Post on 02-Feb-2023
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Management Before Management Before STEMISTEMI
ACC/AHA Guidelines for the Management of Patients with
ST-Elevation Myocardial Infarction
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Identification of Patients at Risk Identification of Patients at Risk of STEMIof STEMI
The presence and status of control of major risk factors for CHD should be evaluated approximately every 3 to 5 years.
10-year risk of developing symptomatic CHD should be calculated for all patients with ≥ 2 major risk factors to assess the need for primary prevention strategies.
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Identification of Patients at Identification of Patients at Risk of STEMIRisk of STEMI
Patients with established CHD or a CHD risk equivalent (diabetes mellitus, chronic kidney disease, > 20% 10-year Framingham risk) should be identified for secondary prevention.
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Onset of STEMIOnset of STEMI
ACC/AHA Guidelines for the Management of Patients with
ST-Elevation Myocardial Infarction
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Prehospital Chest Pain Evaluation Prehospital Chest Pain Evaluation and Treatmentand Treatment
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.
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Options for Transport of Patients Options for Transport of Patients With STEMI and Initial Reperfusion With STEMI and Initial Reperfusion
TreatmentTreatment
EMS Transport
Onset of symptoms of STEMI
EMSDispatc
h
EMS on-scene• Encourage 12-lead ECGs.• Consider prehospital fibrinolytic if capable and EMS-to-needle within 30 min.GOALS
PCIcapable
Not PCIcapable
Hospital fibrinolysis:
Door-to-Needle within 30 min.
EMS Triage Plan
Inter-HospitalTransfer
Golden Hour = first 60 min.Total ischemic time: within 120 min.
Patient EMS Prehospital fibrinolysisEMS-to-needlewithin 30 min.
EMS transportEMS-to-balloon within
90 min.Patient self-transport
Hospital door-to-balloon
within 90 min.
Dispatch
1 min.
5 min.
8 min.
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• 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.Fibrinolysis
Primary PCI
Noninvasive Risk Stratification
LateHospital Careand SecondaryPrevention
PCI or CABG
NotPCI
CapablePCI Capable
Rescue Ischemiadriven
Options for Transport of Patients With Options for Transport of Patients With STEMI and Initial Reperfusion TreatmentSTEMI and Initial Reperfusion Treatment
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Initial Recognition Initial Recognition and Management in the and Management in the Emergency DepartmentEmergency Department
ACC/AHA Guidelines for the Management of Patients with
ST-Elevation Myocardial Infarction
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ED Evaluation of ED Evaluation of Patients With STEMIPatients With STEMI
1. Airway, Breathing, Circulation (ABC)2. Vital signs, general observation3. Presence or absence of jugular venous
distension4. Pulmonary auscultation for rales5. Cardiac auscultation for murmurs and gallops6. Presence or absence of stroke7. Presence or absence of pulses8. Presence or absence of systemic hypoperfusion
(cool, clammy, pale, ashen)
Brief Physical Examination in the ED
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ED Evaluation of ED Evaluation of Patients With STEMIPatients With STEMI
Aortic dissectionPulmonary embolusPerforating ulcer
Tension pneumothoraxBoerhaave syndrome (esophageal rupture with mediastinitis)
Differential Diagnosis of STEMI: Life-Threatening
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ED Evaluation of ED Evaluation of Patients With STEMIPatients With STEMI
PericarditisAtypical anginaEarly repolarization
Wolff-Parkinson-White syndrome
Deeply inverted T-waves suggestive of a central nervous system lesion or apical hypertrophic cardiomyopathy
LV hypertrophy with strain
Brugada syndromeMyocarditisHyperkalemiaBundle-branch blocks
Vasospastic anginaHypertrophic cardiomyopathy
Differential Diagnosis of STEMI: Other Cardiovascular and Nonischemic
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Gastroesophageal reflux (GERD) and spasm
Chest-wall painPleurisyPeptic ulcer disease
Panic attack
Cervical disc or neuropathic pain
Biliary or pancreatic pain
Somatization and psychogenic pain disorder
ED Evaluation of ED Evaluation of Patients With STEMIPatients With STEMI
Differential Diagnosis of STEMI: Other Noncardiac
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ElectrocardiogramElectrocardiogram
If the initial ECG is not diagnostic of STEMI, serial ECGs or continuous ST-segment monitoring should be performed in the patient who remains symptomatic or if there is high clinical suspicion for STEMI.
