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Activating Primary Percutaneous Coronary Intervention for STEMI That Is Not: The Collateral Damage of Improving Door-to-Balloon Time: Comment on “Prevalence and Factors Associated With False-Positive ST-Segment Elevation Myocardial Infarction Diagnoses at Primary Percutaneous Coronary Intervention–Capable Centers”

Activating Primary Percutaneous Coronary Intervention for STEMI That Is Not: The Collateral... Coronary arterial thrombosis secondary to plaque rupture (most common), erosion, or calcified nodule often results in acute ischemic symptoms and electrocardiographic (ECG) changes, specifically ST-segment elevation. Timely clinical identification of ST-segment elevation myocardial infarction (STEMI) is based on acute symptoms and ECG changes. Prompt and effective revascularization of the infarct-related artery can save myocardium and reduce morbidity and mortality.1 The Door-to-Balloon (D2B) Alliance recognizes the importance of door-to-balloon time (DBT) as a core measure of quality for primary percutaneous coronary intervention (PCI) and emphasizes methods to decrease DBT.2 Multiple strategies to reduce DBT include a dedicated on-call (24 hours per day/7 days per week) cardiac catheterization laboratory (CCL) team activated by a single page, acquisition of an ECG at the scene with “computer” interpretation with or without electronic transmission to an emergency department (ED), autonomous activation of the CCL by ED staff or emergency medical service, and organized review of experience with direct feedback to all involved in STEMI recognition and treatment.3 These strategies decrease DBT, but a potential downside to this increasingly fast process is more inappropriate CCL use. This occurs for multiple reasons including “misinterpretation” of clinical findings, primarily of the ECG, alternative diagnosis discovered after activation, activation protocol violation, and morbid conditions with ECG changes mimicking myocardial infarction for which a coronary angiogram would be contraindicated. Inappropriate CCL activation increases cost and exposes patients to unnecessary risk. Frequent, inappropriate CCL activation may result in interdisciplinary distrust, disinterest, and tension. A variety of terms have been proposed to report CCL activation that did not result in CCL use. These have been variably defined as “inappropriate activation,” “overactivation,” “unnecessary activation,” and “false-positive activation”; hence, reports of their occurrence vary widely. In this issue of the Archives, McCabe et al4 report that 36% of autonomous ED physician CCL activations for STEMI were false-positive STEMI diagnosis. In their registry, patients with angiography that did not show a “culprit” lesion (total or subtotal occlusion) and had Thrombolysis in Myocardial Infarction (TIMI) grade III flow in all coronary arteries were considered false-positive STEMI diagnosis regardless of subsequent serial troponin biomarker levels.4 Their false-positive STEMI diagnosis was based on post hoc analysis and could have been the result of an absolutely appropriate CCL activation. If these cases were considered “true activations,” then a lower percentage of the series in study by McCabe et al would have been classified as “false.” McCabe el al choose to consider angiography as the gold standard for defining false-positive STEMI diagnosis but one could question whether all of them were the result of false-positive activation. In a recent analysis of Harmonizing Outcomes With Revascularization and Stents in Acute Myocardial Infarction (HORIZON AMI) and Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications (CADILLAC) trials, 5332 patients with STEMI were reviewed and 932 (17.5%) had TIMI grade III flow on initial angiography.5 The discrepancy between the study by McCabe et al4 and other reports for CCL activation for STEMI6,7 highlight the variability of definitions and need for further guidance in establishing measures for quality of reperfusion programs, particularly given the findings by McCabe et al of an increase of “false activations” without a decrease in DBT over the study period. In an attempt to standardize definition of factors that lead to cancelation of CCL activations for STEMI, the American Heart Association Mission: Lifetime has proposed the terminology “appropriate” vs “inappropriate” for CCL activation.8 “Appropriate” CCL activation is based on clinical findings of the abrupt onset of symptoms of myocardial ischemia with ST-segment elevation on ECG; findings available to