excited to talk to you about the expert consensus document. What we're going to do today is we're just going to give a brief overview of the document and then we're going to go in to give some case presentations that hopefully reflect important points that we wish to make in the document. So please definitely send in some questions if you have on the chat and we'll try to answer them. So I am going to be your cruise director and take you through the document and just sort of give you the sort of the points so that way you understand the flow because it is a extensive document we want to sort of get you familiar with it. So this document came up because we felt that there was a real need to guide practitioners on the best way or the best practices for managing the patient in the lab. There are fantastic ACC AHA guidelines on the management of patients with STEMI and all of the guidelines on managing patients really are patient focused and really talk more about the general aspects like medical therapies and post-procedure care etc. But there's little guideline recommendations for what you do in the cath lab and that's a lot partly because there really is no great evidence for how do you manage thrombus or how do you manage no reflow and partly because the guidelines are really patient focused so on sort of the big aspects of care and less procedurally focused. So we felt this was an important opportunity to present a document. We realized that everybody has different ways and so the flavor of this document is presenting all different ideas and ways to approach things. It's not meant to say necessarily that one approach is better than another. We just really wanted to give you an understanding of the consensus among a group of people who have all of whom do a lot of STEMI care and give you the best idea about how to manage things. So the document starts with cath lab readiness and the initial assessment even though that's not literally a cath lab management this is important and integral to for interventional cardiologists and cath lab team members to work together with EMS and EDs to provide the best you know assessment of patients and timely transfer to the cath lab. We go on to talk about optimal techniques for angiography such as arterial access and how best to perform the diagnostic part of the cath and then we talk about the approach to PCI and we really focus on a big discussion on managing thrombus and managing no reflow. We do discuss intracoronary imaging because we do feel it's important highlighting the rationale for why we want to do intracoronary imaging and the things that you should be looking at for intracoronary imaging. We do have a section on emerging approaches to reduce infarct size which is really more about future directions. A lot of this stuff is just still currently under investigation and we end with special circumstances including anatomical subsets and discussion of non-atherosclerotic causes of STEMI and as I said we also talk about future directions. So there's a lot to cover and hopefully you can sort of take a look and on a Saturday morning when you're just drinking your coffee go ahead and read this document because it's a good read. Okay go to the next slide please. So what I think one of my favorite things is the consensus key points which I think are key to this document. It's a long document there's a lot to be said and as I said we really try to give different approaches to care because we realize there's no particularly right way but the consensus key points are key points that we agreed as a consensus. This required at least 80% of the panel of the authors to vote and we needed to have at least 75% of the votes to be strongly agree or agree on these points. So really important key points. They really emphasize the importance of certain things that we thought were really critical. This is just an example of the key points we provided for management of no reflow but all of the sections have consensus key points. So as I said we're going to start with the time to treatment goals. These are not new these are guideline based treatment goals but we really wanted to sort of remind people of the fact that it's time to treatment is first medical contact to device and the first medical contact will depend on how the patient arrives to the hospital. If they go from home and call EMS the first medical contact is EMS device time. If they come where they walk directly into a PCI hospital the first medical contact is when they arrive at that hospital and if they go on to go to a non-PCI hospital and then get transferred to a PCI hospital the first medical contact is generally when they arrive at the non-PCI hospital. So we really want to emphasize those time to treatment goals. You can go on to the next slide and then within that we really go on to discuss the importance of timely recognition of these infarcts, collaboration and coordination with EMS and your transferring hospitals and the key things that improve timely reperfusion. So we emphasize the need to pre-hospital for EMS presenting patients to give pre-hospital activation of the cath lab. We don't mean just notify the ED that the patient's coming in but let the cath lab know that the patient's on the way. We emphasize that it should be a single page to all cath lab team members not just discuss with the interventional cardiologist and then have them call their team members one single page. We really think EKG transmission is key especially if it goes directly to the cath lab team members. We focus on emergency department bypass in appropriate cases. There's really no need to stop in the ED, transfer stretchers, do a repeat EKG when it's a clear-cut STEMI. There's nothing you're going to do in the ED that you can't provide in the cath lab if they're a stable patient. And then finally we do emphasize the need to have staff either in-house or ideally within 20 to 30 