Confirmed STEMI to PCI-center or closest community hospital?

Alan L Serve

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I've been interested in the topic of transporting a confirmed STEMI to PCI/CABG-centers or to the closest community hospital without PCI/CABG. I know the traditional guidance is to go to the PCI/CABG-center and bypass the community hospital. I've seen this in protocols and textbooks yet neither of those seem to cite any sources which indicate this is supported by the evidence. In an attempt to find something on this topic I came across "The Diagnosis And Treatment Of STEMI In The Emergency Department" by EB Medicine which publishes Emergency Medicine Practice: An Evidence-Based Approach to Emergency Medicine where there is a section on EMS bypassing community hospitals in favor of STEMI centers. Notably the article says
In addition, a recent study compared facilitated PCI (with clopidogrel before catheterization laboratory intervention) occurring within 150 minutes to primary PCI and suggested similar outcomes.58 This finding makes it more reasonable for EMS providers to stop at non-PCI centers for early evaluation and facilitating therapy before transporting a confirmed-STEMI patient to a PCI-capable center.

Citation 58
Assessment of the Safety and Ef cacy of a New Treatment Strategy with Percutaneous Coronary Intervention (AS- SENT-4 PCI) Investigators. Primary versus tenecteplase- facilitated percutaneous coronary intervention in patients with ST-segment elevation acute myocardial infarction (AS- SENT-4 PCI): randomized trial. Lancet. 2006;367(9510):569- 578. (Prospective randomized trial; 1667 patients)
I didn't know what Facilitated PCI means but this seems to describe it rather accurately: "Facilitated PCI is the use of pharmacological therapy (usually fibrinolytic therapy or half-dose fibrinolytic therapy plus glycoprotein IIb/IIIa platelet inhibitors) administered as soon as possible after the onset of symptoms to establish early reperfusion followed by emergent transfer to a PCI facility for planned emergent PCI."source

My takeaway on this is we either start carrying Clopidogrel (aka Plavix, an anticoagulant given for STEMIs and NSTEMIs) or fibrinolytics or GP IIb/IIIa-inhibitors or some combo of that on the ambulance and develop protocols for administering it prehospital or we start teaching our ALS providers to go to the closest ER so they can get Clopidogrel (or another anti-coagulant such as the GP IIb/IIIa inhibitors or half-dose fibrinolytics or some combo) and then continue to the PCI center.

Thoughts? Does anyone know studies which say something different? Please chime in.

-Alan
 

Attachments

  • The Diagnosis And Treatment Of STEMI In The Emergency Department.pdf
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  • Facilitated Percutaneous Coronary Intervention.pdf
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Handsome Robb

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I asked our medical director why we don't carry clodiprogrel and the answer I got was there's conflicting evidence to it's benefit. The problem with taking them to a facility not capable of doing the PCI is that now they need to imp through hoops to set up the transfer, they can't just say "hey here's some plavix now head to the big house" and send you on your merry way.
 
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Alan L Serve

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I asked our medical director why we don't carry clodiprogrel and the answer I got was there's conflicting evidence to it's benefit. The problem with taking them to a facility not capable of doing the PCI is that now they need to imp through hoops to set up the transfer, they can't just say "hey here's some plavix now head to the big house" and send you on your merry way.
He actually said that for Clopidogrel? The study I cite above says not only does it help but it extend the time in which one can wait for PCI. Even if he doesn't agree with Clopidogrel I wonder what he would say about the other anti-platelets or even the anti-coagulants (like GP IIb/IIIa-inhibitors, Enoxaparin/LMWH, or UFH) which definitely increase survival rates.
 
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Alan L Serve

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My takeaway on this is we either start carrying Clopidogrel (aka Plavix, an anticoagulant given for STEMIs and NSTEMIs)
Correction: Clopidogrel is an anti-platelet not an anti-coagulant. I can no longer edit my original post so I am amending it here. My apologies.
 

palmer1121

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That is our protocol in GA region 2. We give 600mg Plavix and 60 units/kg Heparin to a max of 4000 units total dose. Then transport to the closest cath center.
 

NomadicMedic

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For a while, several years ago, Northwest region EMS in Washington state was following a STEMI protocol similar to this, with Plavix, Heparin and a nitro drip. We also had TNKase on board. There were instances in Jefferson County where there could be extended transport times to the PCI capable hospital, and this protocol was used in those cases. Otherwise, it was simply ASA, NTG and Fent to the cath lab.
 

