Prehospital NSTEMI Patient Assessment Paul A. Berlin, MS, NREMT-P

1. Prehospital NSTEMI Patient AssessmentPaul A. Berlin, MS, NREMT-P Identify patients at high risk for NSTEMI. The role of positive cardiac biomarkers in identifying NSTEMI patients.

2. Myocardial Infarction Non-ST � Segment Elevation (NSTEMI) (45%) ST � Segment Elevation (STEMI) (55%) How do we find the 45% of MI patients we are missing?

3. GUSTO IIb: Correlation of 6-month mortality with baseline ECG findings in patients with ACS The presenting electrocardiograms (ECGs) of 12,142 patients enrolled in the Global Use of Strategies To Open Occluded Arteries in Acute Coronary Syndromes (GUSTO-IIb) study, which compared heparin and hirudin in patients with symptoms of myocardial ischemia, were analyzed retrospectively to assess their prognostic value. All patients reported chest pain at rest within 12 hours of admission and had ECG-confirmed myocardial ischemia. Although mortality at 30 days was higher in the group with ST-segment elevation than those in the group with ST-segment depression, their respective curves crossed and diverged after 30 days. Follow-up at 6 months revealed that cumulative mortality was 8.9% in the ST-segment depression group (n=4263), 6.8% in the ST-segment elevation group (n=3369), and 3.4% in the group with isolated T-wave inversion (n=2723). Isolated T-wave inversion was associated with lower death rates than ST-segment changes at both 30 days and 6 months. The presenting electrocardiograms (ECGs) of 12,142 patients enrolled in the Global Use of Strategies To Open Occluded Arteries in Acute Coronary Syndromes (GUSTO-IIb) study, which compared heparin and hirudin in patients with symptoms of myocardial ischemia, were analyzed retrospectively to assess their prognostic value. All patients reported chest pain at rest within 12 hours of admission and had ECG-confirmed myocardial ischemia. Although mortality at 30 days was higher in the group with ST-segment elevation than those in the group with ST-segment depression, their respective curves crossed and diverged after 30 days. Follow-up at 6 months revealed that cumulative mortality was 8.9% in the ST-segment depression group (n=4263), 6.8% in the ST-segment elevation group (n=3369), and 3.4% in the group with isolated T-wave inversion (n=2723). Isolated T-wave inversion was associated with lower death rates than ST-segment changes at both 30 days and 6 months.

4. NSTEMI ECG Features Can Be: ST depression (70-80%) T wave inversion(10-20%) Both ST depression and T wave inversion Normal ECG Bulk of the NSTEMI belong to ST depression group.NSTEMI with purely T wave inversion is less common but occurs mainly in perioperative settings, pre existing CAD.NSTEMI with normal ECG is very rare� but can occur.Bulk of the NSTEMI belong to ST depression group.NSTEMI with purely T wave inversion is less common but occurs mainly in perioperative settings, pre existing CAD.NSTEMI with normal ECG is very rare� but can occur.

5. Assess Applicability for ACS Triage = 21 years of age with symptoms lasting more than 10 minutes but less than 12 hours suspected to be caused by coronary artery disease: Chest discomfort, pressure, crushing pain, tightness, heaviness, cramping, burning, aching sensation, usually in the center of the chest lasting more than a few minutes, or that goes away and comes back. Epigastric (stomach) discomfort, such as unexplained indigestion, belching, or pain. Shortness of breath with or without chest discomfort. Radiating pain or discomfort in 1 or both arms, neck, jaws, shoulders, or back. Other symptoms may include sweating, nausea, vomiting. Women, diabetics, and geriatric patients might not have chest discomfort or pain. Instead they might have nausea/vomiting, back or jaw pain, fatigue/weakness, or generalized complaints.

6. Assess High Risk CriteriaBased on TIMI (Three or more checked, High risk for NSTEMI) Age = 55* 3 or more CAD risk factors: Family history of CAD High BP High cholesterol Diabetes Current smoker Aspirin use in last 7 days Angina in last 24 hours ST-segment deviation on ECG Known coronary disease Elevated cardiac biomarkers

7. NSTEMI vs UA NSTEMI is distinguished from UA by the detection of cardiac markers indicative of myocardial necrosis in NSTEMI and the absence of abnormal elevation of such biomarkers in patients with UA. NSTEMI is myocardial necrosis (evidenced by cardiac markers in blood; troponin I or T and CPK will be elevated) without acute ST-segment elevation or Q waves. ECG changes such as ST-segment depression, T-wave inversion, or both may be present.

8. 8 Reporting Times for Cardiac Markers for the ED This is real data at a hospital that had tried very hard to correct the slow TAT from the lab, shown in green. In reality, they could not and it gets worse at various times of the day and week. Note the top of the bar is 128 minutes but the SC is up to 174 minutes with one SD added (3 hours). By contrast, the Spectral Rapid POCT done at bedside is 15 minutes. This is a no brainer if a hospital will look at there reality.This is real data at a hospital that had tried very hard to correct the slow TAT from the lab, shown in green. In reality, they could not and it gets worse at various times of the day and week. Note the top of the bar is 128 minutes but the SC is up to 174 minutes with one SD added (3 hours). By contrast, the Spectral Rapid POCT done at bedside is 15 minutes. This is a no brainer if a hospital will look at there reality.

9. NSTEMI MORTALITY RATES:EARLY vs LATER CATH

10. Questions? NSTEMI recognition programs are the next step in ACS care following the implementation of strong Prehospital STEMI care programs. Early recognition of NSTEMI using ECG findings, risk stratification and early biomarkers by prehospital care providers can direct patients to appropriate receiving facilities and reduce morbidity and mortality.

11. Reference