2014-09-14 18:16:53

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