New US STEMI Guidelines Are More User Friendly

December 18, 2012

BOSTON — Newly issued US guidelines for the treatment of ST-elevation MI (STEMI) are "much more user friendly for practicing cardiologists and get quickly to the bottom line," says one member of the writing committee, Dr James Fang (University Hospitals Case Medical Center, Cleveland, OH) [1,2].

Fang told heartwire that prior US STEMI recommendations have been "much more encyclopedic," but this time the writing committee tried to focus on what people were going to use. "It can be as authoritative as any document, but if nobody is going to bother picking it up, then we really haven't succeeded in our purpose. We wanted more synthesis of available evidence in our conclusions."

The new 2013 ACCF/AHA guidelines for the management of STEMI are published simultaneously in Circulation and the Journal of the American College of Cardiology, by Dr Patrick O'Gara (Brigham and Women's Hospital, Boston, MA) and colleagues; they were developed in collaboration with the American College of Emergency Physicians (ACEP) and Society for Cardiovascular Angiography and Interventions (SCAI).

Improving Symptom Recognition and Big Emphasis on Cardiac Rehab

 
It can be as authoritative as any document, but if nobody is going to bother picking it up, then we really haven't succeeded in our purpose.
 

Fang says there are a number of key points in the new recommendations: improving recognition of the symptoms of heart attack; advising that ECGs are done in the field by ambulance personnel to facilitate more rapid triage and quicker treatment; stronger endorsement of the use of hypothermia for cardiac-arrest victims; and a bigger push for better cardiac rehabilitation and postprocedural care.

"We have focused on the concept of 'total ischemic time'--not only the technical aspects in terms of the procedure itself and adjuvant therapies, but really concentrating on things like care of the patient prior to arrival and the need to try to get the patient assessed quickly. We can't open a vessel until the patient is identified, and one of the greatest delays in the management of this particular condition is time to recognition, because once it's recognized, we can move quickly.

 
We can't open a vessel artery until the patient is identified, and one of the greatest delays in the management of this particular condition is time to recognition.
 

"We've also addressed the issues of patients who have a cardiac arrest, who become unconscious, with the idea of hypothermia--which has become reasonably well-established, and the guidelines also speak to that," adds Fang. This is the first time the STEMI guidelines have endorsed hypothermia "to this degree," he says, but he cautions that there are many more details that remain to be ironed out (eg, the degree of hypothermia).

Finally, the document puts an overriding emphasis on better cardiac rehabilitation, improving the care of the patient after the procedure. "We wanted to focus on the transition from postprocedure to home, from having a heart attack to the care afterward. This needs to be carefully orchestrated," Fang stresses.

This includes ensuring referral for cardiac rehabilitation, with a table in the new guidelines itemizing considerations such as smoking cessation, cholesterol management, social needs, depression, and cultural and gender-related factors that may contribute to outcomes.

Fang acts as a consultant to Accorda, Novartis, and Thoratec, and his institution has an association with Medtronic. O'Gara has no conflicts of interest. Disclosures for the coauthors are listed in the paper.

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