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STEMI Department of Family and Preventive Medicine

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STEMI Department of Family and Preventive Medicine Powered By Docstoc
					   ACC/AHA Guidelines for the
  Management of Patients with
ST-Elevation Myocardial Infarction




                                     1
                  Applying Classification of
             Recommendations and Level of Evidence
Class I                Class IIa                    Class IIb                     Class III

Benefit >>> Risk       Benefit >> Risk              Benefit ≥ Risk                Risk ≥ Benefit
                       Additional studies with      Additional studies with       No additional studies
                       focused objectives           broad objectives needed;      needed
                       needed                       Additional registry data
                                                    would be helpful              Procedure/Treatment
Procedure/ Treatment   IT IS REASONABLE to                                        should NOT be
SHOULD be              perform                      Procedure/Treatment           performed/administered
performed/             procedure/administer         MAY BE CONSIDERED             SINCE IT IS NOT
administered           treatment                                                  HELPFUL AND MAY BE
                                                                                  HARMFUL


should                 is reasonable                may/might be considered        is not recommended
is recommended         can be useful/effective/     may/might be reasonable        is not indicated
is indicated             beneficial                 usefulness/effectiveness is    should not
is useful/effective/   is probably recommended or    unknown /unclear/uncertain    is not
  beneficial             indicated                   or not well established         useful/effective/beneficial
                                                                                   may be harmful




                                                                                                                   2
    Patient Education for Early Recognition and
                Response to STEMI

                Healthcare providers should instruct patients
I IIa IIb III
                previously prescribed nitroglycerin (NTG) on use

                for chest discomfort or pain and to call 9-1-1 if
                symptoms do not improve or worsen 5 minutes
                after ONE sublingual NTG dose*.
                (* Nitroglycerin Dose: 0.4 mg sublingually)




                                                                3
                Prehospital Chest Pain Evaluation
                         and Treatment
I IIa IIb III     Prehospital EMS providers should administer 162 to 325 mg of
                  aspirin (chewed) to chest pain patients suspected of having STEMI
                  unless contraindicated or already taken by the patient. Although
                  some trials have used enteric-coated aspirin for initial dosing, more
                  rapid buccal absorption occurs with non–enteric-coated
                  formulations.

I IIa IIb III     It is reasonable for all 9-1-1 dispatchers to advise patients without a
                  history of aspirin allergy who have symptoms of STEMI to chew
                  aspirin (162 to 325 mg) while awaiting arrival of prehospital EMS
                  providers. Although some trials have used enteric-coated aspirin for
                  initial dosing, more rapid buccal absorption occurs with non–enteric-
                  coated formulations.



                                                                                       4
                   Prehospital Issues

I IIa IIb III   Prehospital 12-lead ECG by ACLS

                Prehospital fibrinolysis

I IIa IIb III   Reperfusion “checklist” by ACLS providers that
                is relayed with the ECG to a predetermined
                medical control facility and/or receiving
                hospital




                                                             5
                    Prehospital Issues

I IIa IIb III   Prehospital destination protocols
                Patients with STEMI who have cardiogenic
                shock and are <75 yrs old should be brought
                immediately or secondarily transferred to
                facilities capable of cardiac catheterization and
                rapid revascularization with 18 hrs of shock




                                                                6
                      Prehospital Issues

I IIa IIb III   Prehospital destination protocols:
                Patients with STEMI who have contraindications
                to fibrinolytic therapy should be brought
                immediately or secondarily transferred promptly
                (primary-receiving hospital door-to-departure time
                less than 30 min.) to facilities capable of cardiac
                catheterization and rapid revascularization



                                                                 7
   Options for Transport of Patients With
  STEMI and Initial Reperfusion Treatment
                                                                                 Hospital fibrinolysis:
                                                                                   Door-to-Needle
                                                                                    within 30 min.
                                                                              Not PCI
                                                                              capable


  Onset of         9-1-1       EMS on-scene                                                 Inter-
symptoms of        EMS         • Encourage 12-lead ECGs.                                   Hospital
   STEMI         Dispatch      • Consider prehospital fibrinolytic if                      Transfer
                                 capable and EMS-to-needle within
                                 30 min.
                                                                                PCI
                                                                              capable
     GOALS
       5       8
     min.            EMS Transport
              min.
  Patient     EMS        Prehospital fibrinolysis           EMS transport
                         EMS-to-needle        EMS-to-balloon within 90 min.
                         within 30 min.             Patient self-transport
      Dispatch                                     Hospital door-to-balloon
       1 min.                                                within 90 min.


        Golden Hour = first 60 min.           Total ischemic time: within 120 min.