health care providers at the time when activation occurs. This term recognizes that by nature or secondary to initial acute intervention at the scene, STEMI may be dynamic, resulting in intermittent symptoms and ST-segment changes. Adherence to strict criteria of clinical symptoms as reported by McCabe et al4 could help in reducing inappropriate activations. The use of biomarkers and angiography for the appropriateness of CCL activation for STEMI is ill advised because these are not available at the time of activation. Most important for any program is a systematic protocol for the diagnosis and emergent treatment of STEMI including pivotal medical history for comorbid features, patient preference, continuous review of clinical experience, and direct feedback.3,6 Although there is no established acceptable rate of inappropriate activations, it is probably in the 15% to 20% range.6,7 Finally, it is worth noting that criteria used for CCL activation for STEMI in clinical practice likely differs from that for thrombolytic therapy. When the findings for STEMI are obvious, theoretically, either therapy can be initiated, but if the findings are subtle, primary PCI becomes a better option because of lower hemorrhagic complications and potential reversibility. In either case, the quality of acute reperfusion therapy should be judged not only on the basis of door-to-treatment time but also the ratio of “appropriate” vs “inappropriate” activation of reperfusion therapy. A single-minded approach to improving DBT without careful selection will surely result in a concomitant increase in the incidence inappropriate activation of reperfusion therapy. Back to top Article Information Correspondence: Dr Bachour, Cardiac Catheterization Laboratory R5.250, 701 Park Ave, Minneapolis, MN 55415 (bacho003@umn.edu). Published Online: May 7, 2012. doi:10.1001/archinternmed.2012.1117 Financial Disclosure: None reported. References 1. Berger PB, Ellis SG, Holmes DR Jr, et al. Relationship between delay in performing direct coronary angioplasty and early clinical outcome in patients with acute myocardial infarction: results from the global use of strategies to open occluded arteries in Acute Coronary Syndromes (GUSTO-IIb) trial. Circulation. 1999;100(1):14-2010393675PubMedGoogle ScholarCrossref 2. Krumholz HM, Bradley EH, Nallamothu BK, et al. A campaign to improve the timeliness of primary percutaneous coronary intervention: Door-to-Balloon: An Alliance for Quality. JACC Cardiovasc Interv. 2008;1(1):97-10419393152PubMedGoogle ScholarCrossref 3. Bradley EH, Herrin J, Wang Y, et al. Strategies for reducing the door-to-balloon time in acute myocardial infarction. N Engl J Med. 2006;355(22):2308-232017101617PubMedGoogle ScholarCrossref 4. McCabe JM, Armstrong EJ, Kulkarni A, et al. Prevalence and factors associated with false-positive ST-segment elevation myocardial infarction diagnoses at primary percutaneous coronary intervention–capable centers: a report from the Activate-SF Registry. [published online May 7, 2012]. Arch Intern Med. 2012;172(11):864-871Google Scholar 5. Brener SJ, Mehran R, Brodie BR, et al. Predictors and implications of coronary infarct artery patency at initial angiography in patients with acute myocardial infarction (from the CADILLAC and HORIZONS-AMI Trials). Am J Cardiol. 2011;108(7):918-92321764028PubMedGoogle ScholarCrossref 6. Larson DM, Menssen KM, Sharkey SW, et al. “False-positive” cardiac catheterization laboratory activation among patients with suspected ST-segment elevation myocardial infarction. JAMA. 2007;298(23):2754-276018165668PubMedGoogle ScholarCrossref 7. Garvey JL, Monk L, Granger CB, et al. Rates of cardiac catheterization cancelation for ST-segment elevation myocardial infarction after activation by emergency medical services or emergency physicians: results from the North Carolina Catheterization Laboratory Activation Registry. Circulation. 2012;125(2):308-31322147904PubMedGoogle ScholarCrossref 8. American Heart Association Mission: Lifetime. Inappropriate activation form. http://www.heart.org/idc/groups/heart-public/@wcm/@˝global/documents/downloadable/ucm_316080.pdf. Accessed February 21, 2012 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Internal Medicine American Medical Association

Activating Primary Percutaneous Coronary Intervention for STEMI That Is Not: The Collateral Damage of Improving Door-to-Balloon Time: Comment on “Prevalence and Factors Associated With False-Positive ST-Segment Elevation Myocardial Infarction Diagnoses at Primary Percutaneous Coronary Intervention–Capable Centers”

