Management of acute heart attack: 2019 Clinical Practice Guidelines from the Canadian Cardiovascular Society/Canadian Association of Interventional Cardiology

Regionalization of STEMI care

·         Within 10 minutes: first medical contact (FMC) to ECG and diagnosis

·         The development of a heart attack network of care that incorporates the use of prehospital catheterization laboratory activation, single-call patient transfer protocols, and in-field bypass of non-PCI centers to minimize FMC-to-device times for patients who are treated with primary PCI (pPCI)

·         The use of protocols to minimize time to fibrinolysis as well as the development of a formal relationship with a PCI center to enable adjunctive PCI for patients who are treated with fibrinolysis within a STEMI ( ST elevation MI) network.

·         Hospitals and emergency medical services (EMS) within STEMI networks maintain written, updated STEMI management protocols, and audit treatment delays, reperfusion rates and false activation rates to monitor quality metrics.

Management of STEMI patients diagnosed in the prehospital setting

·         EMS personnel obtain an ECG in the field to identify STEMI and alert STEMI care teams of a patient's imminent arrival.

·         If pPCI is used as a default reperfusion strategy for suspected STEMI patients in the field, it is recommended that patients bypass non-PCI-capable centers and instead be transported to the nearest PPCI center with the goal of achieving a maximum FMC-to-device time of ≤120 minutes (ideal FMC-to-device time ≤90 minutes in urban settings). Consider fibrinolytic therapy if this timeline cannot be achieved.

Management of STEMI patients diagnosed in non-PCI-capable centers

·         For patients with STEMI identified at a non-PCI-capable center, if primary PCI is used as the default reperfusion strategy, it is recommended that STEMI networks target a total FMC-to-device time (including interfacility transfer) of ≤120 minutes. Consider fibrinolytic therapy if this timeline cannot be achieved.

·         If pPCI is used as a default reperfusion strategy, target a door-in–door-out time at the transferring hospital of ≤30 minutes.

·         If fibrinolysis is used as a default reperfusion strategy, it is recommended that STEMI networks target a total FMC-to-needle time of ≤30 minutes.

·         Routine rapid transfer to PCI centers after fibrinolysis, immediate PCI for patients with failed reperfusion, and routine angiography with or without PCI within 24 hours after successful fibrinolysis are recommended.

·         When access to cardiac catheterization is available within 120 minutes of FMC, it is not recommended that a strategy of pharmacologic facilitation be used with full-dose fibrinolysis or a combination of fibrinolysis and glycoprotein inhibitor (GPI) or GPI.

Management of STEMI patients at PCI-capable centers

·         For patients with STEMI identified at a primary PCI center, it is recommended that STEMI networks target a FMC-to-device time of ≤90 minutes.

·         In STEMI patients with cardiogenic shock and multivessel disease, non-culprit lesion PCI is not recommended during the initial primary PCI procedure.

·         Routine upfront thrombectomy is not recommended in patients with STEMI who undergo pPCI.

·         Transradial access is recommended over transfemoral access as the preferred access site in STEMI patients undergoing PCI when it can be performed by an experienced radial operator.

·         Use of unfractionated heparin (UFH) is recommended for procedural anticoagulation in patients with STEMI undergoing pPCI.

·         Use of bivalirudin is preferred over UFH or low molecular-weight heparin (LMWH) for procedural anticoagulation in patients with STEMI undergoing pPCI who have a history of heparin-induced thrombocytopenia or a very high risk of bleeding.

·         Fondaparinux is not recommended for procedural anticoagulation in patients with STEMI undergoing primary PCI.

·         It is not recommended that intravenous (IV) or intracoronary (IC) GPI be routinely used for primary PCI.

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Past National President IMA

Revisiting 2018 clinical practice guidelines: ESC Syncope guidelines

The European Society of Cardiology (ESC) guidelines on syncope say that the challenge for doctors is to identify the small number of patients in whom syncope is caused by a potentially life-threatening heart problem. ESC also recommends that intermediate or high risk patients should be evaluated in the emergency department or an outpatient syncope clinic. These guidelines were released in March 2018.

Syncope has been defined in the guidelines as “transient loss of consciousness (TLOC) due to cerebral hypoperfusion, characterized by a rapid onset, short duration, and spontaneous complete recovery”.

TLOC has been defined as “a state of real or apparent LOC with loss of awareness, characterized by amnesia for the period of unconsciousness, abnormal motor control, loss of responsiveness, and a short duration”.

The initial evaluation of syncope should answer four key questions.

• Was the event TLOC?
• In it is a TLOC, is it syncopal or non-syncopal?
• In case of suspected syncope, is there a clear etiological diagnosis?
• Is there evidence to suggest a high risk of cardiovascular events or death?

The initial diagnostic evaluation should comprise of careful history taking, physical examination (BP, both supine and standing) and standard ECG. The findings from the initial evaluation will direct further diagnostic evaluation via echocardiography, immediate ECG monitoring, head-up tilt testing, carotid sinus massage, electrophysiology studies.

Blood tests should be performed when clinically indicated such as,

• Hematocrit or hemoglobin when hemorrhage is suspected
• Oxygen saturation and blood gas analysis when hypoxia is suspected
• Troponin when cardiac ischemia-related syncope is suspected
• D-dimer when pulmonary embolism is suspected

Management depends on evaluation of the patient in the emergency department, which should address the following questions:

• Is there a serious underlying cause that can be identified?   
• If the cause is uncertain, what is the risk of a serious outcome?   
• Should the patient be hospitalized? 

High risk patients are more likely to have cardiac syncope and need urgent hospital admission and comprehensive evaluation. Whereas, syncope in low risk patients is likely to be reflex, situational, or orthostatic; hence, they do not need further evaluation.

The guideline also recommends that friends and relatives use their smartphones to film the attack and recovery.

The following treatments are recommended based on the clinical severity:

• Education regarding lifestyle maneuvers
• Adequate hydration and salt intake
• Discontinuation/reduction of hypotensive therapy
• Counter-pressure maneuvers
• Abdominal binders and/or support stockings
• Head-up tilt sleeping
• Midodrine or fludrocortisone

An implantable cardioverter-defibrillator (ICD) should be considered in patients with unexplained syncope at high risk of sudden cardiac death.

(Source: ESC Press release, Eur Heart J. 2018 Jun 1;39(21):1883-1948)

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Past National President IMA