In-Hospital STEMI Still Neglected, Group Says

Protocols 'should as much as possible mirror' those for ED presentation
ST-segment elevation MI (STEMI) occurring among hospital inpatients is not sufficiently recognized or treated, cardiologists argued, estimating that these cases account for up to 20% of all STEMI treated in hospitals.

"In-hospital STEMI is a unique clinical entity with epidemiology, incidence, and outcomes distinct from that of out-of-hospital STEMI. Mortality rates are 10-fold higher than for out-of-hospital STEMI and can approach mortality rates associated with cardiogenic shock," according to a special communication paper published online in JAMA Cardiology.

"Factors that contribute to delay in recognition, triage, and treatment of in-hospital STEMI include the fact that patients with in-hospital STEMI are frequently on non-cardiology services, symptoms that suggest acute MI may not be recognized, and a formal pathway or protocol for making treatment decisions for patients not receiving a cardiology service who develop STEMI are frequently not established," according to Glenn Levine, MD, of Baylor College of Medicine in Houston, and collaborators of the In-Hospital STEMI Quality Improvement Project.

Moreover, those who have a STEMI after a surgical or invasive procedure are often sedated and unlikely to report overt chest pain, Levine's group added.

What is needed, according to to the authors:

Low threshold throughout the hospital to perform ECGs more quickly in those with hemodynamic decompensation or other signs of acute MI
Process for immediate review and interpretation of the ECG
Formal in-hospital STEMI activation process
"The process of STEMI team or catheterization laboratory activation for an in-hospital STEMI should as much as possible mirror that for patients who present to the emergency department and are diagnosed as having STEMI," the group suggested.

Levine reported financial relationships with the World Heart Federation, American Heart Association/Chinese Society of Cardiology, American College of Cardiology, Associazioni Regionali Cardiologi Ambulatorioli National Congress, and Creative Educational Concepts.