COMMENTARY

Amal Mattu's 2013 Articles You've Gotta Know!

Amal Mattu, MD

Disclosures

December 24, 2013

In This Article

Introduction

A new year is upon us, and as I reflect back on the emergency medicine literature of 2013, I must say that it's been a banner year once again. Many long-held traditional beliefs have been torn down, and plenty of new advances have been proposed.

As in the past few years, I present here my 3 favorite articles of the past calendar year. I'll make the usual disclaimer that these are not necessarily the best articles from a methodological standpoint, but they are practice-changing and focus on high-risk conditions where lives are at stake. These are articles with which all emergency medicine physicians should be familiar.

New Guideline: Management of STEMI

2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction

O'Gara PT, Kushner FG, Ascheim DD, et al; American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines
Circulation. 2013;127:e362-e425

ST-segment elevation myocardial infarction (STEMI) is one of the highest-risk and highest-profile conditions we care for in the emergency department. Every few years, the American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) jointly revise their recommendations for management of patients with STEMI. Most revisions in recent years have been notable for the merry-go-round of antiplatelet and anticoagulant medications. This year's guideline update, however, provided some changes that we (especially long-time readers of EM Viewpoints) have been waiting for.

What follows is a list of a few of those key changes, though I recommend that everyone download a copy of the full guidelines for a more detailed review.

For at least 2 decades, we've been taught that patients presenting with cardiac symptoms plus a presumed-new left bundle branch block (LBBB) pattern on the ECG should be treated for STEMI and receive thrombolytic medications or immediate cardiac catheterization. In EM Viewpoints in 2010, we questioned that practice, and now new LBBB has finally been removed from the guidelines as an indication for emergent reperfusion. Although not specifically addressed in the guidelines, LBBB plus hemodynamic instability or LBBB plus Sgarbossa criteria should probably still result in acute reperfusion therapy.

There's a lot of debate and confusion regarding where and how to measure ST elevation (STE). Do you measure the STE at the J-point? Or at 40 msec after the J-point? And how much STE is considered significant? The current guidelines have clarified this issue.

    – STE should be measured at the J-point.

    – STEMI is defined by STE ≥ 1 mm in at least 2 contiguous leads, with the exception of leads V2-V3.

        ▪ STEMI is defined by STE ≥ 2 mm in leads V2-V3 in men.

        ▪ STEMI is defined by STE ≥ 1.5 mm in leads V2-V3 in women.

Debate regarding low-molecular-weight heparin vs unfractionated heparin has been raging for years. The guidelines now have made it clear that unfractionated heparin is preferred for patients with STEMI who are going for emergent catheterization. Low-molecular-weight heparin is no longer even listed here as an option.

The final key changes that I'll mention pertain to the management of patients with STEMI plus cardiac arrest. The guidelines now give a Class I rating to the use of both therapeutic hypothermia and emergent cardiac catheterization for surviving victims of cardiac arrest who demonstrate STEMI on the ECG. These issues were discussed in more detail in prior EM Viewpoints as well, in 2009, and it's great to see that the guidelines are now endorsing these interventions.

Abstract

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