                                                                                                      8
Options for Transport of Patients With STEMI and
          Initial Reperfusion Treatment
•    Patients receiving fibrinolysis should be risk-stratified to identify need
    for further revascularization with percutaneous coronary intervention
    (PCI) or coronary artery bypass graft surgery (CABG).
•   All patients should receive late hospital care and secondary
    prevention of STEMI.

                                      Noninvasive Risk
                    Fibrinolysis
                                        Stratification
        Not                                                      Late
                                     Rescue Ischemia         Hospital Care
    PCI Capable                               driven        and Secondary
    PCI Capable                                               Prevention

                                        PCI or CABG

                    Primary PCI



                                                                              9
                      Electrocardiogram

                Show 12-lead ECG results to emergency physician
I IIa IIb III
                within 10 minutes of ED arrival in all patients with
                chest discomfort (or anginal equivalent) or other
                symptoms of STEMI.


I IIa IIb III   In patients with inferior STEMI, ECG leads should
                also be obtained to screen for right ventricular
                infarction.



                                                                    10
                    Laboratory Examinations

I IIa IIb III   Laboratory examinations should be performed as part of the
                management of STEMI patients, but should not delay the
                implementation of reperfusion therapy.

                   Serum biomarkers for cardiac damage
                   Complete blood count (CBC) with platelets
                   International normalized ratio (INR)
                   Activated partial thromboplastin time (aPTT)
                   Electrolytes and magnesium
                   Blood urea nitrogen (BUN)
                   Creatinine
                   Glucose
                   Complete lipid profile


                                                                        11
                Biomarkers of Cardiac Damage


I IIa IIb III   Cardiac-specific troponins should be used as the
                optimum biomarkers for the evaluation of patients
                with STEMI who have coexistent skeletal muscle
                injury.


I IIa IIb III   For patients with ST elevation on the 12-lead ECG
                and symptoms of STEMI, reperfusion therapy
                should be initiated as soon as possible and is not
                contingent on a biomarker assay.



                                                                    12
                               Imaging
                Patients with STEMI should have a portable chest
I IIa IIb III   X-ray, but this should not delay implementation of
                reperfusion therapy (unless a potential
                contraindication is suspected, such as aortic
                dissection).

                Imaging studies such as a high quality portable chest
I IIa IIb III   X-ray, transthoracic and/or transesophageal
                echocardiography, and a contrast chest CT scan or
                an MRI scan should be used for differentiating STEMI
                from aortic dissection in patients for whom this
                distinction is initially unclear.


                                                                     13
                            Nitroglycerin

I IIa IIb III   Patients with ongoing ischemic discomfort should
                receive sublingual NTG (0.4 mg) every 5 minutes for a
                total of 3 doses, after which an assessment should be
                made about the need for intravenous NTG.


I IIa IIb III   Intravenous NTG is indicated for relief of ongoing
                ischemic discomfort that responds to nitrate therapy,
                control of hypertension, or management of pulmonary
                congestion.




                                                                  14
                           Nitroglycerin
I IIa IIb III
                Nitrates should not be administered to patients with:
                • systolic pressure < 90 mm Hg or ≥ to 30 mm Hg
                  below baseline
                • severe bradycardia (< 50 bpm)
                • tachycardia (> 100 bpm) or
                • suspected RV infarction.

I IIa IIb III
                Nitrates should not be administered to patients who
                have received a phosphodiesterase inhibitor for
                erectile dysfunction within the last 24 hours (48
                hours for tadalafil).



                                                                   15
                          Analgesia


                Morphine sulfate (2 to 4 mg intravenously with
I IIa IIb III
                increments of 2 to 8 mg intravenously repeated at
                5 to 15 minute intervals) is the analgesic of choice
                for management of pain associated with STEMI.




                                                                   16
                           Aspirin
I IIa IIb III

                Aspirin should be chewed by patients who have
                not taken aspirin before presentation with
I IIa IIb III
                STEMI. The initial dose should be 162 mg (Level
                of Evidence: A) to 325 mg (Level of Evidence: C)



    Although some trials have used enteric-coated aspirin for
    initial dosing, more rapid buccal absorption occurs with
    non–enteric-coated formulations.



                                                                17
                        Beta-Blockers
                Oral beta-blocker therapy should be administered
I IIa IIb III
                promptly to those patients without a contraindication,
                irrespective of concomitant fibrinolytic therapy or
                performance of primary PCI.



I IIa IIb III   It is reasonable to administer intravenous beta-
                blockers promptly to STEMI patients without
                contraindications, especially if a tachyarrhythmia or
                hypertension is present.



