CARDIOVASCULAR TEAM APPROACH SERIES PREHOSPITAL MANAGEMENT OF ACUTE S TEMI PRACTICAL APPROACHES AND INTERNATIONAL STRATEGIES FOR EARLY INTERVENTION Volume Editors: Edga r do Es coba r , MD, FACC, FAHA Aleja ndr o Ba r ba gela t a , MD, FAHA, FSCAI Prehospital Management of Acute STEMI Practical Approaches and International Strategies for Early Intervention The Cardiovascular Team Approach A book series focusing on the interprofessional team approach for the management and prevention of cardiovascular diseases. Editors-in-Chief: Joseph S. Alpert, MD, FAHA, FACC, MACP, FESC Lynne T. Braun, PhD, CNP, FAHA, FAAN Barbara J. Fletcher, RN, MN, FAHA, FAAN Gerald Fletcher, MD, FAHA, FACC, FACP Look for these and other forthcoming series titles from Cardiotext Publishing. Volume 1: Heart Failure: Strategies to Improve Outcomes Ileana L. Piña, MD, MPH, FACC, FAHA, and Elizabeth A. Madigan, PhD, RN, FAAN, editors Volume 2: Prehospital Management of Acute STEMI: Practical Approaches and International Strategies for Early Intervention Edgardo Escobar, MD, FACC, FAHA, and Alejandro Barbagelata, MD, FAHA, FSCAI, editors Volume 3: Acute Coronary Syndrome: Urgent and Follow-up Care Eileen Handberg, PhD, ARNP, BC, FAHA, FACC, and R. David Anderson, MD, MS, FACC, FSCAI, editors Volume 4: Atrial Fibrillation: A Multidisciplinary Approach to Improving Patient Outcomes N.A. Mark Estes III MD, FACC, FHRS, FAHA, FESC, and Albert L. Waldo, MD, PhD (Hon), FACC, FHRS, FAHA, FACCP, editors Please visit www.cardiotextpublishing.com for more information about this series. Prehospital Management of Acute STEMI Practical Approaches and International Strategies for Early Intervention The Cardiovascular Team Approach Series VOLUME 2 Edgardo Escobar, MD, FACC, FAHA Alejandro Barbagelata, MD, FAHA, FSCAI Volume Editors Joseph S. Alpert, MD, FAHA, FACC, MACP, FESC Lynne T. Braun, PHD, CNP, FAHA, FAAN Barbara J. Fletcher, RN, MN, FAHA, FAAN Gerald Fletcher, MD, FAHA, FACC, FACP Editors-in-Chief Minneapolis, Minnesota © 2015 Joseph S. Alpert, Lynne T. Braun, Barbara J. Fletcher, Gerald Fletcher Cardiotext Publishing, LLC 3405 W. 44th Street Minneapolis, Minnesota 55410 USA www.cardiotextpublishing.com Any updates to this book may be found at: cardiotextpublishing.com/prehospital-management-of-acute-stemi Comments, inquiries, and requests for bulk sales can be directed to the publisher at: [email protected]. All rights reserved. No part of this book may be reproduced in any form or by any means without the prior permission of the publisher. All trademarks, service marks, and trade names used herein are the property of their respective owners and are used only to identify the products or services of those owners. This book is intended for educational purposes and to further general scientific and medical knowledge, research, and understanding of the conditions and associated treatments discussed herein. This book is not intended to serve as and should not be relied upon as recommending or promoting any specific diagnosis or method of treatment for a particular condition or a par- ticular patient. It is the reader’s responsibility to determine the proper steps for diagnosis and the proper course of treatment for any condition or patient, including suitable and appropriate tests, medications or medical devices to be used for or in conjunction with any diagnosis or treatment. Due to ongoing research, discoveries, modifications to medicines, equipment and devices, and changes in government regulations, the information contained in this book may not reflect the latest standards, developments, guidelines, regulations, products or devices in the field. Readers are responsible for keeping up to date with the latest developments and are urged to review the latest instructions and warnings for any medicine, equipment or medical device. Readers should consult with a specialist or contact the vendor of any medicine or medical device where appropriate. Except for the publisher’s website associated with this work, the publisher is not affiliated with and does not sponsor or endorse any websites, organizations or other sources of information referred to herein. The publisher and the authors specifically disclaim any damage, liability, or loss incurred, directly or indirectly, from the use or application of any of the contents of this book. Unless otherwise stated, all figures and tables in this book are used courtesy of the authors. Library of Congress Control Number: 2015933408 ISBN: 978-1-935395-66-9 Printed in the United States of America To my wife Josefina for her patience and to ITMS, Telemedicina for giving me the inspiration —Edgardo Escobar To my beloved wife and 3 beautiful children —Alejandro Barbagelata Contents About the Editors-in-Chief xiii About the Authors xv Abbreviations xix Introduction I ncreasing Importance of Prehospital Care of ST-Segment Elevation Myocardial Infarction 1 Edgardo Escobar and Alejandro Barbagelata Part 1:  Program Development for Prehospital STEMI  Care  Systems:  Focus on the  United States  Experience Chapter 1 Delays and Decision Points in Prehospital STEMI Management Systems: A Framework for Reducing the Gap Between the Scientific Guidelines and the Real-World Experience 7 Qiangjun Cai and Alejandro Barbagelata Introduction 7 Patient Delay—Early Symptom Recognition 8 System Delay—First Medical Contact, Door-to-Balloon, and Door-in Door-out 10 Prehospital ECG 14 False Activation—The “Collateral Damage” of Reducing Time to Reperfusion 17 Systems of Care—The AHA Mission: Lifeline® Program STEMI Networks 20 Cardiac Arrest in STEMI—Time Is Life: Extending the Chain of Survival 23   vii viii Contents Prehospital Fibrinolysis or Pharmacoinvasive Therapy in the Real World—Why It Does Not Work in the United States 25 Conclusion 28 References 28 Chapter 2 The Time Dilemma and Decision Making for Prehospital Fibrinolysis, Hospital Fibrinolysis, and/or Transfer to a Percutaneous Coronary Intervention Center 37 Freij Gobal, Abdul Hakeem, Zubair Ahmed, and Barry F. Uretsky Introduction 37 “Time is Muscle” and the “Golden Hour” for Reperfusion 38 Therapeutic Options with Anticipated Delay to PPCI of > 90 to 120 Minutes 45 Adjunctive Prehospital Pharmacotherapy 54 Conclusion 61 References 62 Chapter 3 Prehospital ECG Acquisition/Interpretation: Emerging Technology Applied to STEMI Care 69 Michael J. Pompliano and George L. Adams Introduction 69 Advancements in Technology 70 ECG Acquisition 71 Interpretation Accuracy 72 Benefits of ECG Telemedicine for Triage and Mobilization of Resources 76 Future of the Prehospital ECG and Telemedicine 80 Conclusion 82 References 82 Chapter 4 ECG Pitfalls in Early Recognition of STEMI: Ischemic Versus Nonischemic ST Elevation 87 Henry D. Huang, Waleed T. Kayani, Salman J. Bandeali, and Yochai Birnbaum Introduction 87