Thirteenth bethesda conference: Emergency cardiac care

BETHESDA CONFERENCE REPORT

Thirteenth Bethesda Conference: Emergency Cardiac Care*

Sponsored by the American College of Cardiology September 26 and 27, 198 1, Heart House, Bethesda, Maryland

Opening Statement MAX HARRY

WEIL, MD, PhD, FACC,

Chairman

- GARY J. ANDERSON,

Following the traditions established by the American College of Cardiology more than 15 years ago, the Bethesda Conferences have developed reports bearing on cardiologic practices. The Bethesda Conferences were designed to deal with the controversial medical issues for which guidelines were needed. Like each of its 12 predecessors, this Bethesda Conference addressed those subjects that were perceived to be of critical importance with respect to their impact on patient care and national policies bearing on the delivery of that care. The socalled “Delphi” method, which was developed by the Rand Corporation more than 25 years ago, was utilized. It was based on the deliberations of a broadly representative group of experts as a basis for peer consensus. Position statements were developed by individual experts. The Conference participants were organized into five Task Forces and the statements were circulated to the members of the Task Forces before the meeting. A free interchange of concepts and supporting data before and at the Conference provided the basis on which peer consensus was reached by individual Task Forces. The reports of individual Task Forces were then deliberated and acted on by the Conference meeting in plenary session. The specific objective of this Conference was to provide guidelines for optimal emergency cardiac care before hospital admission, in the Emergency Department and in the 6 hours after hospital admission. In recognition of the rapidly increasing complexity and costs of

MD, FACC, Co-Chairman

cardiologic care, the focus was on options by which the highest quality of life-saving cardiac care could be consistently and economically delivered in the context of current Emergency Medical Service systems and the resources of community hospitals. Methods of organization, staffing and patient care were evaluated together with specific professional requirements for competent diagnosis and treatment. The Conference sought to delineate those components that are of proved value and importance and to identify practices that would best be curtailed or discontinued. The concept of a Bethesda Conference on Emergency Cardiac Care was conceived in 1973 by Dr. Leonard Dreifus, then Chairman of the Bethesda Conference Committee, in collaboration with Dr. Leonard Cobb, who was then serving as Chairman of an Ad Hoc Committee on Emergency and Pre-hospital Care. The project evolved over the following years, largely through the efforts of the members of the College’s Emergency Cardiac Care Committee serving as the Steering Committee of this Conference with the generous cooperation of Dr. James Lewis and the members of the American Heart Association’s Sub-Committee on Emergency Cardiac Care. The Conferees are pleased by the culmination of their efforts in the publication of this report. It presents a peer consensus of practices that will undoubtedly provide a resource for continuing improvement of both policy and practices related to medical and surgical

The recommendations set forth in this report are those of The Conference participants and do not necessarily reflect the official position of the American College of Cardiology. The companies, foundations and government agencies who were the financial supporters of the Conference are listed in Appendix l

Address for reprints: American College of Cardiology, Heart House, 9111 Old Georgetown Road, Bethesda, Maryland 208 14.

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BETHESDA CONFERENCE:OPENING STATEMENT

interventions in emergency cardiovascular health care. However, there was neither intent nor concern on the part of the Steering Committee or the Conferees that the document be complete in the sense of encompassing the totality of emergency cardiac care. Like all consensus reports, the viewpoints expressed often represent a compromise of divergent opinions. In some cases, the data available to the experts did not make it possible to do other than point to the need for additional objective information. Until such data are available, the Conference preserved the option of acknowledging differing practices. Even in those instances in which a consensus was reached, the Conferees were unanimous in their viewpoint that the specific content of this report is in-

tended to complement rather than to supersede the judgment of the well trained clinician with respect to the care of an individual patient. Moreover, the very rapid advances in cardiologic research make it likely that some of the consensus statements may become obsolete even before the ink on these pages is dry. To the many colleagues and organizations who have given so much of themselves to this effort, to the professional specialty organizations and health agencies that have collaborated with us, to those organizations that have lent their financial support and, most of all, to the staff of the American College of Cardiology and especially to Mr. David Feild, we express our sincere gratitude.

