Transcription
What I'd like to do today, this morning, is really put together what I think are the top ten tricks for treating STEMI. I'm gonna start with this quote: "Humanity's greatest advances are not in its discoveries, but how those discoveries are applied"—Bill Gates at the Harvard commencement. And a lot of what we've done in STEMI, and a lot of the progress we've made, has really been putting this in place. And so we'll come back to that. What's really happened? And the best data that we have about STEMI in the United States comes from the National Inpatient Survey. And you can see that we've increased our primary PCI, so that it's almost up to eighty percent. At the same time, we've decreased in-hospital mortality, but the total number of STEMI's is decreasing too, probably because of primary prevention and dual antiplatelet therapy out there. So what are the top ten tricks?
Number one: Have a plan. Have a plan. And that includes two things: have a standardized protocol in place. Every hospital in America should have a standardized protocol in place for how they deal with STEMI. Have a plan. And second of all, when you get the EKG and you have, and you're preparing for that patient, come have an individualized patient plan based on the EKG and clinical history. Is this a late presenter? Is it an early presenter? A 29-year-old postpartum patient? Have a plan in your head about how you're going to approach this patient. So this is critically important—that you're ready to how you approach it.
Number two: Adequate antiplatelet therapy. Critically important. P2Y12 inhibition in particular has completely changed the escape, the scope of how we take care of STEMI patients. I'm a strong girl even pretreatment for STEMI, see in particular. There's absolutely no reason not to pretreat—get the P2Y12 inhibitor on board as fast as you can. Perhaps a girl anticoagulant onset, more potent and less variability. Clearly, there's a benefit there. Kingler. I'm going to show on a slide that it's it, and my question is: is there a role for GP IIb/IIIa inhibitors at all in STEMI anymore? I think very limited, if we have adequate P2Y12 inhibitors. This is Kingler, and this is actually shows you if the drug was free. This is perfect, what we want in terms of any platelet—you turn the drug on and you have immediate drop in platelet; you have perfect right away within a minute. And then you turn the drug off, and by sixty minutes you're really back to normal. But even even when you certainly turn it off, you start losing it. It's really what we want. Okay. Now then, the times that you need to use Cangrelor are pretty limited for STEMI—probably patients who have out-of-hospital cardiac arrest or cardiogenic shock, or if you think that they haven't had adequate oral P2Y12 inhibition in there. But I think—do you think P2Y12 inhibition is essential?
The next one, next really thing is adequate antithrombin therapy. This continues to be controversial, but there's a lot of data, double-blind placebo-controlled data, that show that there's less bleeding with Bivalirudin. And if you look at these, all these patients are high bleeding risk, case by definition, being in a STEMI. They're similar recurrent ischemia. There's this question about stent thrombosis. I think personally, if you pretreat with P2Y12 and any other barriers, and especially if you let the Bivalirudin run out, you get rid of that problem. There's also data that says that you support that have a reduction in mortality with Bivalirudin, although it's it's less strong, and they're less—they decrease bleeding. So the only problem is the cost. So this is one of those things that I think you'll at least need to think about.
Tip number four: Use nitroglycerin. Avoid pressors. Avoid pressors. Avoid pressors. You know, for STEMI, if you give dopamine, all you do is constrict—you vasoconstrict. And one of the major top tips is going to be it's about blood flow. Avoid pressors. And if you look at all the data, even encourage any shock, you saw the data that show the pressors really hard to show that they work. And it's so common—someone's blood pressure goes to 80 and we give them pressors—give them more nitro, seriously. Use nitroglycerin; avoid pressors.
Multivessel disease—really important thing. And if you look at multivessel disease, forty to fifty, sixty-five percent of our patients have multivessel disease, more if you're encouraging shock. Those patients clearly have worse outcome. When do you intervene? Is it based on data? How do you decide? Really important issue. Lots of you at different ways. Do we in fact only do we do multivessel PCI or preventive PCI in the same procedure, with or without MRI in the same hospital? Is it synchro with or without stress out of hospital? What's that all—it's not clear yet. But I will say that the data shows now that same-day doing a non-culprit vessel overall is supportive. The timing still needs to be worked out, and there's not enough patients. But so we're—I'm going to come down with multivessel disease is this—this comes down to judgment, judgment, judgment. So if you have a severe LAD and you have so a little bit of slow flow and the patient presented late and you have a large anterior infarct and you have an OM lesion or you have a mid-right lesion, leave it alone. You have a big anterior infarct here and you have suboptimal flow, leave it alone. On the other hand, if you have a mid-right lesion and it took you two minutes and you have TIMI three flow, fix that LAD. This is about judgment, and all clinical trials are not going to do it. And it's really, really important to know when to do the other vessel and when not to do the other vessel.
