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《心肺复苏指南》参考资料（英文版）Part 8：Stabilization of the Patient With Acute Coronary Syndromes

Acute Coronary Syndromes cute myocardial infarction (AMD and unstable angina rest "and Part 7.3: "Management of Symptomatic Brady- ollec-cardia and Tachycardia") An overview of recommended care for the ACS patient is illustrated in Figure 1, the Acute Coronary Syndromes

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Part 8: Stabilization of the patient with acute Coronary Syndromes A cute myocardial infarction(AMI)and unstable angina rest "and Part 7.3: " Management of Symptomatic Brady (UA)are part of a spectrum of clinical di ardia and Tachycardia") ively identified as acute coronary syndromes(ACS). The pathophysiology common to this spectrum of disease is a An overview of recommended care for the ACS patient is ruptured or eroded atheromatous plaque. -s The electrocar illustrated in Figure l, the Acute Coronary Syndrom diographic (ECG) presentation of these syndromes encom- Igorithm. Part 8 provides details of the care highlighted in asses ST-segment elevation myocardial infarction (STEMD), the numbered algorithm boxes. Box numbers in the text ST-segment depression, and nondiagnostic ST-segment and correspond to the numbered boxes in the algorithm T-wave abnormalities. A non-ST-elevation myocardial in- In this part the abbreviation AMI refers to acute myocar- rction (NSTEMi) is diagnosed cardiac markers are positive with ST-segment depression or with nonspecific or The diagnosis and treatment of AMI, however, will often normal ECGs. Sudden cardiac death may occur with any of differ for patients with STEMI versus NSTEMI. Note care- these conditions. ACS is the most common proximate cause fully which is being discussed of sudden cardiac death 6-10 Effective interventions for patients with ACS, particularly Out-of-Hospital Management STEMI, are extremely time-sensitive. The first healthcare Recognition(Figure 1, Box 1) providers to encounter the ACS patient can have a big impact Treatment offers the greatest potential benefit for myocardial on patient outcome if they provide efficient risk stratification, salvage in the first hours of STEMI. Thus, it is imperative that critical that basic life support(BLS)and advanced cardiovas- ACS as quickly as possible. Delays to therapy occur during 3 cular life support(ACLS)healthcare providers who care for intervals: from onset of symptoms to patient recognition, ACS patients in the out-of-hospital, emergency department during out-of-hospital transport, and during in-hospital eval (ED), and hospital environments be aware of the principles and priorities of assessment and stabilization of these uation. Patient delay to symptom recognition often constitutes the longest period of delay to treatment. atients These guidelines target BLS and ACLs healthcare provid The classic symptom associated with ACs is chest discom ers who treat patients with ACS within the first hours after fort, but symptoms may also include discomfort in other areas onset of symptoms, summarizing key out-of-hospital, ED of the upper body, shortness of breath, sweating, nausea, and and some initial critical-care topics that are relevant to lightheadedness. The symptoms of AMI are characteristically more intense than angina and last >15 minutes. Atypical tions from the acciaha Guidelines, 1.12 which are used symptoms or unusual presentations of ACS are more com- throughout the United States and Canada. 3 As with an medical guidelines, these general recommendations must be Public education campaigns increase public awareness and knowledge of the symptoms of heart attack but have only rea wl tion to individual patients by knowledgeable he transient effects. 20 For patients at risk for ACS(and for their families), physicians should discuss the appropriate use of The primary goals of therapy for patients with ACS are to nitroglycerin and aspirin, activation of the emergency medi- cal services(EMS) system, and location of the nearest Reduce the amount of myocardial necrosis that occurs in hospital that offers 24-hour emergency cardiovascular care. patients with MI, preserving left ventricular (LV) function ecent ACC/AHA guidelines recommend that the patient or and preventing heart failure family members activate the EMS system rather than call Prevent major adverse cardiac events(MACE): death, their physician or drive to the hospital if chest discomfort nonfatal MI, and need for urgent revascularization unimproved or worsening 5 minutes after taking I nitroglyc Treat acute, life-threatening complications of ACS, such as erin tablet or using nitroglycerin spray. 