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ElectrocardiogramElectrocardiogram
Show 12-lead ECG results to emergency physician within 10 minutes of ED arrival in all patients with chest discomfort (or anginal equivalent) or other symptoms of STEMI.In patients with inferior STEMI, ECG leads should also be obtained to screen for right ventricular infarction.
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Laboratory ExaminationsLaboratory Examinations
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
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Cardiac-specific troponins should be used as the optimum biomarkers for the evaluation of patients with STEMI who have coexistent skeletal muscle injury.
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.
Biomarkers of Cardiac DamageBiomarkers of Cardiac Damage
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Patients with STEMI should have a portable chest 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 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.
ImagingImaging
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Supplemental oxygen should be administered to patients with arterial oxygen desaturation (SaO2 < 90%).
It is reasonable to administer supplemental oxygen to all patients with uncomplicated STEMI during the first 6 hours.
OxygenOxygen
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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.
Intravenous NTG is indicated for relief of ongoing ischemic discomfort that responds to nitrate therapy, control of hypertension, or management of pulmonary congestion.
NitroglycerinNitroglycerin
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Nitrates should not be administered to patients with:
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).
• systolic pressure < 90 mm Hg or ≥ to 30 mm Hg below baseline
• severe bradycardia (< 50 bpm)• tachycardia (> 100 bpm) or• suspected RV infarction.
NitroglycerinNitroglycerin
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AnalgesiaAnalgesia
Morphine sulfate (2 to 4 mg intravenously with 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.
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AspirinAspirin
Aspirin should be chewed by patients who have not taken aspirin before presentation with 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.
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Oral beta-blocker therapy should be administered promptly to those patients without a contraindication, irrespective of concomitant fibrinolytic therapy or performance of primary PCI.
It is reasonable to administer intravenous beta-blockers promptly to STEMI patients without contraindications, especially if a tachyarrhythmia or hypertension is present.
Beta-BlockersBeta-Blockers
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ReperfusionReperfusion
• Given the current literature, it is not possible to say definitively that a particular reperfusion approach is superior for all pts, in all clinical settings, at all times of day
• The main point is that some type of reperfusion therapy should be selected for all appropriate pts with suspected STEMI
• The appropriate & timely use of some reperfusion therapy is likely more important than the choice of therapy
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ReperfusionReperfusion
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.
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Media campaignPatient education
Methods of Speeding Time to
Reperfusion
Greater use of 9-1-1
Prehospital Rx
MI protocolCritical pathway
Quality improvement program
Bolus lytics
Dedicated PCI team
5 min < 30 min D-B ≤ 90 minD-N ≤ 30 min
Goals
Prehospital ECG
Patient Transport Inhospital
Reperfusion
ReperfusionReperfusion
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Symptom Recognition
Call to Medical System
ED Cath LabPreHospital
Delay in Initiation of Reperfusion Therapy
Increasing Loss of Myocytes
Treatment Delayed is Treatment Treatment Delayed is Treatment DeniedDenied
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Contraindications and CautionsContraindications and Cautionsfor Fibrinolysis in STEMIfor Fibrinolysis in STEMI
Absolute Contraindications
• Any prior intracranial hemorrhage• 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 hoursNOTE: Age restriction for fibrinolysis has
been removed compared with prior guidelines.
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Contraindications and CautionsContraindications and Cautionsfor Fibrinolysis in STEMIfor Fibrinolysis in STEMI
Absolute Contraindications
• Suspected aortic dissection• Active bleeding or bleeding diathesis (excluding menses)
• Significant closed-head or facial trauma within 3 months
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Contraindications and CautionsContraindications and Cautionsfor Fibrinolysis in STEMIfor Fibrinolysis in STEMI
• History of chronic, severe, poorly controlled 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)
RelativeContraindications
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Contraindications and CautionsContraindications and Cautionsfor Fibrinolysis in STEMIfor Fibrinolysis in STEMI
RelativeContraindications
• Recent (< 2 to 4 weeks) internal bleeding
• 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
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Reperfusion Options for STEMI PatientsReperfusion Options for STEMI PatientsStep OneStep One: Assess Time and Risk.: Assess Time and Risk.