Archives of Internal Medicine , Volume 172 (11) – Jun 11, 2012

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Publisher
American Medical Association
Copyright
Copyright © 2012 American Medical Association. All Rights Reserved.
ISSN
0003-9926
eISSN
1538-3679
DOI
10.1001/archinternmed.2012.1117
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Abstract

Coronary arterial thrombosis secondary to plaque rupture (most common), erosion, or calcified nodule often results in acute ischemic symptoms and electrocardiographic (ECG) changes, specifically ST-segment elevation. Timely clinical identification of ST-segment elevation myocardial infarction (STEMI) is based on acute symptoms and ECG changes. Prompt and effective revascularization of the infarct-related artery can save myocardium and reduce morbidity and mortality.1 The Door-to-Balloon (D2B) Alliance recognizes the importance of door-to-balloon time (DBT) as a core measure of quality for primary percutaneous coronary intervention (PCI) and emphasizes methods to decrease DBT.2 Multiple strategies to reduce DBT include a dedicated on-call (24 hours per day/7 days per week) cardiac catheterization laboratory (CCL) team activated by a single page, acquisition of an ECG at the scene with “computer” interpretation with or without electronic transmission to an emergency department (ED), autonomous activation of the CCL by ED staff or emergency medical service, and organized review of experience with direct feedback to all involved in STEMI recognition and treatment.3 These strategies decrease DBT, but a potential downside to this increasingly fast process is more inappropriate CCL use. This occurs for multiple reasons including “misinterpretation” of clinical findings, primarily of the ECG, alternative diagnosis discovered after activation, activation protocol violation, and morbid conditions with ECG changes mimicking myocardial infarction for which a coronary angiogram would be contraindicated. Inappropriate CCL activation increases cost and exposes patients to unnecessary risk. Frequent, inappropriate CCL activation may result in interdisciplinary distrust, disinterest, and tension. A variety of terms have been proposed to report CCL activation that did not result in CCL use. These have been variably defined as “inappropriate activation,” “overactivation,” “unnecessary activation,” and “false-positive activation”; hence, reports of their occurrence vary widely. In this issue of the Archives, McCabe et al4 report that 36% of autonomous ED physician CCL activations for STEMI were false-positive STEMI diagnosis. In their registry, patients with angiography that did not show a “culprit” lesion (total or subtotal occlusion) and had Thrombolysis in Myocardial Infarction (TIMI) grade III flow in all coronary arteries were considered false-positive STEMI diagnosis regardless of subsequent serial troponin biomarker levels.4 Their false-positive STEMI diagnosis was based on post hoc analysis and could have been the result of an absolutely appropriate CCL activation. If these cases were considered “true activations,” then a lower percentage of the series in study by McCabe et al would have been classified as “false.” McCabe el al choose to consider angiography as the gold standard for defining false-positive STEMI diagnosis but one could question whether all of them were the result of false-positive activation. In a recent analysis of Harmonizing Outcomes With Revascularization and Stents in Acute Myocardial Infarction (HORIZON AMI) and Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications (CADILLAC) trials, 5332 patients with STEMI were reviewed and 932 (17.5%) had TIMI grade III flow on initial angiography.5 The discrepancy between the study by McCabe et al4 and other reports for CCL activation for STEMI6,7 highlight the variability of definitions and need for further guidance in establishing measures for quality of reperfusion programs, particularly given the findings by McCabe et al of an increase of “false activations” without a decrease in DBT over the study period. In an attempt to standardize definition of factors that lead to cancelation of CCL activations for STEMI, the American Heart Association Mission: Lifetime has proposed the terminology “appropriate” vs “inappropriate” for CCL activation.8 “Appropriate” CCL activation is based on clinical findings of the abrupt onset of symptoms of myocardial ischemia with ST-segment