ESC Congress 2017 In Review – Focus on CAD&ACS - 8

Main Session

Future Challenges in STEMI Treatment
Borja Ibanez, MD, PhD, University Hospital Fundación
Jiménez Díaz, Madrid, Spain, pointed out that of the 159
recommendations in the 2017 STEMI guidelines, almost
half are level of evidence C, which is based on the consensus of expert opinions, small studies, retrospective
studies, or registries. Prof Ibanez discussed several areas
with gaps in the evidence and where future research is
needed. Public campaigns are needed to reduce patient
delay and improve prehospital management.
Although head-to-head trials have demonstrated the benefits of primary PCI over fibrinolysis, the
extent to which the PCI-related time delay diminishes
the advantages of PCI over fibrinolysis is not clear. The
PCI-related time delay that potentially mitigates the
benefits of PCI has been calculated in various studies
as from 60 to 120 minutes. However, there have been

no dedicated studies to determine the best cut-off
time. Identification of the best cut-off time to choose
a reperfusion strategy is of extreme importance and
should be addressed in future studies. Among the
areas highlighted were interventions to limit infarct
size, optimal regimens of combination antithrombotic
therapies (prehospital and long-term post discharge),
the role of ß-blockers in patients with reperfused MI,
revascularisation of the non-infarct-related artery, and
experience with novel therapies beyond clinical trials
(ie, in general clinical practice [Ford I, Norrie J. N Engl J
Med. 2016]). There is a need for less selective and less
expensive pragmatic trials that are more easily generalised to clinical practice involving a wider spectrum
of centres and patients across the world. More observational data from registries and clinical databases is
also needed for quality assessment.

Table 5. Quality Indicators
Type of Indicator Process

Quality Indicator

Structural measures (organisation)

1. The centre should be part of a network specifically developed for the rapid and efficient
management of STEMI patients with written protocols covering the following points:
* Single emergency telephone number for patients to contact the emergency services
* Prehospital interpretation of the ECG for diagnosis and strategy decision
* Prehospital activation of the catheterisation laboratory
* Transportation (ambulance-helicopter) equipped with ECG defibrillators

Performance measures for reperfusion therapy

1. Proportion of STEMI patients arriving in the first 12 h receiving reperfusion therapy.
2. Proportion of patients with timely reperfusion therapy, defined as:
* Patients attended to in the pre-hospital setting:
− 90 min from STEMI diagnosis to IRA wire crossing for reperfusion with PCI
− < 10 min from STEMI diagnosis to lytic bolus for reperfusion with fibrinolysis
* Transferred patients:
− < 120 min from STEMI diagnosis to IRA wire crossing for reperfusion with PCI
− < 30 min door-in-door-out for patients presenting in a non-PCI centre (en route to a
PCI centre)

Performance measures for risk assessment in hospital

1. Proportion of patients having LVEF assessed before discharge.

Performance measures for antithrombotic treatment in hospital

1. Proportion of patients without a clear and documented contraindication for aspirin and/
or a P2Y12 inhibitor, discharged on DAPT.

Performance measures for discharge medication and counselling

1. Proportion of patients without contra-indications with a statin (high-intensity) prescribed at
discharge.
2. Proportion of patients with LVEF ≤ 40% or clinical evidence of heart failure and without
contraindications with a β-blocker prescribed at discharge.
3. Proportion of patients with LVEF ≤ 40% or clinical evidence of heart failure without contraindications with an ACE inhibitor (or ARB if not tolerated) prescribed at discharge.
4. Proportion of patients with smoking cessation advice/counselling at discharge.
5. Proportion of patients without contraindications enrolled in a secondary prevention/
cardiac rehabilitation program at discharge.

Outcome measures

1. 30-day adjusted mortality (eg, GRACE risk score-adjusted).
2. 30-day adjusted readmission rates.

Opportunity-based composite quality indicators

1. Proportion of patients with LVEF > 40% and no evidence of heart failure receiving at
discharge low-dose aspirin, a P2Y12 inhibitor, and high-intensity statins.
2. Proportion of patients with LVEF ≤ 40% and/or heart failure receiving at discharge
low-dose aspirin, a P2Y12 inhibitor, high-intensity statins, an ACE inhibitor (or ARB), and
a β-blocker.

Patient-reported outcomes

1. Availability of a program to obtain feedback regarding the patient's experience and
quality of information received, including the following points:
* Angina control
* Explanations provided by doctors and nurses (about the disease, benefit/risk of
discharge treatments, and medical follow-up)
* Discharge information regarding what to do in case of recurrence of symptoms and
recommendation to attend a rehabilitation program (including smoking cessation and
diet counselling)

ACE, angiotensin converting enzyme; ARB, angiotensin II receptor blocker; DAPT, dual antiplatelet therapy; ECG, electrocardiogram; LVEF, left ventricular ejection
fraction; PCI, percutaneous coronary intervention; STEMI, ST-segment elevation myocardial infarction.
Reprinted from Ibanez B, James S et al. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation:
The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC).
Eur Heart J 2017; doi:10.1093/eurheartj/ehx419. By permission of Oxford University Press on behalf of the European Society of Cardiology.
8

October 2017

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