Time Since Symptom Onset
Time Required for Transport to a Skilled
PCI Lab
Risk of STEMI
Risk of Fibrinolysis
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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
Reperfusion Options for STEMI PatientsReperfusion Options for STEMI Patients Step 2:Step 2: Select Reperfusion Treatment. Select Reperfusion Treatment.
If presentation is < 3 hours and there is no delay to an invasive strategy, there is no preference for either strategy.
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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
Reperfusion Options for STEMI PatientsReperfusion Options for STEMI Patients Step 2:Step 2: Select Reperfusion Treatment. Select Reperfusion Treatment.
If presentation is < 3 hours and there is no delay to an invasive strategy, there is no preference for either strategy.
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FibrinolysisFibrinolysis
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 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).
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FibrinolysisFibrinolysis
In the absence of contraindications, it is 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 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.
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FibrinolysisFibrinolysis
Fibrinolytic therapy should not be administered to asymptomatic patients whose initial symptoms of STEMI began more than 24 hours earlier.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.
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Primary PCI for STEMI:Primary PCI for STEMI:General ConsiderationsGeneral 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
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
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Primary PCI for STEMI:Primary PCI for STEMI:Specific ConsiderationsSpecific Considerations
Medical contact–to-balloon or door-to-balloon should be within 90 minutes.
PCI preferred if > 3 hours from symptom onset.
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.
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Primary PCI for STEMI:Primary PCI for STEMI:Specific ConsiderationsSpecific Considerations
Primary PCI should be performed in patients less 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.
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Primary PCI for STEMI:Primary PCI for STEMI:Specific ConsiderationsSpecific Considerations
Primary PCI is reasonable in selected patients 75 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.
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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
b. Hemodynamic or electrical instability
c. Persistent ischemic symptoms.
Primary PCI for STEMI:Primary PCI for STEMI:Specific ConsiderationsSpecific Considerations
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Rescue PCIRescue PCI
Rescue PCI should be performed in patients less 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.
Rescue PCI should be performed in patients with severe CHF and/or pulmonary edema (Killip class 3) and onset of symptoms within 12 hours.
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Rescue PCIRescue PCI
Rescue PCI is reasonable for selected patients 75 years or older with ST elevation or LBBB or who develop shock within 36 hours of MI and are suitable for revascularization that can be performed within 18 hours of shock.
It is reasonable to perform rescue PCI for patients with one or more of the following:
a. Hemodynamic or electrical instability
b. Persistent ischemic symptoms.
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PCI for Cardiogenic ShockPCI for Cardiogenic ShockPrimary PCI is recommended for patients less than 75 years with ST elevation or LBBB or who develop shock within 36 hours of MI and are suitable for revascularization that can be performed within 18 hours of shock.
Primary PCI is reasonable for selected patients 75 years or older with ST elevation or LBBB or who develop shock within 36 hours of MI and are suitable for revascularization that can be performed within 18 hours of shock.
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Cardiogenic Shock
1-2 vessel CAD Moderate 3-vessel CAD
Severe 3-vessel CAD
Left main CAD
PCI IRA
PCI IRA Immediate CABG
Staged Multivessel PCI
Staged CABG Cannot be performed
Early Shock, Diagnosed on Hospital Presentation
Delayed Onset Shock Echocardiogram to Rule Out
Mechanical Defects
Cardiac Catheterization and Coronary Angiography
IABP
Fibrinolytic therapy if all of the following are present:
1. Greater than 90 minutes to PCI2. Less than 3 hours post STEMI onset3. No contraindications
Arrange prompt transfer to invasive procedure-capable center
Arrange rapid transfer to invasive procedure-capable
center
PCI for Cardiogenic ShockPCI for Cardiogenic Shock
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PCI After FibrinolysisPCI After Fibrinolysis
In patients whose anatomy is suitable, PCI should be
performed for the following:
Objective evidence of recurrent MI
Moderate or severe spontaneous/provocable myocardial ischemia during recovery from STEMI
Cardiogenic shock or hemodynamic instability.