                                                                    18
                  Reperfusion
The medical system goal is to facilitate rapid recognition

and treatment of patients with STEMI such that door-to-

needle (or medical contact–to-needle) time for initiation

of fibrinolytic therapy can be achieved within 30

minutes or that door-to-balloon (or medical contact–to-

balloon) time for PCI can be kept within 90 minutes.



                                                             19
                                 Symptom Onset to Balloon Time and
                                  Mortality in Primary PCI for STEMI

                               6 RCTs of Primary PCI by Zwolle Group 1994 – 2001
                                                   N = 1791
                            12                                                 P < 0.0001
    One-year mortality, %




                            10

                             8

                             6

                             4
                                               RR = 1.08 [1.01 – 1.16] for each 30 min delay
                             2                                   (P = 0.04)

                             0 0       60       120       180       240       300    360
                                      Symptoms to balloon inflation (minutes)


DeLuca et al. Circulation 2004;109:1223.

                                                                                               20
                             PCI vs Fibrinolysis for STEMI:
                             Short Term Clinical Outcomes

                   35

                   30        PCI                           P < 0.0001
                             Fibrinolysis
   Frequency (%)




                   25
                                                                 21
                   20                                                                                     P < 0.0001

                   15   P=0.0002                                                                               13
                                   P=0.0003   P < 0.0001                                        P=0.032
                             9                                                                             8
                   10    7               7          7                                             7
                                                                        P=0.0004
                                                             6                     P < 0.0001         5
                                   4.5
                   5                          2.2
                                                                         1 2         0 1
                   0
                        Death      Death, Recurr. Recurr. Total Hemorrh. Major                             Death
                                     no     MI Ischemia Stroke Stroke Bleed                                  MI
                                    SHOCK
                                     data                                                                   CVA
 N = 7739


Keeley et al. The Lancet 2003;361:13.
                                                                                                                       21
            Contraindications and Cautions
               for Fibrinolysis in STEMI

Absolute          • Any prior intracranial hemorrhage
Contraindications • Known structural cerebral vascular lesion
                    (e.g., arteriovenous malformation)
                    • Known malignant intracranial neoplasm
                      (primary or metastatic)
                    • Ischemic stroke within 3 months EXCEPT
                      acute ischemic stroke within 3 hours

        NOTE: Age restriction for fibrinolysis has been removed
        compared with prior guidelines.



                                                                  22
          Contraindications and Cautions
             for Fibrinolysis in STEMI

Absolute          • Suspected aortic dissection
Contraindications
                  • Active bleeding or bleeding diathesis
                    (excluding menses)
                  • Significant closed-head or facial trauma
                    within 3 months




                                                               23
            Contraindications and Cautions
               for Fibrinolysis in STEMI
Relative         • History of chronic, severe, poorly controlled
Contraindications hypertension
                 • Severe uncontrolled hypertension on
                   presentation (SBP > 180 mm Hg or DBP >
                   110 mm Hg)
                 • History of prior ischemic stroke greater than
                   3 months, dementia, or known intracranial
                   pathology not covered in contraindications
                 • Traumatic or prolonged (> 10 minutes) CPR
                   or major surgery (< 3 weeks)




                                                              24
            Contraindications and Cautions
               for Fibrinolysis in STEMI

Relative          • Recent (< 2 to 4 weeks) internal bleeding
Contraindications • Noncompressible vascular punctures
                  • For streptokinase/anistreplase: prior
                    exposure (> 5 days ago) or prior allergic
                    reaction to these agents
                  • Pregnancy
                  • Active peptic ulcer
                  • Current use of anticoagulants: the higher the
                    INR, the higher the risk of bleeding




                                                              25
      Reperfusion Options for STEMI Patients
       Step 2: Select Reperfusion Treatment.
If presentation is < 3 hours and there is no delay to an invasive
       strategy, there is no preference for either strategy.
Fibrinolysis generally preferred
 Early presentation ( ≤ 3 hours from symptom
  onset and delay to invasive strategy)
 Invasive strategy not an option
     Cath lab occupied or not available
     Vascular access difficulties
      No access to skilled PCI lab

 Delay to invasive strategy
    Prolonged transport
    Door-to-balloon more than 90 minutes
    > 1 hour vs fibrinolysis (fibrin-specific agent) now


                                                                26
    Reperfusion Options for STEMI Patients
     Step 2: Select Reperfusion Treatment.
If presentation is < 3 hours and there is no delay to an invasive strategy,
                 there is no preference for either strategy.
Invasive strategy generally preferred
 Skilled PCI lab available with surgical backup
      Door-to-balloon < 90 minutes

• High Risk from STEMI
    Cardiogenic shock, Killip class ≥ 3

 Contraindications to fibrinolysis, including
  increased risk of bleeding and ICH

 Late presentation
     > 3 hours from symptom onset

 Diagnosis of STEMI is in doubt

                                                                              27
                             Fibrinolysis


I IIa IIb III   In the absence of contraindications, fibrinolytic
                therapy should be administered to STEMI
                patients with symptom onset within the prior 12
                hours.