PARTICIPANTS

MAX HARRY WEIL, MD, PhD, FACC Professor of Clinical Medicine and Biomedical Engineering Chairman, Division of Critical Care Medicine University of Southern California and Director, Institute of Critical Care Medicine Los Angeles, California Chairman GARY J. ANDERSON, MD, FACC Professor of Medicine and Physiology Director, Heart Station Hahnemann Medical College d Hospital Likoff Cardiovascular Institute Philadelphia, Pennsylvania Co-Chairman WILLIAM B. ABRAMS, MD, FACC Adjunct Professor of Medicine Jefferson Medical College Thomas Jefferson University Philadelphia, Pennsylvania and Executive Director Clinical Pharmacology Merck Sharp & Dohme West Point, Pennsylvania (Merck Sharp & Dohme representative) TASK FORCE IV ROBERT J. ADOLPH, MD, FACC Professor of Medicine Director, Cardiac Research Laboratory University of Cincinnati College of Medicine Cincinnati, Ohio TASK FORCE IV

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WILLBERT S. ARONOW, MD, FACC Professor of Medicine, Pharmacology, Therapeutics and Community Environmental Medicine University of California, Irvine and Chief, Cardiovascular Section Veterans Administration Medical Center Long Beach, California (American College of Chest Physicians representative) TASK FORCE II JAMES M. ATKINS, MD, FACC Associate Professor of Medicine University of Texas/Health Science Center Dallas, Texas TASK FORCE II ROY M. BAKER, MD, FACC Chairman of Duval County Hospital Authority Clinical Professor of Medicine and Pediatrics University of Florida Jacksonville, Florida TASK FORCE I CO-CHAIRMAN ROBERT MITCHEL BALDWIN Design Engineer Michigan Instruments, Inc. Grand Rapids, Michigan (Emergency Medical Services Foundation representative) TASK FORCE Ill DANIEL S. BERMAN, MD, FACC Director, Nuclear Cardiology Cedars-Sinai Medical Center and

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Associate Clinical Professor of Radiology (Nuclear Medicine) UCLA School of Medicine Los Angeles, California TASK FORCE Ill DAVID R. BOYD, MDCM Associate Bureau Director Office for Emergency Medical Services U.S. Department of Health and Human Services Rockville, Maryland TASK FORCE II ROBERT 0. BRANDENBURG, MD, FACC Consultant in Internal Medicine and Cardiovascular Diseases Mayo Clinic Professor of Medicine Mayo Medical School Rochester, Minnesota (Past President, American College of Cardiology) FLOATER MARY BUCKLEY, RN Coordinator, Paramedic Program Davenport College Center for the Study of Emergency Medical Services Grand Rapids, Michigan (Emergency Medical Services Foundation representative) TASK FORCE Ill VIRGINIA CURTIN CAPASSO, RN, MSN State EMS Nurse Coordinator Massachusetts Office of Emergency Medical Services Boston, Massachusetts (Emergency Department Nurses Association representative) TASK FORCE I

BETHESDA CONFERENCE-PARTICIPANTS

FRANCIS M. CHARBONNIER. Engineering Manager Hewlett-Packard Company McMinnville, Oregon (Hewlett-Packard Company representative) TASK FORCE Ill