12 ntricular fibrillation (VF)/pulseless ventricular tachycardia(VT), symptomatic bradycardias, and unstable Initial EMS Care(Figure 1, Box 2) chycardias(see Part 7. 2:"Management of Cardiac Ar lalf of the patients who die of AMI do so before reaching the hospital. VF or pulseless VT is the precipitating rhythm in (Circulation. 2005: 112: TV-89-IV-110) o 2005 American Heart Association most of these deaths, 2-23 and it is most likely to develop during the first 4 hours after onset of symptoms. 24-27 Com- This special supplement to Circulation is freely available at munities should develop programs to respond to out-of- hospital cardiac arrest that include prompt recognition of DOI: 10.1161/CIRCULATIONAHA. 105.166561 symptoms of ACS, early activation of the EMS system, an

Part 8: Stabilization of the Patient With Acute Coronary Syndromes Acute myocardial infarction (AMI) and unstable angina (UA) are part of a spectrum of clinical disease collectively identified as acute coronary syndromes (ACS). The pathophysiology common to this spectrum of disease is a ruptured or eroded atheromatous plaque.1–5 The electrocardiographic (ECG) presentation of these syndromes encompasses ST-segment elevation myocardial infarction (STEMI), ST-segment depression, and nondiagnostic ST-segment and T-wave abnormalities. A non–ST-elevation myocardial infarction (NSTEMI) is diagnosed if cardiac markers are positive with ST-segment depression or with nonspecific or normal ECGs. Sudden cardiac death may occur with any of these conditions. ACS is the most common proximate cause of sudden cardiac death.6 –10 Effective interventions for patients with ACS, particularly STEMI, are extremely time-sensitive. The first healthcare providers to encounter the ACS patient can have a big impact on patient outcome if they provide efficient risk stratification, initial stabilization, and referral for cardiology care. It is critical that basic life support (BLS) and advanced cardiovascular life support (ACLS) healthcare providers who care for ACS patients in the out-of-hospital, emergency department (ED), and hospital environments be aware of the principles and priorities of assessment and stabilization of these patients. These guidelines target BLS and ACLS healthcare providers who treat patients with ACS within the first hours after onset of symptoms, summarizing key out-of-hospital, ED, and some initial critical-care topics that are relevant to stabilization. They also continue to build on recommendations from the ACC/AHA Guidelines,11,12 which are used throughout the United States and Canada.13 As with any medical guidelines, these general recommendations must be considered within the context of local resources and application to individual patients by knowledgeable healthcare providers. The primary goals of therapy for patients with ACS are to ● Reduce the amount of myocardial necrosis that occurs in patients with MI, preserving left ventricular (LV) function and preventing heart failure ● Prevent major adverse cardiac events (MACE): death, nonfatal MI, and need for urgent revascularization ● Treat acute, life-threatening complications of ACS, such as ventricular fibrillation (VF)/pulseless ventricular tachycardia (VT), symptomatic bradycardias, and unstable tachycardias (see Part 7.2: “Management of Cardiac Arrest” and Part 7.3: “Management of Symptomatic Bradycardia and Tachycardia”) An overview of recommended care for the ACS patient is illustrated in Figure 1, the Acute Coronary Syndromes Algorithm. Part 8 provides details of the care highlighted in the numbered algorithm boxes. Box numbers in the text correspond to the numbered boxes in the algorithm. In this part the abbreviation AMI refers to acute myocardial infarction, whether associated with STEMI or NSTEMI. The diagnosis and treatment of AMI, however, will often differ for patients with STEMI versus NSTEMI. Note carefully which is being discussed. Out-of-Hospital Management Recognition (Figure 1, Box 1) Treatment offers the greatest potential benefit for myocardial salvage in the