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Clinical Policy: Emergency Department Management of Patients Needing Reperfusion Therapy for Acute ST-Segment Elevation Myocardial Infarction

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Clinical Policy: Emergency Department Management of Patients Needing Reperfusion Therapy for Acute ST-Segment Elevation Myocardial Infarction CARDIOLOGY/CLINICAL POLICY Clinical Policy: Emergency Department Management of Patients Needing Reperfusion Therapy for Acute ST-Segment Elevation Myocardial Infarction From the American College of Emergency Physicians Clinical Policies Subcommittee (Writing Committee) on Reperfusion Therapy for Acute ST-Segment Elevation Myocardial Infarction: Susan B. Promes, MD, MBA (Subcommittee Chair) Jonathan M. Glauser, MD, MBA Michael D. Smith, MD, MBA Sam S. Torbati, MD Michael D. Brown, MD, MSc (Committee Chair) Members of the American College of Emergency Physicians Clinical Policies Committee (Oversight Committee): Michael D. Brown, MD, MSc (Chair 2014-2017) Michael D. Smith, MD, MBA Richard Byyny, MD, MSc (Methodologist) Molly E. W. Thiessen, MD Deborah B. Diercks, MD, MSc Christian A. Tomaszewski, MD, MS, MBA Seth R. Gemme, MD Jonathan H. Valente, MD Charles J. Gerardo, MD, MHS Stephen P. Wall, MD, MSc, MAEd (Methodologist) Steven A. Godwin, MD Stephen J. Wolf, MD Sigrid A. Hahn, MD, MPH Stephen V. Cantrill, MD (Liaison with Quality and Patient Benjamin W. Hatten, MD, MPH Safety Committee) Jason S. Haukoos, MD, MSc (Methodologist) Jon Mark Hirshon, MD, MPH, PhD (Board Liaison 2016- Graham S. Ingalsbe, MD (EMRA Representative 2015-2017) 2017) Amy Kaji, MD, MPH, PhD (Methodologist) Rhonda R. Whitson, RHIA, Staff Liaison, Clinical Policies Heemun Kwok, MD, MS (Methodologist) Committee and Subcommittee Revising the Reperfusion Bruce M. Lo, MD, MBA, RDMS Therapy for Acute Myocardial Infarction Clinical Policy Sharon E. Mace, MD Travis Schulz, MLS, AHIP, Staff Liaison, Clinical Policies Devorah J. Nazarian, MD Committee Jean A. Proehl, RN, MN, CEN, CPEN (ENA Representative 2015-2017) Approved by the ACEP Board of Directors June 28, 2017 Susan B. Promes, MD, MBA Kaushal H. Shah, MD Richard D. Shih, MD Endorsed by the Emergency Nurses Association Scott M. Silvers, MD August 22, 2017 Policy statements and clinical policies are the official policies of the American College of Emergency Physicians and, as such, are not subject to the same peer review process as articles appearing in the journal. Policy statements and clinical policies of ACEP do not necessarily reflect the policies and beliefs of Annals of Emergency Medicine and its editors. 0196-0644/$-see front matter Copyright © 2017 by the American College of Emergency Physicians. https://doi.org/10.1016/j.annemergmed.2017.09.035 724 Annals of Emergency Medicine Volume 70, no. 5 : November 2017 Clinical Policy [Ann Emerg Med. 2017;70:724-739.] perform the intervention. What are the sources of these delays? What are the indications for fibrinolytic therapy in the age of PCI? These questions are critical for emergency ABSTRACT physicians who practice in rural and remote locations Ischemic heart disease is the leading cause of death in the without immediate access to PCI centers. Aside from the world. More than half a million patients present to immediate outcomes for reperfusion and death, data on emergency departments across the United States each year long-term functional outcomes are critical to determine the with ST-segment elevation myocardial infarctions.1 Timely impact these interventions ultimately have on patient lives. reperfusion is critical to saving myocardium at risk. Finally, the role of pain relief—in particular, opioid use—is Multiple studies have been conducted that demonstrate discussed in light of newer research that raises some that improved care processes are linked to improved concern over long-term outcomes in chest pain patients survival in patients having an acute myocardial infarction. treated with opioids. This clinical policy from the American College of This clinical policy addresses 3 issues that are relevant to Emergency Physicians addresses key issues in reperfusion practicing emergency physicians. The first 2 questions for patients with acute ST-segment elevation myocardial address whether there is a benefit to giving fibrinolytic infarction. A writing subcommittee conducted a systematic therapy to STEMI patients when PCI will be delayed and review of the literature to derive evidence-based whether transfer to a PCI-capable facility for the STEMI recommendations to answer the following clinical patient decreases the incidence of major adverse cardiac questions: (1) In adult patients having an ST-segment events (MACE). The clinical heterogeneity among the elevation myocardial infarction, are there patients for research studies investigating these topics make whom treatment with fibrinolytic therapy decreases the interpretation of the results challenging. For example, there incidence of