PhD

KANU CHATTERJEE, MD, FACC Lucie Stern Professor of Cardiology Professor of Medicine Associate Chief, Cardiovascular Division Director, Coronary Care Unit Moffitt Hospital University of California San Francisco, California TASK FORCE IV PETER A. CHEVALIER, PhD Senior Staff Scientist Pacing and Clinical Research Medtronic, Inc. Minneapolis, Minnesota (Medtronic, Inc. representative) TASK FORCE V LEONARD A. COBB, MD, FACC Director, Division of Cardiology Harborview Medical Center and Professor of Medicine University of Washington Seattle, Washington TASK FORCE II JAY N. COHN, MD, FACC Professor of Medicine University of Minnesota Medical School and Head, Cardiovascular Division University of Minnesota Hospital Minneapolis, Minnesota TASK FORCE IV R. ADAMS COWLEY, MD Professor of Thoracic and Cardiovascular Surgery Director, Maryland Institute for Emergency Medical Services Systems Baltimore, Maryland TASK FORCE I VICE ADMIRAL J. WILLIAM COX, MC, USN; MD, PhD. FACC Surgeon General Bureau of Medicine and Surgery Department of the Navy Washington, D.C. TASK FORCE I SIMON DACK, MD, FACC Editor-in-Chief American Journal of Cardiology New York, New York (Past President, American College of Cardiology) FLOATER

JAMES E. DALEN, MD, FACC Professor and Chairman University of Massachusetts Medical School and Physician-in-Chief University of Massachusetts Hospital Worcester, Massachusetts TASK FORCE II ANTHONY N. DEMARIA, MD, FACC Professor of Medicine University of Kentucky College of Medicine and Director, Cardiovascular Division Department of Medicine University of Kentucky Medical Center Lexington, Kentucky TASK FORCE Ill JOHN S. DERRYBERRY, MD Instructor Department of Preventive and Community Medicine Vanderbilt University School of Medicine Shelbyville, Tennessee (American Academy of Family Physicians representative) TASK FORCE IV JAMES C. DILLON, MD, FACC Associate Professor of Medicine Indiana University Medical Center and Course Director Freshmen Emergency Medicine Indiana University School of Medicine Indianapolis, Indiana TASK FORCE Ill CHAIRMAN SOL EDELSTEIN, MD Associate Professor Health Care Science and Anesthesiology and Director, Division of Emergency Medicine George Washington University Medical Center Washington, D.C. (American Society of Anesthesiologists representative) TASK FORCE II GORDON A. EWY, MD, FACC Professor of Medicine University of Arizona College of Medicine and Director, Diagnostic Cardiology Arizona Health Sciences Center Tucson, Arizona TASK FORCE V PETER L. FROMMER, MD, FACC Acting Director National Heart, Lung, and Blood Institute National Institutes of Health Bethesda, Maryland TASK FORCE V

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SEYMOUR FURMAN, MD, FACC Professor of Surgery Albert Einstein College of Medicine and Attending Surgeon Division of Cardiothoracic Surgery Department of Surgery Montefiore Hospital and Medical Center Bronx, New York TASK FORCE V SIDNEY GOLDSTEIN, MD, FACC Professor of Clinical Medicine University of Michigan and Head, Division of Cardiovascular Medicine Henry Ford Hospital Detroit, Michigan TASK FORCE Ill JOHN E. GOULD Associate Director Division of Education and Community Programs American Heart Association Dallas, Texas FLOATER ROLF M. GUNNAR, MD, FACC Professor of Medicine Chief, Section of Cardiology Loyola University Stritch School of Medicine Maywood, Illinois (American College of Physicians representative) TASK FORCE IV CHAIRMAN HUBERT T. GURLEY, MD Director, Department of Emergency Medicine The Johns Hopkins Hospital Baltimore, Maryland (University Association of Emergency Medicine representative) TASK FORCE Ill WARD M. HAMILTON Manager, Emergency Products Datascope Corp. Paramus, New Jersey (Datascope Corp. representative) TASK FORCE V CHARLES R. HATCHER, JR, MD, FACC Professor of Surgery and Chief, Cardio-Thoracic Surgery Emory University School of Medicine and Director Emory University Clinic Atlanta, Georgia TASK FORCE V CO-CHAIRMAN PETER R. HOLBROOK, MD Associate Professor of Anesthesiology and Child Health and Development