first hours of STEMI. Thus, it is imperative that healthcare providers evaluate, triage, and treat patients with ACS as quickly as possible. Delays to therapy occur during 3 intervals: from onset of symptoms to patient recognition, during out-of-hospital transport, and during in-hospital evaluation. Patient delay to symptom recognition often constitutes the longest period of delay to treatment.14 The classic symptom associated with ACS is chest discomfort, but symptoms may also include discomfort in other areas of the upper body, shortness of breath, sweating, nausea, and lightheadedness. The symptoms of AMI are characteristically more intense than angina and last 15 minutes. Atypical symptoms or unusual presentations of ACS are more common in elderly, female, and diabetic patients.15–19 Public education campaigns increase public awareness and knowledge of the symptoms of heart attack but have only transient effects.20 For patients at risk for ACS (and for their families), physicians should discuss the appropriate use of nitroglycerin and aspirin, activation of the emergency medical services (EMS) system, and location of the nearest hospital that offers 24-hour emergency cardiovascular care. Recent ACC/AHA guidelines recommend that the patient or family members activate the EMS system rather than call their physician or drive to the hospital if chest discomfort is unimproved or worsening 5 minutes after taking 1 nitroglycerin tablet or using nitroglycerin spray.12 Initial EMS Care (Figure 1, Box 2) Half of the patients who die of AMI do so before reaching the hospital. VF or pulseless VT is the precipitating rhythm in most of these deaths,21–23 and it is most likely to develop during the first 4 hours after onset of symptoms.24 –27 Communities should develop programs to respond to out-ofhospital cardiac arrest that include prompt recognition of symptoms of ACS, early activation of the EMS system, and (Circulation. 2005;112:IV-89-IV-110.) © 2005 American Heart Association. This special supplement to Circulation is freely available at http://www.circulationaha.org DOI: 10.1161/CIRCULATIONAHA.105.166561 IV-89

Part 8: Stabilization of the Patient With Acute Coronary Syndromes Iv-9 if needed, early CPR(see Part 4: Adult Basic Life Support") therapy. We recommend that out-of-hospital paramedics and early access to an automated external defibrillator(AEd acquire and transmit either diagnostic-quality ECGs or their through community AED programs(see Part 5:"Electrical interpretation of them to the receiving hospital with advance Therapies").28 EMS and dispatch system personnel should be notification of the arrival of a patient with ACS( Class IIa). If trained to respond to cardiovascular emergencies. EMS providers identify STEMI on the ECG, it is reasonable Dispatchers and EMs providers must be trained to recog- for them to begin to complete a fibrinolytic checklist(Figure nize symptoms of ACS. Dispatchers should advise patients with no history of aspirin allergy or signs of active or recent strointestinal bleeding to chew an aspirin(160 to 325 mg) Out-of-Hospital Fibrinolysis hile awaiting the arrival of EMS providers(Class Ila). 29 Clinical trials have shown the benefit of initiating fibrinolysis EMS providers should be trained to determine the time of as soon as possible after onset of ischemic-type chest pain in onset of symptoms and to stabilize, triage, and transport the patients with STEMI or new or presumably new left bundle patient to an appropriate facility and to provide prearrival branch block(LBBB). 67. 71 Several prospective studies(LOE notification. EMS providers should monitor vital signs and 1)72-74 have documented reduced time to administration of cardiac rhythm and be prepared to provide CPr and defibril- fibrinolytics and decreased mortality rates when out-of lation if needed hospital fibrinolytics were administered to patients with EMS providers may administer oxygen to all patients STEMI and no contraindications to fibrinoly the patient is hypoxemic, providers should titrate therapy Physicians in the Grampian Region Early Anistreplase based on monitoring of oxyhemoglobin saturation(Class Trial(GREAT)73 administered fibrinolytic therapy to patients ).30-44 If the patient has not taken aspirin and has no history at home 130 minutes earlier than to patients at the hospital of aspirin allergy and no evidence of recent gastrointestinal bleeding, EMs providers should give the patient nonenteric and noted a 50% reduction in hospital mortality rates and greater l-year and 5-year survival rates in those treated aspirin(160 to 325 mg) to chew( Class I). 