ACS management — the Mayo approach in the Midwest

The Cardiology on the Green conference also heard from Dr Greg Barsness, Assistant Professor of Medicine and Consultant in the Department of Cardiovascular Disease and Radiology at the Mayo Clinic. Dr Barsness spoke on the topic, ‘ACS management in the Midwest’ of the US.

In keeping with the interactive nature of the conference, attendees were invited to download a custom-built app and to respond to questions on therapy options in clinical case studies and to put their own questions to the presenters via a large screen.

“Management of acute coronary syndrome (ACS) is complex; when we think about the number of options for the treatment of one patient with ACS, there are actually more than 200 different combinations of things we can do for any given patient who presents with ACS,” Dr Barsness told the attendees. “All of these treatment permutations have different effects on bleeding and thrombosis risk, so tailoring different therapies to a given patient is difficult. Therefore, having a global strategy that you can tweak for an individual patient seems to be the way to do it [treat ACS].”

Dr Barsness discussed such a strategy in the Midwest for treating ACS, particularly in patients with ST elevation infarctions, which he referred to as “the fast-track for STEMI”. This involves a cohort of referral hospitals in the peripheral area; helicopter transport; emergency ambulance transport; the central referral centre, the Mayo Clinic; CATH labs; and cardiac ICU consultants.

He acknowledged the differences in population densities between Rochester and the greater Dublin areas and the different perspective this provides. Dr Barsness also provided an overview of how the system works for an ACS patient, as well as outlining the evolution of the system design.

“The underlying primary principle is that all acute ST elevation infarctions deserve some type of reperfusion, unless contraindicated, and [it is important] to develop effective therapy to all patients in a timely manner.”

Primary PCI

He drew attention to the 18 per cent relative risk reduction with the administration of thrombolysis, which is effective in a broad range of patients in all subsets, with the exception of cases of ST depression. However, the people most likely to benefit from reperfusion are also those patients who have the most risk associated with thrombolytic therapy, he explained.

“All of these things can make something else a better option, and that something else is primary PCI [percutaneous coronary intervention],” Dr Barsness explained, while outlining the benefits of primary PCI compared to thrombolytic therapy, on the understanding that it can be delivered in a timely fashion.

The Midwest system is advertised to patients via posters in healthcare centres, with a single phone number that a patient can call to activate the chain of events in the ACS care system, he added.

Presenting a case study to illustrate the mechanics of the treatment system in the Midwest, Dr Barsness summarised:

“Essential components of this are system feedback, optimal medical therapy, risk modification, and cost-effectiveness,” he told the conference.

“We use helicopter transport a lot but it’s extremely expensive [upwards of $40,000 per transport], so this is not a protocol suitable for all systems… But I think with good organisation and communication, every system can improve, and modifying the things we can influence improves the overall cost-effectiveness.”

His presentation was followed by a talk from Prof Kieran Daly of the ICS, who was a Consultant Cardiologist at Galway University Hospital from 1984 until last year. Prof Daly is a Fellow of the European Society of Cardiology and founder of Croí, and he delivered a talk on ‘ACS Management in Ireland’ to provide the attendees with context on the different systems of ACS management in Ireland and the US.