                In the absence of contraindications, fibrinolytic
I IIa IIb III
                therapy should be administered to STEMI
                patients with symptom onset within the prior 12
                hours and new or presumably new left bundle
                branch block (LBBB).



                                                                    28
                             Fibrinolysis

                In the absence of contraindications, it is
I IIa IIb III
                reasonable to administer fibrinolytic therapy to
                STEMI patients with symptom onset within the
                prior 12 hours and 12-lead ECG findings
                consistent with a true posterior MI.

                In the absence of contraindications, it is
I IIa IIb III   reasonable to administer fibrinolytic therapy to
                patients with symptoms of STEMI beginning in
                the prior 12 to 24 hours who have continuing
                ischemic symptoms and ST elevation > 0.1 mV
                in ≥ 2 contiguous precordial leads or ≥ 2 adjacent
                limb leads.


                                                                     29
                                Fibrinolysis

I IIa IIb III   Fibrinolytic therapy should not be administered to
                asymptomatic patients whose initial symptoms of
                STEMI began more than 24 hours earlier.


I IIa IIb III   Fibrinolytic therapy should not be administered to
                patients whose 12-lead ECG shows only ST-
                segment depression, except if a true posterior MI
                is suspected.



                                                                     30
                    Primary PCI for STEMI:
                    General Considerations
                 Patient with STEMI (including posterior MI) or MI
                  with new or presumably new LBBB
                 PCI of infarct artery within 12 hours of symptom
                  onset
I IIa IIb III    Balloon inflation within 90 minutes of presentation
                 Skilled personnel available (individual performs > 75
                  procedures per year)
                 Appropriate lab environment (lab performs > 200
                  PCIs/year of which at least 36 are primary PCI for
                  STEMI)
                 Cardiac surgical backup available


                                                                        31
                    Primary PCI for STEMI:
                    Specific Considerations
I IIa IIb III
                Medical contact–to-balloon or door-to-balloon
                should be within 90 minutes.

I IIa IIb III

                PCI preferred if > 3 hours from symptom onset.

I IIa IIb III
                Primary PCI should be performed in patients with
                severe congestive heart failure (CHF) and/or
                pulmonary edema (Killip class 3) and onset of
                symptoms within 12 hours.


                                                                   32
                   Primary PCI for STEMI:
                   Specific Considerations


                Primary PCI should be performed in patients less

I IIa IIb III   than 75 years old with ST elevation or LBBB who
                develop shock within 36 hours of MI and are
                suitable for revascularization that can be
                performed within 18 hours of shock.




                                                               33
                     Primary PCI for STEMI:
                     Specific Considerations

                Primary PCI is reasonable in selected patients 75
I IIa IIb III   years or older with ST elevation or LBBB who
                develop shock within 36 hours of MI and are suitable
                for revascularization that can be performed within 18
                hours of shock.




                                                                    34
                  Primary PCI for STEMI:
                  Specific Considerations

                It is reasonable to perform primary PCI for
                patients with onset of symptoms within the prior
                12 to 24 hours and 1 or more of the following:

                a. Severe CHF
I IIa IIb III

                b. Hemodynamic or electrical instability

                c. Persistent ischemic symptoms.




                                                                   35
                        PCI After Fibrinolysis

                In patients whose anatomy is suitable, PCI should be
                performed for the following:
I IIa IIb III

                    Objective evidence of recurrent MI

I IIa IIb III
                    Moderate or severe spontaneous/provocable
                    myocardial ischemia during recovery from STEMI
I IIa IIb III

                    Cardiogenic shock or hemodynamic instability.




                                                                    36
                        PCI After Fibrinolysis

I IIa IIb III
                It is reasonable to perform routine PCI in patients
                with left ventricular ejection fraction (LVEF) ≤ 0.40,
                CHF, or serious ventricular arrhythmias.

I IIa IIb III
                It is reasonable to perform PCI when there is
                documented clinical heart failure during the acute
                episode, even though subsequent evaluation
                shows preserved LV function (LVEF > 0.40).
I IIa IIb III
                Routine PCI might be considered as part of
                an invasive strategy after fibrinolytic therapy.