45-48 earlier 75,76 Delaying fibrinolytic treatment by I hour in- EMS providers should administer up to 3 nitroglycerin creased the hazard ratio of death by 20%o, which is equivalent tablets(or spray) for ongoing symptoms at intervals of 3 to 5 to the loss of 43 lives per 1000 patients over 5 years minutes if permitted by medical control and if the patient A meta-analys of out-of-hospital fibrinolytic trials found remains hemodynamically stable(systolic blood pressure a relative improvement of 17% in outcome associated with [!>90 mm Hg or no more than 30 mm Hg below out-of-hospital fibrinolytic therapy, particularly when therapy baseline], heart rate between 50 and 100 beats per minute was initiated 60 to 90 minutes earlier than in the hospital. 71A [bpm)).4950 EMS providers can administer morphine for chest pain unresponsive to nitroglycerin if authorized by protocol documented decreased all-cause hospital mortality rates hospital stabilization and care is included in the following among patients treated with out-of-hospital fibrinolysis com- pared with in-hospital fibrinolysis(odds ratio [OR]: 0.83 95% confidence interval [CI]: 0.70 to 0.98)with a number Out-of-Hospital ECGs needed to treat of 62 to save I extra life with out-of-hospital Out-of-hospital 12-lead ECGs and advance notification to the ibrinolysis. Results were similar regardless of the trainin receiving facility speed the diagnosis, shorten the time to fibrinolysis, and may be associated with decreased mortality The ECC Guidelines 200077 recommended consideration rates.51-64 The reduction in door-to-reperfusion therapy in- of out-of-hospital fibrinolysis for patients with a transport terval in most studies ranges from 10 to 60 minutes. EMS time >l hour. But in a recent Swiss study (LOE 1), 74 providers can efficiently acquire and transmit diagnostic prehospital administration of fibrinolytics significantly de- quality ECGs to the ED53-58. 65. 6 with a minimal increase(0.2 creased the time to drug administration even in an urban to 5.6 minutes)in the on-scene time interval. 52-56, 65-68 setting with relatively short transport intervals (<15 Qualified and specially trained paramedics and prehospital minutes) nurses can accurately identify typical ST-segment elevation In summary, out-of-hospital administration of fibrinolytics (I mm in 2 or more contiguous leads) in the 12-lead ECG to patients with STEMI with no contraindications is safe with specificity ranging from 91% to 100% and sensitivity feasible, and reasonable( Class lla). This intervention may be ranging from 71% to 97% when compared with emergency performed by trained paramedics, nurses, and physicians fo medicine physicians or cardiologists. 69. 0 Using radio or cell patients with symptom duration of 30 minutes to 6 hours phone, they can also provide advance notification to the System requirements include protocols with fibrinolytic eceiving hospital of the arrival of a patient with ACS.56,61-64 checklists, ECG acquisition and interpretation, experience in We recommend implementation of out-of-hospital 12-lead ACLS, the ability to communicate with the receiving institu- ECG diagnostic programs in urban and suburban EMS tion, and a medical director with training/experience in systems( Class I). Routine use of 12-lead out-of-hospital ECG management of STEMI. A process of continuous quality and advance notification is recommended for patients with improvement is required. Given the operational challenge signs and symptoms of ACS(Class Ila). A 12-lead out-of- required to provide out-of-hospital fibrinolytics, most EMS hospital ECG with advance notification to the ED may be systems should focus on early diagnosis with 12-lead ECG beneficial for STEMI patients by reducing time to reperfusion rapid transport, and advance notification of the ED(verbal