major adverse cardiac events when is no standard definition of MACE. MACE may include percutaneous coronary intervention is delayed? (2) In adult such endpoints as death, revascularization, stroke, and patients having an ST-segment elevation myocardial congestive heart failure, but not all studies use the same infarction, does transfer to a percutaneous coronary endpoints. Definitions for MACE will be identified in the intervention center decrease the incidence of major adverse policy as appropriate for clarity. In addition, there is no cardiac events? (3) In adult patients undergoing reperfusion uniformity on timing metrics. The final critical question therapy, should opioids be avoided to prevent adverse examines the safety of opioid use in this population. outcomes? Evidence was graded and recommendations This is a revision of the 2006 American College of were made based on the strength of the available data. Emergency Physicians (ACEP) clinical policy on reperfusion therapy in emergency department (ED) INTRODUCTION patients with suspected acute myocardial infarction (MI).3 Although timely percutaneous coronary intervention (PCI) has become the standard treatment for ST-segment elevation myocardial infarction (STEMI), the fact remains METHODOLOGY that only a minority of hospitals in the United States are This clinical policy is based on a systematic review with capable of performing this intervention on site, and even critical analysis of the medical literature meeting the fewer can provide 24-hour access to the intervention. inclusion criteria. Searches of MEDLINE, MEDLINE When a patient presents with STEMI, national guidelines InProcess, Cochrane, EMBASE, and Scopus databases were recommend a first medical-contact-to-device time of less performed. All searches were limited to human studies than 90 minutes for individuals presenting to a PCI- published in English. Specific key words/phrases, years used capable site and less than 120 minutes from first medical- in the searches, dates of searches, and study selection are contact-to-device time for those who need to be transferred identified under each critical question. In addition, relevant to a PCI-capable hospital.2 Although very few patients are articles from the bibliographies of included studies and treated solely with fibrinolytic therapy without an more recent articles identified by committee members and angiographic assessment of their coronary arteries, the time- reviewers were included. dependent nature of getting the patient to a PCI center This policy is a product of the ACEP clinical policy requires knowledge of how delays affect clinical outcomes. development process, including internal and external Systems have been developed for rapid out-of-hospital review, and is based on the existing literature; when triage to PCI-capable centers and for rapid interhospital literature was not available, consensus of Clinical Policies transfer from a noncapable PCI facility to one that can Committee members was used and noted as such in the Volume 70, no. 5 : November 2017 Annals of Emergency Medicine 725 Clinical Policy recommendation (ie, consensus recommendation). Review question for which it is being considered. As such, it was comments were received from emergency physicians, possible for a single article to receive a different Class of cardiologists, individual members of the American College Evidence rating when addressing a different critical of Cardiology Foundation/American Heart Association, a question. Question-specific Classes of Evidence grading patient representative, and members of ACEP’s Medical- may be found in the Evidentiary Table included at the end Legal Committee. Comments were received during a 60- of this policy. day open-comment period, with notices of the comment period sent in an e-mail to ACEP members, published in EM Today, and posted on the ACEP Web site. The Translation of Classes of Evidence to responses were used to further refine and enhance this Recommendation Levels clinical policy; however, responses do not imply Based on the strength of evidence grading for each endorsement. Clinical policies are scheduled for revision critical question (ie, Evidentiary Table), the subcommittee every 3 years; however, interim reviews are conducted when drafted the recommendations and the supporting text technology, methodology, or the practice environment synthesizing the evidence using the following guidelines: fi Level A recommendations. Generally accepted changes signi cantly. ACEP was the funding source for this fl clinical policy. principles for patient care that re ect a high degree of clinical certainty (eg, based on evidence from one or more Class of Evidence I or multiple Class of Evidence II Assessment of Classes of Evidence studies). Two methodologists independently graded and assigned Level B recommendations. Recommendations for a preliminary Class of Evidence for all articles used in the patient care
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