STEMI Recommendations from Thought Leaders at LUMEN 2011

LUMEN (www.lumenami.com), a meeting focusing on both the STEMI process and procedure, took place February 24-26 in Miami, Florida. Transradial access, left ventricular support devices, and cell therapy are the most cutting-edge developments in the treatment of ST-elevation myocardial infarction (STEMI) today, emphasized LUMEN course director Dr. Sameer Mehta in his opening remarks. Over 200 LUMEN attendees experienced a full day of transradial access education, and reports on left ventricular assist devices (LVAD) and cell therapy research by leading physicians, allowing for in-depth immersion in these topics. In addition, four key aspects of STEMI care continued as the core of LUMEN education: 1) Interventional cardiology (with co-director Dr. Samin Sharma); 2) Door-to-balloon management (with co-director Dr. Cindy Grines); 3) Emergency medicine and pre-hospital management (with co-director Dr. Ivan Rokos), and; 4) Global STEMI strategies (with co-director Dr. Tan Huay Cheem). Along with an ambitious agenda, LUMEN sought to actively engage participants, with a pace that left room for attendee-faculty comments and interaction. The meeting’s opening session on Thursday afternoon allowed for audience give-and-take with LUMEN course directors, exploring five common STEMI management situations. Faculty and attendees created a rich environment in which to hone STEMI and door-to-balloon management skills, speaking from experiences that ranged widely across the country and globally.

Transradial Symposium: “Radial first; femoral as bailout”

A Terumo-sponsored breakfast meeting on transradial access took place the next day, exploring complex coronary interventions and difficult clinical subsets. Next, LUMEN opened with a transradial symposium, a new focus for 2011. Speakers included Tejas Patel, MD, from Ahmadabad, India, with perhaps the world’s most extensive experience in transradial STEMI interventions, Sunil Rao, MD, director of the transradial STEMI track at LUMEN 2011 and a leading proponent of transradial access in the United States, as well as Dr. Mitch Krucoff and Dr. Ramon Quesada. Dr. Rao opened by noting that early on, “nobody believed in the association between bleeding and reduced mortality,” and he had a hard time getting papers published on this topic. “I’m not saying bleeding leads to mortality, except at the extremes,” he said. But even with mild bleeding, therapy is halted, Dr. Rao pointed out, and it can have a negative impact. In fact, we need to address both thrombosis and bleeding in interventional patients, he said, because “otherwise, you are treating only half the patient.” In fact, making good pharmacological choices can result in reduced 30-day and 3-year mortality, noted Dr. Rao. He opened the question of how the radial approach interacts with current medical pathways, and whether use of the radial approach might permit a more aggressive interventional strategy. Data do not yet answer this question, he concluded. Dr. Krucoff next introduced Dr. Tejas Patel as “the most experienced transradial interventionalist in the world.” Dr. Patel began by pointing out that the major vascular complication rate in randomized clinical trials is consistently zero, and that trials have mostly shown no delay in reperfusion when transradial intervention is used in acute myocardial infarction (AMI). He went on to share some complex cases recently performed at his center via the radial approach. Dr. Patel advocates treating AMI patients radially only after the learning curve is completed, recommending 250 elective coronary angiograms and 75 percutaneous coronary interventions (PCIs) prior to attempting radial access in a STEMI patient. Begin with a hemodynamically stable AMI patient, he noted, and always do a simultaneous wrist and groin prep, in case the patient requires an intra-aortic balloon pump (IABP). Dr. Patel offered several transradial procedure tips, including a tip for beginners: inject contrast through the puncture cannula before introducing the sheath. Dr. Ramon Quesada took up the theme of practical advice by sharing some cases that went wrong as he went through his own radial learning curve, with the hope that what he learned could help others avoid the same problems. Dr. Quesada’s early experience, from 1998-2001, resulted in a 9% crossover (to femoral) rate, with a 7% rate for interventions. He noted that newly published data from the TALENT study (Sciahbasi et al, Am Heart J, Jan 2011) showed that for beginners, the left radial was easier by fluoro time and dose, as well as time to access, but he cautioned that ultimately, operators should be comfortable accessing from both sides. If the patient is obese or if the physician is still on the learning curve, Dr. Quesada recommended the use of ultrasound to guide the puncture (making the puncture simple and easy, despite the ultrasound being a bit cumbersome). A piece of advice repeated often was “You never push; you advance gently.” Dr. Rao next spoke on beginning a transradial program, and emphasized approaching transradial “with a problem-solving attitude. Don’t get frustrated.” Cherry-picking your cases, he said, is a recipe for frustration. Dr. Mitch Krucoff added, “Doing ‘radial first’ means thinking ‘radial first,’ then using common sense.” Dr. Krucoff also brought up the scenario of medication “crossover,” i.e., EMS may administer pharmacologic therapy as they bring in a STEMI patient, but the cath lab may want to switch the medication. Data have shown this type of crossover leads to increased bleeding risk. Dr. Krucoff pointed out that if transradial access is appropriate, perhaps it should be used in these patients. Dr. Rao recommended at least one year’s experience with radial access before doing STEMI patients, and noted, “success of transradial primary PCI is dependent almost entirely on cath lab staff.” Importantly, he noted data from experienced radial operator Dr. Ian Gilchrist that showed reduced door-to-balloon times with the use of radial access. From a time perspective, Dr. Rao indicated that radial access itself should take no more than two minutes. Dr. Rao concluded with the comment, “I firmly believe the longer you’ve been doing intervention, the easier it is to switch [to radial].” Experienced operators, he said, understand catheter behavior and anatomy.

