On Monday, the American College of Cardiology Foundation and the American Heart Association released the 2013 Guidelines for the Management of ST-Elevation Myocardial Infarction. Their last updates to these guidelines were in 2004 and 2006, so this is an important milestone.
If you have been following our blog and podcast, most of the changes will not be earth shattering. We have long been advocates of evidence based STEMI care, which has put us at the bleeding edge as the guidelines take time to catch up. What does this mean for you, our readers?
Our readers have been ahead of the game! We're constantly impressed by your breadth and depth of knowledge.
The 2013 guidelines makes these changes, which we've covered before, to the identification of STEMI:
- "New or presumed new" Left Bundle Branch Block is no longer an indication for a STEMI.
- Providers should use Sgarbossa's criteria to diagnose STEMI in the presence of LBBB. (Editor's Note: we're going to go ahead and add that our readers should take this one step further and utilize Smith's modification to Sgarbossa's criteria.)
- Isolated ST-depression in V1-V4 is an indication of a posterior STEMI.
- Widespread ST-depression with ST-elevation in aVR is an indication of proximal LAD or LMCA occlusion. (Editor's Note: the evidence points more towards this being an indication of 3-vessel disease or near occlusion of the LAD/LMCA.)
- Hyperacute T-waves, e.g. de Winter ST/T-wave changes, are an early indicator of a STEMI.
The honest answer is we probably would not have written a post about these guidelines if it were not for the following gem, buried on page 10 in the section on Regional Systems of Care (emphasis mine):
"For patients who call 9-1-1, direct care begins with FMC, defined as the time at which the EMS provider arrives at the patient’s side. EMS personnel should be accountable for obtaining a prehospital ECG, making the diagnosis, activating the system, and deciding whether to transport the patient to a PCI-capable or non–PCI capable hospital."
Folks, a joint task force of cardiologists has just placed the responsibility for the diagnosis and activation of a STEMI in the hands of EMS providers!
Many systems are already ahead of the game when it comes to STEMI care, but others lag behind.
We've taken responsibility for the care of cardiac arrest victims and now is the time we acknowledge the critical role we play in STEMI care.
- Does your system acknowledege paramedic diagnosis of STEMI?
- Are you ready to take on the responsibility of diagnosis and activation of STEMI?