elevation on ECG; findings available to health care providers at the time when activation occurs. This term recognizes that by nature or secondary to initial acute intervention at the scene, STEMI may be dynamic, resulting in intermittent symptoms and ST-segment changes. Adherence to strict criteria of clinical symptoms as reported by McCabe et al4 could help in reducing inappropriate activations. The use of biomarkers and angiography for the appropriateness of CCL activation for STEMI is ill advised because these are not available at the time of activation. Most important for any program is a systematic protocol for the diagnosis and emergent treatment of STEMI including pivotal medical history for comorbid features, patient preference, continuous review of clinical experience, and direct feedback.3,6 Although there is no established acceptable rate of inappropriate activations, it is probably in the 15% to 20% range.6,7 Finally, it is worth noting that criteria used for CCL activation for STEMI in clinical practice likely differs from that for thrombolytic therapy. When the findings for STEMI are obvious, theoretically, either therapy can be initiated, but if the findings are subtle, primary PCI becomes a better option because of lower hemorrhagic complications and potential reversibility. In either case, the quality of acute reperfusion therapy should be judged not only on the basis of door-to-treatment time but also the ratio of “appropriate” vs “inappropriate” activation of reperfusion therapy. A single-minded approach to improving DBT without careful selection will surely result in a concomitant increase in the incidence inappropriate activation of reperfusion therapy. Back to top Article Information Correspondence: Dr Bachour, Cardiac Catheterization Laboratory R5.250, 701 Park Ave, Minneapolis, MN 55415 (bacho003@umn.edu). Published Online: May 7, 2012. doi:10.1001/archinternmed.2012.1117 Financial Disclosure: None reported. References 1. Berger PB, Ellis SG, Holmes DR Jr, et al. Relationship between delay in performing direct coronary angioplasty and early clinical outcome in patients with acute myocardial infarction: results from the global use of strategies to open occluded arteries in Acute Coronary Syndromes (GUSTO-IIb) trial. Circulation. 1999;100(1):14-2010393675PubMedGoogle ScholarCrossref 2. Krumholz HM, Bradley EH, Nallamothu BK, et al. A campaign to improve the timeliness of primary percutaneous coronary intervention: Door-to-Balloon: An Alliance for Quality. JACC Cardiovasc Interv. 2008;1(1):97-10419393152PubMedGoogle ScholarCrossref 3. Bradley EH, Herrin J, Wang Y, et al. Strategies for reducing the door-to-balloon time in acute myocardial infarction. N Engl J Med. 2006;355(22):2308-232017101617PubMedGoogle ScholarCrossref 4. McCabe JM, Armstrong EJ, Kulkarni A, et al. Prevalence and factors associated with false-positive ST-segment elevation myocardial infarction diagnoses at primary percutaneous coronary intervention–capable centers: a report from the Activate-SF Registry. [published online May 7, 2012]. Arch Intern Med. 2012;172(11):864-871Google Scholar 5. Brener SJ, Mehran R, Brodie BR, et al. Predictors and implications of coronary infarct artery patency at initial angiography in patients with acute myocardial infarction (from the CADILLAC and HORIZONS-AMI Trials). Am J Cardiol. 2011;108(7):918-92321764028PubMedGoogle ScholarCrossref 6. Larson DM, Menssen KM, Sharkey SW, et al. “False-positive” cardiac catheterization laboratory activation among patients with suspected ST-segment elevation myocardial infarction. JAMA. 2007;298(23):2754-276018165668PubMedGoogle ScholarCrossref 7. Garvey JL, Monk L, Granger CB, et al. Rates of cardiac catheterization cancelation for ST-segment elevation myocardial infarction after activation by emergency medical services or emergency physicians: results from the North Carolina Catheterization Laboratory Activation Registry. Circulation. 2012;125(2):308-31322147904PubMedGoogle ScholarCrossref 8. American Heart Association Mission: Lifetime. Inappropriate activation form. http://www.heart.org/idc/groups/heart-public/@wcm/@˝global/documents/downloadable/ucm_316080.pdf. Accessed February 21, 2012

Journal

Archives of Internal MedicineAmerican Medical Association

Published: Jun 11, 2012

Keywords: percutaneous coronary intervention,st segment elevation myocardial infarction,door to balloon time,false-positive results

References