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CONFERENCE-PARTICIPANTS

George Washington University School of Medicine and Health Sciences and Director, Intensive Care Unit Children’s Hospital National Medical Center Washington, D.C. (Society of Critical Care Medicine representative) TASK FORCE Ill LEONARD N. HOROWITZ, MD, FACC Associate Professor of Medicine Hahnemann Medical College & Hospital Likoff Cardiovascular Institute and Director Clinical Cardiac Electrophysiology Laboratory Philadelphia, Pennsylvania TASK FORCE IV BRUCE D. JANIAK, MD Director, Department of Emergency Medicine The Toledo Hospital Toledo, Ohio (American College of Emergency Physicians representative) TASK FORCE I, PETER KOTILAINEN,

PhD

Manager Clinical Evaluation Center Electronics for Medicine/Honeywell, Inc. Worcester, Massachusetts (E for M/Honeywell, Inc. representative) TASK FORCE V COSTAS T. LAMBREW, MD. FACC Professor of Medicine University of Vermont College of Medicine and Associate Vice President for Health Education Maine Medical Center Portland, Maine TASK FORCE IV CO-CHAIRMAN ROBERT C. LEINBACH, MD, FACC Associate Professor of Medicine Harvard Medical School and Associate Physician Massachusetts General Hospital Boston, Massachusetts TASK FORCE V A. JAMES LEWIS, MD, FACC Associate Clinical Professor of Medicine UCLA School of Medicine Los Angeles, California and Chairman, Subcommittee on Emergency Cardiac Care American Heart Association

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(American Heart Association representative) TASK FORCE II CHAIRMAN REGINALD I. LOW, MD Assistant Professor Director, Coronary Care Unit University of Kentucky Medical Center Lexington, Kentucky TASK FORCE Ill DAVID C. MACGREGOR, MD, FACC Vice President, Medical Research Cordis Corporation Miami, Florida and Associate Professor Department of Surgery University of Toronto Toronto, Ontario (Cordis Corporation representative) TASK FORCE V WILLIAM J. MANDEL. MD, FACC Associate Professor of Medicine UCLA School of Medicine and Chief, Clinical Electrocardiography Cedars-Sinai Medical Center Los Angeles, California TASK FORCE Ill

Baylor College of Medicine and Texas Children’s Hospital Houston, Texas (President, American College of Cardiology) FLOATER EUGENE L. NAGEL, MD, FACC Clinical Professor Department of Anesthesiology University of Florida College of Medicine Gainesville, Florida and Staff Anesthesiologist Winter Haven Hospital Winter Haven, Florida TASK FORCE II BILL H. NEWMAN, MSEE Co-Chairman, Defibrillator Committee Association for the Advancement of Medical Instrumentation and Director, Cardiovascular Research Physio-Control Corporation Redmond, Washington (Association for the Advancement of Medical Instrumentation and PhysioControl Corporation representative) TASK FORCE II

WILLIAM BRADLEY MARTIN, MD, FACC Medical Manager Cardiovascular Research The Upjohn Company Kalamazoo, Michigan (The Upjohn Company representative) TASK FORCE IV

RICHARD NOWAK, MD Associate Director Division of Emergency Medicine Henry Ford Hospital Detroit, Michigan (American College of Emergency Physicians representative) TASK FORCE Ill

KEVIN M. MCINTYRE, MD, JD, FACC Assistant Professor of Medicine Harvard Medical School Boston, Massachusetts and Assistant Chief of Cardiology Veterans Administration Hospital West Roxbury, Massachusetts TASK FORCE II CO-CHAIRMAN

WILLIAM W. PARMLEY, MD, FACC Professor of Medicine University of California (San Francisco) and Chief of Cardiology Moffitt Hospital San Francisco, California TASK FORCE V CHAIRMAN RONALD S. PENNOCK, MD, FACC Associate Professor of Medicine Hahnemann Medical College & Hospital Likoff Cardiovascular Institute Philadelphia, Pennsylvania TASK FORCE I CHAIRMAN