LUMEN Achievement Award

The annual LUMEN Achievement Award was presented by Dr. Mehta to Dr. Alice Jacobs, for her leadership and contributions to global STEMI initiatives and pioneering work with the American Heart Association’s Mission: Lifeline. Mission: Lifeline is a community-based, national initiative to develop strategies to increase the number of STEMI patients with timely access to primary PCI. Starting in September 2010, Mission: Lifeline began bronze, silver and gold awards to registered STEMI systems, and is now moving forward with system certification.

Adult Stem Cell Therapy

Dr. Timothy Henry and Dr. Ajit Mullasari each presented on cutting-edge cell therapy research at their respective facilities, and offering thoughtful reflection on its potential widespread use in STEMI patients. Dr. Henry commented that the focus on politics surrounding cell therapy research is unfortunate. We need to look at it like any other therapy and consider the risks and benefits, he said. Regardless, the focus of current research is on adult stem cells, with the goal of enhancing the body’s “natural process of regeneration.” Which cell is the best cell to use? It depends on what you are trying to do, he said. Adult stem cells include circulating, bone marrow (hematopoietic, mesenchymal) and tissue-specific cells (such as fat and muscle). Cells themselves work in multiple different ways, explained Dr. Henry:

• Cell as cell
• Cell as factory (the current, most important subject of research)
• Cell as courier (future goal)

Since mortality and morbidity for STEMI is so low, is there a role for stem cells today? Yes, said Dr. Henry, “when the horse is out of the barn!” Meaning, he said, that the focus should be on patients with persistent left ventricular dysfunction. Trials have shown benefit for patients with an ejection fraction consistently below a median of 45%. Stem cell trials have also shown a reduction in recurrent MI and rehospitalization for heart failure. While safety has been established, open questions remain, such as exactly when to treat and with what stem cell type.

Left Ventricular Support Devices

Attendees began the second day of LUMEN with an accredited breakfast symposium on the role of hemodynamic assist in the high-risk interventional setting, supported by Maquet Cardiovascular. Data on left ventricular support devices, including the latest data on the Impella (Abiomed, Inc., Danvers, Mass.) and TandemHeart (CardiacAssist, Inc., Pittsburgh, Penn.) were presented by Dr. William O’Neill, Dr. Samin Sharma, Dr. Rajesh Dave, and Dr. Jose Marquez. Dr. Sharma noted some recent innovations in the Impella device, such as a simplified user interface, backloading of the wire, and a simplified setup (2-3 min). At his center, Dr. Sharma said, if left ventricular ejection fraction (LVEF) is > 30%, they will use an IABP during a large MI with cardiogenic shock. If LVEF is LUMEN Master Lecture Dr. Dean Kereiakes presented the LUMEN Master Lecture on the topic of “Pharmaceutical Management of STEMI Interventions,” discussing the latest data on bivalirudin, clopidogrel, prasugrel and ticagrelor. Thus far, he noted, ticagrelor (although not yet approved by the FDA) appears to provide preferential benefit versus clopidogrel or prasugrel in patients with impaired renal function. However, prasugrel may have better data favoring STEMI and diabetic patients. Dr. Kereiakes is the head of Mission: Lifeline in Ohio, and recommendations for Ohio hospitals are as follows: the optimal strategy is bivalirudin and prasugrel (60 mg oral loading dose) or clopidogrel 600 mg, unless lytics are given, in which case, clopidogrel 300 mg should be used.

STEMI Education

Join fellow professionals next year at LUMEN 2012 to hear presentations and discussions from those working on the front lines of STEMI care. EKG certification, critical nursing issues, cooling and hypothermia, door-to-balloon times, complex case review, adjunct devices in STEMI, critical emergency department issues, and global strategies for STEMI care will continue as core aspects of STEMI education at LUMEN. Each year, not only do leading faculty members bring forward their own experiences and strategies, but they also engage with and learn from many LUMEN attendees: a wide range of physicians, nurses, technologists, paramedics, STEMI coordinators, and administrators. Learn more at www.lumenami.com Thank you to the exhibitors and sponsors of LUMEN 2011, without whom this meeting would not be possible:

• Abiomed
• ACIST Medical Systems
• Angel Medical
• Atrium Medical Corporation
• Boston Scientific
• Daiichi Sankyo, Inc.
• Florida Hospital DeLand
• MAQUET Cardiovascular
• Medivance
• MEDRAD Interventional/Possis
• Philips InnerCool
• Physio-Control
• STENTYS
• Teleflex
• Terumo Medical Corporation
• ZOLL Medical Corporation