if needed, early CPR (see Part 4: “Adult Basic Life Support”) and early access to an automated external defibrillator (AED) through community AED programs (see Part 5: “Electrical Therapies”).28 EMS and dispatch system personnel should be trained to respond to cardiovascular emergencies. Dispatchers and EMS providers must be trained to recognize symptoms of ACS. Dispatchers should advise patients with no history of aspirin allergy or signs of active or recent gastrointestinal bleeding to chew an aspirin (160 to 325 mg) while awaiting the arrival of EMS providers (Class IIa).29 EMS providers should be trained to determine the time of onset of symptoms and to stabilize, triage, and transport the patient to an appropriate facility and to provide prearrival notification. EMS providers should monitor vital signs and cardiac rhythm and be prepared to provide CPR and defibrillation if needed. EMS providers may administer oxygen to all patients. If the patient is hypoxemic, providers should titrate therapy based on monitoring of oxyhemoglobin saturation (Class I).30 – 44 If the patient has not taken aspirin and has no history of aspirin allergy and no evidence of recent gastrointestinal bleeding, EMS providers should give the patient nonenteric aspirin (160 to 325 mg) to chew (Class I).45– 48 EMS providers should administer up to 3 nitroglycerin tablets (or spray) for ongoing symptoms at intervals of 3 to 5 minutes if permitted by medical control and if the patient remains hemodynamically stable (systolic blood pressure [SBP] 90 mm Hg [or no more than 30 mm Hg below baseline], heart rate between 50 and 100 beats per minute [bpm]).49,50 EMS providers can administer morphine for chest pain unresponsive to nitroglycerin if authorized by protocol or medical control. Additional information about out-ofhospital stabilization and care is included in the following sections. Out-of-Hospital ECGs Out-of-hospital 12-lead ECGs and advance notification to the receiving facility speed the diagnosis, shorten the time to fibrinolysis, and may be associated with decreased mortality rates.51– 64 The reduction in door-to–reperfusion therapy interval in most studies ranges from 10 to 60 minutes. EMS providers can efficiently acquire and transmit diagnosticquality ECGs to the ED53,58,65,66 with a minimal increase (0.2 to 5.6 minutes) in the on-scene time interval.52,56,65– 68 Qualified and specially trained paramedics and prehospital nurses can accurately identify typical ST-segment elevation (1 mm in 2 or more contiguous leads) in the 12-lead ECG with specificity ranging from 91% to 100% and sensitivity ranging from 71% to 97% when compared with emergency medicine physicians or cardiologists.69,70 Using radio or cell phone, they can also provide advance notification to the receiving hospital of the arrival of a patient with ACS.56,61– 64 We recommend implementation of out-of-hospital 12-lead ECG diagnostic programs in urban and suburban EMS systems (Class I). Routine use of 12-lead out-of-hospital ECG and advance notification is recommended for patients with signs and symptoms of ACS (Class IIa). A 12-lead out-ofhospital ECG with advance notification to the ED may be beneficial for STEMI patients by reducing time to reperfusion therapy. We recommend that out-of-hospital paramedics acquire and transmit either diagnostic-quality ECGs or their interpretation of them to the receiving hospital with advance notification of the arrival of a patient with ACS (Class IIa). If EMS providers identify STEMI on the ECG, it is reasonable for them to begin to complete a fibrinolytic checklist (Figure 2). Out-of-Hospital Fibrinolysis Clinical trials have shown the benefit of initiating fibrinolysis as soon as possible after onset of ischemic-type chest pain in patients with STEMI or new or presumably new left bundle branch block (LBBB).67,71 Several prospective studies (LOE 1)72–74 have documented reduced time to administration of fibrinolytics and decreased mortality rates when out-ofhospital fibrinolytics were administered to patients with STEMI and no contraindications to fibrinolytics. Physicians in the Grampian Region Early Anistreplase Trial (GREAT)73 administered fibrinolytic therapy to patients at home 130 minutes earlier than to patients at the hospital and noted a 50% reduction in hospital mortality rates and greater 1-year and 5-year survival rates in those treated earlier.75,76 Delaying fibrinolytic treatment by 1 hour increased the hazard ratio of death by 20%, which is equivalent to the loss of 43 lives per 1000 patients over 5 years. A meta-analysis of out-of-hospital fibrinolytic trials found a relative improvement