minutes of travel. Go on to the next slide. So as I mentioned we do talk about sort of optimal approaches for diagnostic angiography and we want to emphasize radial artery access. We know that it's a class 1 recommendation in the revascularization guidelines. They do state that it should be done in a class 1 if it can be done in systems or in places with radial artery expertise. We feel that at this point in time everybody should have radial artery expertise and we emphasize the importance of radial artery access. But we also do want to emphasize that there are situations in which femoral artery access is necessary and we go on to discuss those situations. Next slide please. We then focus a lot of attention on managing thrombus and no reflow which will be some of our talks on the presentations we provide. And in this section we talk about how you would approach a subtotal occlusion or a total occlusion with thrombus and the steps that you would take and the considerations you would have for whether you would go with direct stenting or just balloon angioplasty or in the situation where you have a very large thrombus burden, the situations where you might want to consider intracoronary vasodilators, thrombectomy or intravenous or intracoronary antiplatelets. Go ahead to the next slide. Finally, we really love this part. We talk about intravascular imaging. It's one thing to say you use intravascular imaging but it's a reminder to say what are we using with this imaging. We're getting an understanding of the proximal and distal reference diameters, the type of plaque and the lesion length and then we're using post-PCI, we're using these imaging to ensure that we have optimal stent opposition and good expansion. Next slide. So as I mentioned we have additional sections on special circumstances such as how do you approach cardiogenic shock, post-lytic patients, patients with multivessal disease, when you have an infarct involving a coronary artery bypass graft and when you have stent thrombosis. We go on to talk about anatomical considerations like what do you do in bifurcation disease, calcified lesions and aneurysms or ectasia. And finally we talk about non-atherosclerotic causes of STEMI such as epicardial coronary vasospasm, SCAD, thrombosis and minoca. And so you know that's basically it. We're going to go on to talk about some really great cases. We have some really great cases lined up for you all but I really did want to give a big shout out and a thank you to all of my co-authors. You know for their amazing insight and direction, their knowledge and expertise in caring for STEMI patients really really helped put this document together and make it a solid document. But importantly I also want to and this is just a picture of some of our co-authors. This was in July when we made some last-minute changes to the document. We were all together but not everybody's on this picture. Sorry this is not all the co-authors. But I really want to give a big shout out to a SCI leadership and SCI. You know they recognize the need to educate the physicians and to really provide us as a clinician with practical information and by allowing us to be able to give to produce these documents and give us the support and the direction and the leadership to get these documents done. It's how we're able to provide this to you as the clinician. So thank you very much. Thank you Dr. Thomas-Holland for that a wonderful presentation and overview. You know I will just echo that that you know your point about the consensus key points. They're just all these areas that there's just not enough randomized data or trials yet are common clinical scenarios that we see every day in the cat lab that there is the need for for some information as to how to take care of these patients. And I think again this is an extensive document addressing and all of these areas but really provides those key consensus points along a number of very experienced interventional cardiologists from from SCI that provide some some guidance in these areas. So again really congratulations and any comments from the panel before we move to some of the presentations I will be of any input from anybody. No I agree that this fills a gap that the guidelines don't fill because it's more practical and it's issues that we face and decisions that are difficult and have to be timely so I'm hoping this will help some people you know give some options treatment options when they're treating patients with STEMI. Dr. Cohen I know you've been involved in a number of guidelines and documents across your career. How do you see this document help you know interventional cardiologists in our community? I think it's a very practical guideline because you know we all train in different institutions and then they're like inbred practices and this allows us to harmonize and you know there is things that these group we were doing and that I was not doing that I that made lots of sense and then I learned from this group and writing this writing these these documents so I think it's a it's a great resource to harmonize practices and then to read it do a journal club to do it to go through cath conference to do like what we're doing now grab one STEMI case and then dissect the case and go through all the the aspects that we discussed in the in the in the document so it's a great initiative and I applaud the sky and thank you so much for being here so wonderful you know so again we have a series of cases that I think would really invite discussion about many of these key consensus points and really educational highlights so so we'll start with the first presentation again we've introduced all speakers but again a pleasure to introduce Dr. Don Abbott who will be speaking on a case of refractory nerve reflow. Please Dr. Abbott.

STEMI management

cath lab practices

angiography techniques

intracoronary imaging

interventional cardiology