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PCI After FibrinolysisPCI After Fibrinolysis
It is reasonable to perform routine PCI in patients with left ventricular ejection fraction (LVEF) ≤ 0.40, CHF, or serious ventricular arrhythmias.
Routine PCI might be considered as part of an invasive strategy after fibrinolytic therapy.
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).
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Assessment of ReperfusionAssessment of Reperfusion
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.
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Ancillary Therapy to ReperfusionAncillary Therapy to Reperfusion
Unfractionated heparin (UFH) should be given
intravenously in:
Patients undergoing PCI or surgical revascularization
After alteplase, reteplase, tenecteplase
After streptokinase, anistreplase, urokinase in patients at high risk for systemic emboli.
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Ancillary Therapy to ReperfusionAncillary Therapy to Reperfusion
Low molecular-weight heparin (LMWH) might be considered an acceptable alternative to UFH in patients less than 75 years who are receiving fibrinolytic therapy in the absence of significant renal dysfunction.
Enoxaparin used with tenecteplase is the most comprehensively studied.
Platelet counts should be monitored daily in patients taking UFH.
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AspirinAspirin
A daily dose of aspirin (initial dose of 162 to 325 mg orally; maintenance dose of 75 to 162 mg) should be given indefinitely after STEMI to all patients without a true aspirin allergy.
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ThienopyridinesThienopyridines
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.
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ThienopyridinesThienopyridines
In patients taking clopidogrel in whom CABG is 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.
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ThienopyridinesThienopyridines
Clopidogrel is probably indicated in patients receiving fibrinolytic therapy who are unable to take aspirin because of hypersensitivity or gastrointestinal intolerance.
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Glycoprotein IIb/IIIa InhibitorsGlycoprotein IIb/IIIa Inhibitors
It is reasonable to start treatment with abciximab as early as possible before primary PCI (with or without stenting) in patients with STEMI.Treatment with tirofiban or eptifibatide may be considered before primary PCI (with or without stenting) in patients with STEMI.
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Other Pharmacological MeasuresOther Pharmacological Measures
Angiotensin converting enzyme (ACE)
inhibitorsAngiotensin receptor blockers
(ARB) Aldosterone blockersGlucose controlMagnesiumCalcium channel blockers
Inhibition of the renin -angiotensin -aldosterone system
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ACE/ARB: Within 24 HoursACE/ARB: Within 24 Hours
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 < 0.40An ARB should be given to ACE-intolerant patients with either clinical or radiological signs of HF or LVEF < 0.40.
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ACE/ARB: Within 24 HoursACE/ARB: Within 24 Hours
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.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).
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Strict Glucose Control During STEMIStrict Glucose Control During STEMI
An insulin infusion to normalize blood glucose is recommended for patients and complicated courses.
It is reasonable to administer an insulin infusion to normalize blood glucose even in patients with an uncomplicated course.
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Hospital ManagementHospital Management
ACC/AHA Guidelines for the Management of Patients with
ST-Elevation Myocardial Infarction
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Sample Admitting Orders for the Sample Admitting Orders for the Patient With STEMIPatient With STEMI
1. Condition: Serious
2. Normal Saline or D5W intravenous to keep vein open
3. Vital signs: Heart rate, blood pressure, respiratory rate
4. Monitor: Continuous ECG monitoring for arrhythmia/ST-segment deviation
5. Diet: NCEP ATP III Therapeutic Lifestyle Changes, low sodium diet
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Sample Admitting Orders for the Sample Admitting Orders for the Patient With STEMIPatient With STEMI
6.
Activity: Bed rest with bedside commode, light activity when stable
7.
Oxygen: 2 L/min when stable for 6 hrs, reassess need (i.e., O2 sat < 90%). Consider discontinuing if O2 saturation is > 90%.
