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

Leave a Reply

Your email address will not be published. Required fields are marked *

EMS 12-Lead

Cardiac Rhythm Analysis, 12-Lead ECG Interpretation, Resuscitation

JEMS Talk: Google Hangout

Comments
Dominic
Conclusion to 59 Year Old Male: Unwell
Great discussion on a difficult 12lead! I follow these very closely and based on pt presentation and 12lead tracing, this was a difficult or to treat with impending heart failure, hypotension, and trouble breathing. Thanks for the follow up and look forward to next week!
2015-07-06 20:53:35
Billy
Conclusion to 59 Year Old Male: Unwell
Hmmmm, I was fairly close. Sounds like most of the treatment occurred IN Hospital. Love case studies, and that one was good.
2015-07-06 20:28:25
Kori
59 Year Old Male: Unwell
There's the point! There is are no P waves, and the rhythm is irregulary-irregular-atrial fibrillation. If you look, it is rsR phenomen-RBBB, BUT there are huge ST elevations on all leads from V1-V5 (that's why the QRS complexes look so broad). I and aVL is clearly ST elevation suggesting STEMI. In limb leads you can…
2015-07-06 10:12:16
Vince DiGiulio
Conclusion to 59 Year Old Male: Unwell
I'll expand on this in the next post but unfortunately I actually wasn't present for this case so I can't give my direct account of how things happened. That said, from the notes I read and word-of-mouth from those involved (which I suspect painted things in a better light than I would have viewed them),…
2015-07-06 04:09:22
Matt King
Conclusion to 59 Year Old Male: Unwell
Hey Vince thanks for the through follow up with this case. I am curious how his rate was controlled since he was hypotensive and maybe an unknown onset of when his A-Fib stated(thinking anticoagulation first)? As you know the wrong approach could be devastating in this PT with risks of further infarction, stroke, or death…
2015-07-05 14:10:57

ECG Medical Training

12-Lead ECG Challenge Smartphone App

Photobucket

12-Lead ECG Challenge Smartphone App - $5.99

  • Apple iOS
  • Android
  • Amazon
  • Web Based

  • FRN-TV video review
  • iMedicalApps.com review
  • Interested in resuscitation?

    FireEMS Blogs eNewsletter

    Sign-up to receive our free monthly eNewsletter

    Visitor Map / Stats

    Locations of visitors to this page


    LATEST EMS NEWS

    HOT FORUM DISCUSSIONS