The number one, the out-of-hospital cardiac arrest, and we talked a little bit about it yesterday, but cool matters. Cooling the patient as fast as possible makes a big difference in terms of recovery. On that data we showed from Minneapolis Heart Institute, if you did look at the STEMI patients' survival to hospital discharge neurologically intact was 66 percent. That's really a major improvement, and it's possible and it's been consistent over years with good cooling in place. And you don't make it up as it goes. This has to be standardized and in place and prepared for ahead of time. And if you look at it, whether you are transferred from 200 miles away or you came in town, the outcomes of the patients without out-of-hospital cardiac arrest were equivalent. So it can be done if you have a system in place.
Tip number seven is cardiogenic shock. Is it really ever too late? And I'll tell you, I changed on this. I would say that six or seven years ago, there was this group, you know, bringing that patient to the cath lab who was on a Lucas device, whose pressures are 50. Well, I would say, are you sure that patient's not dead? And that I think I was concerned about doing that. And this is the data, early data that came from the Level 1 shock team that was around 20 patients. About 75 percent of them had ECMO, about 75 percent of them were cooled, and about 75 percent were on a Lucas device. So not all had everything, but you get the point—really, really, really sick patients. And I thought the mortality would be really 80-90 percent, but it wasn't—it was over 60 percent survival to hospital discharge neurologically intact. And on the right-hand corner, look at the improvement in ejection fractions. This is an area that I think it's not for the faint of heart, but I think that this really advanced cardiogenic shock patient, especially if it's a young patient, it's worth working on and having a system in place to do it, because I do think you'll save lives. And then once they leave their hospital, their mortality is the same as if they never had shock at all. So these patients are salvageable to be completely normal the rest of their life.
And then the next, next, or next tip, for problem they're eight, the problem is blood flow. Open the artery quickly. And I personally go with the guide first. I do the culprit artery first. I know there's a little controversy about that, but I think a lot of people do it. If you take the guide up and something's funny, like it doesn't make sense, you can always take it out and shoot the other coronary. But in a few, if you think it's eight millimeters of an inch of ST-elevation, go up with the right guide and fix it. If you have an LAD, fix it. What's gonna make me not fix that artery? And trust me, people say it's not delay, but there is delay. I think the issue about radial versus femoral is important. It depends on your lab. And I've been in a lab that was mostly femoral; now I'm going to allow this mostly radial. And they think there's pros and cons. The key is being able to do it quickly and having a system that's used to using it and doing it quickly. Use nitroglycerin and adenosine at the end of the case. Use lots of nitroglycerin and lots of adenosine. The problem is blood flow. You need to optimize blood flow. You need to have want with TIMI III flow. And I put—I am—an hour, I think, is in particular, if you want to pick out high-risk patients, I think IMR is a very useful thing at the end of the case. I like it also because you use adenosine automatically, but it will put—it'll predict those patients who have microvascular obstruction and help pull out the really high-risk STEMI patients in terms of the of the timing and turn on opening the arteries. I thought it was instructive to put this lab, this is from Minneapolis Heart Institute, about 500 STEMI a year, nine different operators, so they all do about 50 a year. You can see everyone has done over 400 PCI's, and you know, the time from arrival in the cath lab to device ranged from eleven and a half minutes to 17 minutes. That's because the system works. I moved to Cedars, and the time from arrival in the cath lab to device is about 37 or 38 minutes. So the point is you need to really—this is something that you can do. Blood flow matters. You need to do—do as quickly as possible. That's the STEMI pager. What? Yes.
The next important thing is time matters. You want—you know, this whole issue that it really doesn't matter and because of this door-to-balloon time and that that particle, those published in the New England Journal that showed an if no difference in mortality, it's unfortunately misleading. Time matters for sure. And so you should be thinking about that throughout your system. You should be looking at it; should do it as quickly as possible—that's safely—but you should always listen to the patient. You should always know the clinical situation, so you know what to be looking for. But time still matters. And this is really the famous graph from Dr. Gerson, JAMA, that shows really as you drop off, you lose myocardium, you lose myocardial salvage for sure. So man, the last one, I'm going to stay finished with my first tip: have a plan, but with flexibility. Told that patient, you use the standardized protocol, have your plan in place to start with, be prepared as can be, be prudent and make good choices. And then last is be humble, because those of you who know and take care of coronary disease, you see something new every day. Every day something surprises you. So be prepared, be prudent, be humble. And let that—I'll end with Yogi: "You've got to be very careful if you don't know where you're going, because you might not get there." So thank you very much. [Applause]