8.
Medications: NTG, ASA, beta-blocker, ACE, ARB, pain meds, anxiolytics, daily stool softener
9.
Laboratory tests: cardiac biomarkers, CBC w/platelets, INR, aPTT, electrolytes, Mg2+, BUN, creatinine, glucose, serum lipids
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Emergency Management of Complicated Emergency Management of Complicated STEMISTEMI
Administer• Fluids• Blood transfusions• Cause-specific interventionsConsider vasopressors
Arrhythmia
Bradycardia Tachycardia
Systolic BPGreater than 100 mm Hg
Systolic BP 70 to 100 mm HgNO signs/symptoms
of shock
Systolic BP70 to 100 mm HgSigns/symptoms
of shock
Systolic BP less than 70 mm Hg Signs/symptoms of
shock
Dobutamine2 to 20
mcg/kg per minute IV
Low Output -Cardiogenic
Shock
Nitroglycerin10 to 20 mcg/min
IV
Dopamine5 to 15
mcg/kg per minute IV
Norepinephrine0.5 to 30 mcg/min IV
Hypovolemia
Administer• Furosemide IV 0.5 to 1.0 mg/kg• Morphine IV 2 to 4 mg• Oxygen/intubation as needed• Nitroglycerin SL, then 10 to 20 mcg/min IV if SBP greater than 100 mm Hg• Dopamine 5 to 15 mcg/kg per minute IV if SBP 70 to 100 mm Hg and signs/symptoms of shock present• Dobutamine 2 to 20 mcg/kg per minute IV if SBP 70 to 100 mm Hg and no signs/symptoms of shock
Firs
t li
ne o
f ac
tion
Seco
nd l
ine
of
acti
onTh
ird
line
of
acti
on
See Section 7.7in the ACC/AHA
Guidelines for Patients With ST-Elevation
Myocardial Infarction
Check Blood Pressure
Clinical signs: Shock, hypoperfusion, congestive heart failure, acute pulmonary edema
Most likely major underlying disturbance?
Further diagnostic/therapeutic considerations (should be considered in nonhypovolemic shock)Diagnostic Therapeutic ♥ Pulmonary artery catheter ♥
Intra-aortic balloon pump ♥ Echocardiography ♥
Reperfusion/revascularization ♥ Angiography for MI/ischemia ♥ Additional diagnostic studies
Acute Pulmonary Edema
Check Blood Pressure
Systolic BP Greater than 100 mm
Hg and not less than 30
mm Hg below baselineACE Inhibitors
Short-acting agent such as captopril (1
to 6.25 mg)
Circulation 2000;102(suppl I):I-172-I-216.
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Arrhythmias During Acute Phase of STEMI:Arrhythmias During Acute Phase of STEMI: Electrical Instability Electrical Instability
VPBs K+ , Mg++, beta blocker
VT Antiarrhythmics, DC shock
AIVR Observe unless hemodynamiccompromise
NPJT Search for cause (e.g., dig toxicity)
Arrhythmia Treatment
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Sinus Tach Treat cause; beta blocker
Afib / Flutter Treat cause; slow ventricular rate; DC shock
PSVT Vagal maneuvers; beta blocker, verapamil /
diltiazem; DC shock
Arrhythmias During Acute Phase of Arrhythmias During Acute Phase of STEMI:STEMI:
Pump Failure / Excess Sympathetic Tone Pump Failure / Excess Sympathetic Tone Arrhythmia Treatment
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Sinus Brady Treat if hemodynamic compromise;
atropine / pacing
Junctional Treat if hemodynamic compromise;
atropine / pacing
Arrhythmias During Acute Phase of Arrhythmias During Acute Phase of STEMI:STEMI:
Bradyarrhythmias Bradyarrhythmias Arrhythmia Treatment
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Arrhythmias During Acute Phase of Arrhythmias During Acute Phase of STEMI: STEMI:
AV Conduction Disturbances AV Conduction Disturbances
Escape Rhythm His Bundle Distal< 120 ms > 120 ms45 - 60 Often < 30
Duration of AVB 2 - 3 days Transient
Mortality Low High (CHF, VT)
Rx Observe PM (ICD)
Proximal Distal