of 17% in outcome associated with out-of-hospital fibrinolytic therapy, particularly when therapy was initiated 60 to 90 minutes earlier than in the hospital.71 A meta-analysis of 6 trials involving 6434 patients (LOE 1)72 documented decreased all-cause hospital mortality rates among patients treated with out-of-hospital fibrinolysis compared with in-hospital fibrinolysis (odds ratio [OR]: 0.83; 95% confidence interval [CI]: 0.70 to 0.98) with a number needed to treat of 62 to save 1 extra life with out-of-hospital fibrinolysis. Results were similar regardless of the training and experience of the provider. The ECC Guidelines 200077 recommended consideration of out-of-hospital fibrinolysis for patients with a transport time 1 hour. But in a recent Swiss study (LOE 1),74 prehospital administration of fibrinolytics significantly decreased the time to drug administration even in an urban setting with relatively short transport intervals (15 minutes).74 In summary, out-of-hospital administration of fibrinolytics to patients with STEMI with no contraindications is safe, feasible, and reasonable (Class IIa). This intervention may be performed by trained paramedics, nurses, and physicians for patients with symptom duration of 30 minutes to 6 hours. System requirements include protocols with fibrinolytic checklists, ECG acquisition and interpretation, experience in ACLS, the ability to communicate with the receiving institution, and a medical director with training/experience in management of STEMI. A process of continuous quality improvement is required. Given the operational challenges required to provide out-of-hospital fibrinolytics, most EMS systems should focus on early diagnosis with 12-lead ECG, rapid transport, and advance notification of the ED (verbal Part 8: Stabilization of the Patient With Acute Coronary Syndromes IV-91

lV-92 Circulation December 13, 2005 CHEST PAIN CHECKLIST FOR STEMI FIBRINOLYTIC THERAPY Step One: Has patient experienced chest discomfort for greater than 15 minutes and less than 12 hours? Does ECG show STEM or presumably new LBBB? Step Two H ANT of the following is CHECKED YEs, fibrinolysis MAY be contraindicated Systolic BP greater than 180 mm Hg O YES Diastolic BP greater than11mm地 ○YEs Right vs. left arm systolic BP difference greater than 15 mm Hg History of structural central nervous system disease Significant closed headnfacial trauma within the previous 3 months oooo Recent (within 6 wks)major trauma, surgery (including Laser eye surgery), GI/GU bleed Bleeding or dotting problem or on blood thinners ○YEs CPR greater than 10 minutes ○YEs Pregnant female erminal cancer, severe liver or kidney dise Step Three: IfAw ef the following is CHECKED \Is, CONSIDER Transport/ Transfer to PCI Facility Heart rate greater than or equal to 100 bpm AND systolic BP less than 100 mm Hg ○YEs Pulmonary edema(rales Signs of shock (cool, dammy ○Y gure 2. Fibrinolytic Checklist. interpretation or direct transmission of ECG) instead of fibrinolysis when transport can be completed in <60 minutes out-of-hospital delivery of fibrinolysis with a physician in a mobile intensive care unit. There is no direct evidence, however, to suggest that these strategies are safe or effective. Patients judged to be at highest risk for a of-Hospital Triage complicated transfer were excluded from some of these ital and EMS protocols should clearly identify criteria studies for transfer of patients to specialty centers and conditions In summary, at this time there is inadequate evidence to under which fibrinolytics should be initiated before transfer recommend out-of-hospital triage to bypass non-PCI-capable When transfer is indicated, the ACC/AHA guidelines recom- hospitals to bring patients to a PCI center(Class Indetermi- mend a door-to-departure time <30 minutes. 