COLIN J. McMILLIN, MD Chairman, Subcommittee on Emergency Cardiac Care Medical Advisory Committee Canadian Heart Foundation and Consultant in Internal Medicine and Cardiology Charlottetown, Clinic Charlottetown, Prince Edward Island, Canada (Canadian Heart Foundation representative) TASK FORCE I

JOSEPH REDDING, MD Professor of Anesthesiology Medical University of South Carolina and Head, Division of Respiratory/Critical Care Medical University Hospital Charleston, South Carolina TASK FORCE V

DAN G. McNAMARA, MD, FACC Chief, Pediatric Cardiology

LAWRENCE R. ROSE, MD Associate Director,

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BETHESDA CONFERENCE-PARTICIPANTS

Professional Services National Center for Health Services Research Department of Health and Human Services Washington, D.C. TASK FORCE II LES SAMPSON, RN, CCRN Assistant Director Continuing Nursing Education for Critical Care Medical College of Pennsylvania Philadelphia, Pennsylvania (American Association of Critical Care Nurses representative) TASK FORCE I LEO SCHWARTZ Chief, Emergency Medical Services Branch National Highway Traffic Safety Administration Washington, DC. TASK FORCE II LEWIS P. SCOTT, Ill, MD, FACC Professor of Pediatrics George Washington School of Medicine and Chairman of Cardiology Children’s Hospital National Medical Center Washington, D.C. (American Academy of Pediatrics representative) TASK FORCE Ill RALPH SHABETAI, MD, FACC Professor of Medicine Associate Director of Cardiology University of California (San Diego) and Chief, Cardiology Section San Diego Veterans Administration Medical Center San Diego, California TASK FORCE I CO-CHAIRMAN

ERNEST G. SICILIANO, MD Associate Director of Professional Communications Merck Sharp 8 Dohme West Point, Pennsylvania (Merck Sharp & Dohme representative) TASK FORCE IV BORYS SURAWICZ, MD, FACC Professor of Medicine Indiana University School of Medicine Indianapolis, Indiana (Past President, American College of Cardiology) TASK FORCE I PANAGIOTIS

N. SYMBAS,

MD, FACC

Professor of Surgery Thoracic and Cardiovascular Surgery Division Emory University School of Medicine and Director, Thoracic and Cardiovascular Division Grady Memorial Hospital

Surgery

and Director, Daniel C. Elin Surgical Research Laboratory Emory University School of Medicine Atlanta, Georgia TASK FORCE V ROBERT TEMPLE, MD Director Division of Cardio-Renal Drug Products Bureau of Drugs Food and Drug Administration Rockville, Maryland TASK FORCE IV JOHN TUCKMAN, MD Associate Medical Director Ayerst Laboratories New York, New York (Ayerst Laboratories representative) TASK FORCE IV

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C. MARK VASU, MD, FACC Assistant Clinical Professor Michigan State University School of Medicine East Lansing, Michigan and Director, Center for the Study of Emergency Medical Services Davenport College Grand Rapids, Michigan TASK FORCE Ill CO-CHAIRMAN ROBERT B. WALLACE, MD Professor and Chairman Department of Surgery Georgetown University Hospital Washington, D.C. (American College of Surgeons representative) TASK FORCE V JAMES V. WARREN, MD, FACC Professor of Medicine Ohio State University School of Medicine Columbus, Ohio TASK FORCE III MYRON L. WEISFELDT, MD, FACC Robert L. Levy Professor of Cardiology Johns Hopkins University and Director, Cardiology Divisions Johns Hopkins and Baltimore City Hospitals Baltimore, Maryland TASK FORCE V AMERICAN STAFF

COLLEGE OF CARDIOLOGY

WILLIAM D. NELLIGAN, CAE Executive Director WILLIAM D. COUGHLAN, CAE Deputy Executive Director DAVID J. FEILD Director, Special Projects

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