                                                                         37
                    Assessment of Reperfusion
I IIa IIb III
                It is reasonable to monitor the pattern of ST elevation,
                cardiac rhythm and clinical symptoms over the 60 to 180
                minutes after initiation of fibrinolytic therapy.

                Noninvasive findings suggestive of reperfusion include:

                 Relief of symptoms

                 Maintenance and restoration of hemodynamic and/or
                  electrical instability

                 Reduction of ≥ 50% of the initial ST-segment elevation
                  pattern on follow-up ECG 60 to 90 minutes after
                  initiation of therapy.


                                                                           38
                               Aspirin



                A daily dose of aspirin (initial dose of 162 to
I IIa IIb III
                325 mg orally; maintenance dose of 75 to 162
                mg) should be given indefinitely after STEMI to
                all patients without a true aspirin allergy.




                                                                  39
                          Thienopyridines
I IIa IIb III
                In patients for whom PCI is planned, clopidogrel
                should be started and continued:

                     • ≥ 1 month after bare-metal stent
                     • ≥ 3 months after sirolimus-eluting stent
                     • ≥ 6 months after paclitaxel-eluting stent
                     • Up to 12 months in absence of high risk for
                     bleeding.




                                                                     40
                          Thienopyridines


                In patients taking clopidogrel in whom CABG is
I IIa IIb III   planned, the drug should be withheld for at
                least 5 days, and preferably for 7 days, unless
                the urgency for revascularization outweighs the
                risk of excessive bleeding.




                                                                  41
                 Glycoprotein IIb/IIIa Inhibitors

I IIa IIb III   It is reasonable to start treatment with
                abciximab as early as possible before primary
                PCI (with or without stenting) in patients with
                STEMI.

I IIa IIb III   Treatment with tirofiban or eptifibatide may be
                considered before primary PCI (with or
                without stenting) in patients with STEMI.



                                                                  42
                    ACE/ARB: Within 24 Hours
I IIa IIb III
                An ACE inhibitor should be administered orally
                within the first 24 hours of STEMI to the following
                patients without hypotension or known class of
                contraindications:
                • Anterior infarction
                 Pulmonary congestion
                 LVEF < 0.40

I IIa IIb III
                An ARB should be given to ACE-intolerant patients
                with either clinical or radiological signs of HF or LVEF
                < 0.40.



                                                                      43
                   ACE/ARB: Within 24 Hours

I IIa IIb III   An ACE inhibitor administered orally can be useful
                within the first 24 hours of STEMI to the following
                patients without hypotension or known class
                contraindications:
                 Anterior infarction
                 Pulmonary congestion
                 LVEF < 0.40.

I IIa IIb III
                An intravenous ACE inhibitor should not be given to
                patients within the first 24 hours of STEMI because
                of the risk of hypotension (possible exception:
                refractory hypotension).


                                                                      44
         Summary of Pharmacologic Rx: Ischemia

                                 1st            During       Hosp DC +
                                 24 h           Hosp         Long Term
      Aspirin                 162-325 mg        75-162        75-162
                                chewed         mg/d p.o.     mg/d p.o.
   Fibrinolytic                tPA,TNK,
                                rPA, SK
                             60U/kg (4000)       aPTT
         UFH                12 U/kg/h (1000)   1.5 - 2 x C
                            aPTT 1.5 - 2 x C
  Beta-blocker                 Oral daily      Oral daily    Oral daily


JACC 2004;44: 671
Circulation 2004;110: 588                                             45
   Summary of Pharmacologic Rx: LVD, Sec. Prev.,

                       1st           During Hosp      Hosp DC +
                       24 h                           Long Term
   ACEI            Anterior MI,                          Oral
               Pulm Cong., EF < 40        Oral           Daily
   ARB             ACEI intol.,           Daily       Indefinitely
                   HF, EF < 40
  Aldo                               No renal dysf,    Same as
 Blocker                             K+ < 5.0 mEq/L     during
                                        On ACEI,        Hosp.
                                        HF or DM
  Statin                             Start w/o lipid Indefinitely,
                                         profile     LDL << 100

JACC 2004;44:671
Circ 2004;110:588                                               46
       What to do at EJCH ?
• RUSH HOUR OR CARDIOGENIC SHOCK
  6 – 10 AM & 4 – 7 PM
  Drip and ship – Give Lytics and Airlift to
  EMORY HOSPITAL

• NON RUSH HOUR : e.g. 2 AM
  Drip and ship – Give lytics and ship by
  ambulance to EMORY HOSPITAL

                                               47

				
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