2 It may be nate). Local protocols for EMS providers are appropriate to appropriate for the EMS medical director to institute a policy guide the destination of patients with suspected or confirmed therapy only, particularly for patients who provide medicalSTEMI of out-of-hospital bypass of hospitals that Interven- tional therapy. Patients who require interventional therapy Interfacility Transfer may include those with cardiogenic shock, pulmonary edema, All patients with STEMI and symptom duration of =12 hours large infarctions, and contraindications to fibrinolytic are candidates for reperfusion therapy with either fibrinolysis therapy or PCI(Class D). When patients present directly to a facility At present no randomized studies have directly compared capable of providing only fibrinolysis, 3 treatment options ar triage with an experienced percutaneous coronary interven- available: administering fibrinolytics with admission to that on(PCi) center with medical the local hospital, transferring the patient for primary PCI, or giving hospital.Extrapolation from several randomized trials on fibrinolytics and then transferring the patient to a specialized interfacility transfer78-80 suggests that STEMI patients tri- center. The decision is guided by a risk-benefit assessment aged directly to a primary PCI facility may have better that includes evaluation of duration of symptoms, complica outcomes related to the potential for earlier treatment. A ons, contraindications, and the time delay from patient cost-efficacy substudy of the Comparison of Angioplasty and contact to fibrinolysis versus potential delay to PCI balloon Prehospital Thrombolysis in Acute Myocardial Infarction (CAPTIM) trials suggests that direct transport to a primary In 2 prospective studies (LOE 2)78-80 and a meta-analy PCI facility may be more cost-effective than out-of-hospit is,2 patients with STEMI who presented 3 to 12 hours after

interpretation or direct transmission of ECG) instead of out-of-hospital delivery of fibrinolysis. Triage and Transfer Out-of-Hospital Triage Hospital and EMS protocols should clearly identify criteria for transfer of patients to specialty centers and conditions under which fibrinolytics should be initiated before transfer. When transfer is indicated, the ACC/AHA guidelines recommend a door-to-departure time 30 minutes.12 It may be appropriate for the EMS medical director to institute a policy of out-of-hospital bypass of hospitals that provide medical therapy only, particularly for patients who require interventional therapy. Patients who require interventional therapy may include those with cardiogenic shock, pulmonary edema, large infarctions, and contraindications to fibrinolytic therapy. At present no randomized studies have directly compared triage with an experienced percutaneous coronary intervention (PCI) center with medical management at the local hospital. Extrapolation from several randomized trials on interfacility transfer78 – 80 suggests that STEMI patients triaged directly to a primary PCI facility may have better outcomes related to the potential for earlier treatment. A cost-efficacy substudy of the Comparison of Angioplasty and Prehospital Thrombolysis in Acute Myocardial Infarction (CAPTIM) trial81 suggests that direct transport to a primary PCI facility may be more cost-effective than out-of-hospital fibrinolysis when transport can be completed in 60 minutes with a physician in a mobile intensive care unit. There is no direct evidence, however, to suggest that these strategies are safe or effective. Patients judged to be at highest risk for a complicated transfer were excluded from some of these studies. In summary, at this time there is inadequate evidence to recommend out-of-hospital triage to bypass non–PCI-capable hospitals to bring patients to a PCI center (Class Indeterminate). Local protocols for EMS providers are appropriate to guide the destination of patients with suspected or confirmed STEMI. Interfacility Transfer All patients with STEMI and symptom duration of 12 hours are candidates for reperfusion therapy with either fibrinolysis or PCI (Class I). When patients present directly to a facility capable of providing only fibrinolysis, 3 treatment options are available: administering fibrinolytics with admission to that hospital, transferring the patient for primary PCI, or giving fibrinolytics and then transferring the patient to a specialized center. The decision is guided by a risk-benefit assessment that includes evaluation of duration of symptoms, complications, contraindications, and the time delay from patient contact to fibrinolysis versus potential delay to PCI balloon inflation. In 2 prospective studies (LOE 2)78 – 80 and a meta-analysis,82 patients with STEMI who presented 3 to 12 hours after Figure 2. Fibrinolytic Checklist. IV-92 Circulation December 13, 2005

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