RocketMedic

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Alan, I think the core of the problem is EMTALA. It is not at all unrealistic waiting an hour for paperwork, acceptance, arranging transport, etc.

Prehospital thrombolytics seem to be a better option than having to drop into hospitals, unless we are discussing super rural
 

Carlos Danger

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Alan, I think the core of the problem is EMTALA. It is not at all unrealistic waiting an hour for paperwork, acceptance, arranging transport, etc.

Prehospital thrombolytics seem to be a better option than having to drop into hospitals, unless we are discussing super rural

There is no reason for that whatsoever. Pre-arranged transfer agreements can and should exist which bypass ALL of the red tape and make transfers take no longer than a quick phone call once the diagnosis of MI has been made. Exactly the same way it should work with trauma.

Prehospital fibrinolysis has been tried and didn't work.
 
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Alan L Serve

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Prehospital fibrinolysis has been tried and didn't work.

Fibrinolytics are just one option and are usually a last-resort due to bleeding, but anti-platelets and anti-coagulants are more what I'm thinking about and appears to actually be in place. Do you have a study which talks about prehospital fibrinolytics not working?
 

Jim37F

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I'm in an urban area, bypassing my closest to go to the STEMI Receiving Center means maybe 10-15 min longer drive time...maybe. With traffic. No reason to stop at the closer one just to have to arrange follow on transport later on.
 
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Alan L Serve

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I'm in an urban area, bypassing my closest to go to the STEMI Receiving Center means maybe 10-15 min longer drive time...maybe. With traffic. No reason to stop at the closer one just to have to arrange follow on transport later on.
It appears that an urban center is not the most ideal place to consider anti-coagulant or fibrinoltic therapy in the prehospital setting, but the use of anti-platelet ASA is already in use and adding the anti-platelet Clopidogrel seems to be warranted by the numerous studies showing improved outcomes.
 

kev54

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San Juan Island EMS does it in the field. Remember small hospital and a ferry ride but even if the helicopter is flying still about 1-2 hours to definitive PCI care rural hospital may be what you get. They are doing pre hospital thrombolytics but again rural area. There protocols can be looked up online to if you want to see. They are using Heparin and Plavix. They might be open to an email to see what studies they based that off of for there protocol development.
 

TransportJockey

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It's funny that out here in the Houston Metro, with cath labs everywhere, there are services that initiate heparin and plavix in the field
 

ERDoc

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I never understood the thought process of taking a pt to a hospital that can't properly care for them. When I work at my rural site, we give a heparin bolus and PO Brillinta. The cardiologist is called as soon as we know we have a STEMI. The pt doesn't even come off the EMS stretcher. Ideally we like to get the pt on the road again in less than 20 minutes. It would make more sense, if the pt is otherwise stable, to give the meds to EMS and let them skip the waste of time at the outside hospital. Really, it would make more sense to bypass the ER and just head to the cath lab.
 
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Alan L Serve

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I never understood the thought process of taking a pt to a hospital that can't properly care for them. When I work at my rural site, we give a heparin bolus and PO Brillinta. The cardiologist is called as soon as we know we have a STEMI. The pt doesn't even come off the EMS stretcher. Ideally we like to get the pt on the road again in less than 20 minutes. It would make more sense, if the pt is otherwise stable, to give the meds to EMS and let them skip the waste of time at the outside hospital. Really, it would make more sense to bypass the ER and just head to the cath lab.

Interesting that you use Tricagrelor vs Clopidogrel. Are you using LMWH or UFH?
 

MrJones

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He actually said that for Clopidogrel? The study I cite above says not only does it help but it extend the time in which one can wait for PCI....
Perhaps he has read studies that indicate otherwise, thus his statement that there's conflicting evidence. Wouldn't be the first time, and certainly won't be the last.....
 
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Alan L Serve

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Perhaps he has read studies that indicate otherwise, thus his statement that there's conflicting evidence. Wouldn't be the first time, and certainly won't be the last.....
That might be true. Can you ask him which specific studies he has read that promote this view? I would really be interested in them.
 

SpecialK

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Primary PCI (pPCI) is the treatment of choice for STEMI, so take the STEMI to the cath lab. I cannot even believe we are having this discussion.

Thrombolysis is reserved for those patients who cannot receive PCI within a reasonable time frame (varies a little bit internationally - but approximately two hours from symptom onset).
 
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