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Recommendations for Treatment of Atrioventricular and Intraventricular Conduction Disturbances During STEMI
INTRAVENTRICULAR CONDUCTION Norm al
ACTION CLASS ACTIO N CLASS ACTIO N CLASS ACTIO N CLASS ACTIO N CLASS ACTION CLASS ACTIO N CLASSObserve I Observe I Observe I Observe IIb Observe IIa Observe III O bserve IIIA III A III A III A* III A III A III A IIITC III TC IIb TC IIb TC I TC I TC I TC ITV III TV III TV III TV III TV III TV IIa TV IIa
Old or New Observe I Observe IIb Observe IIb Observe IIb Observe IIb Observe III O bserve IIIFascicular block A III A III A III A* III A III A III A III(LAFB or LPFB) TC IIb TC I TC IIa TC I TC I TC I TC I
TV III TV III TV III TV III TV III TV IIa TV IIbObserve I Observe III Observe III Observe III Observe III Observe III O bserve IIIA III A III A III A* III A III A III A IIITC IIb TC I TC I TC I TC I TC I TC ITV III TV IIb TV IIb TV IIb TV IIb TV IIa TV IIaObserve III Observe III Observe III Observe III Observe III Observe III O bserve IIIA III A III A III A* III A III A III A IIITC I TC I TC I TC I TC I TC IIb TC IIbTV IIb TV IIa TV IIa TV IIa TV IIa TV I TV I
Fascicular Observe III Observe III Observe III Observe III Observe III Observe III O bserve IIIblock + RBBB A III A III A III A* III A III A III A III
TC I TC I TC I TC I TC I TC IIb TC IIbTV IIb TV IIa TV IIa TV IIa TV IIa TV I TV I
Alternating Observe III Observe III Observe III Observe III Observe III Observe III O bserve IIIleft and right A III A III A III A* III A III A III A IIIbundle branch TC IIb TC IIb TC IIb TC IIb TC IIb TC IIb TC IIbblock TV I TV I TV I TV I TV I TV I TV I
Norm al
Old bundle branch block
New bundle branch block
M obitz II second degree AV blockM obitz I second degree AV blockFirst degree AV blockANTERIOR M I NO N-ANTERIOR ANTERIO R M I NO N-ANTERIOR ANTERIO R M I NO N-ANTERIO R
Atrioventricular Conduction
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ICD Implantation After STEMIOne Month After STEMI;
No Spontaneous VT or VF 48 hours post-STEMI
EF < 0.30
EPS
Yes
+NEJM 349: 1836,2003
EF 0.31 - 0.40
No
No ICD.Medical
Rx
EF > 0.40
-
Additional Marker of Electrical Instability?
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Algorithm for Management of Recurrent Ischemia/Infarction After
STEMIObtain 12-lead ECG
YES NO
Consider (re) administration of
YES NO
Is patient a candidate for
revascularization?
ST-segment elevation?
•Escalation of medical therapy (nitrates, beta-blockers)
•Anticoagulation if not already given•Consider IABP for hemodynamic instability,
poor LV function, or a large area of myocardium at risk•Correct secondary causes of ischemia
Recurrent ischemic-type discomfort at rest after STEMI
YES NO
Refer for nonurgent
catheterization
Refer for urgent catheterization (consider
IABP)
Is ischemia controlled by escalation
of medical therapy?
YES
Coronary angiography
Revascularization with PCI and/or CABG as dictated by
anatomy
NO
Can catheterization
be performed promptly?*
Obtain 12-lead ECG
YES NO
Consider (re) administration of fibrinolytic therapy
YES NO
Is patient a candidate for
revascularization?
Is patient a candidate for
revascularization?
ST-segment elevation?ST-segment elevation?
•Escalation of medical therapy (nitrates, beta-blockers)
•Anticoagulation if not already given•Consider IABP for hemodynamic instability,
poor LV function, or a large area of myocardium at risk•Correct secondary causes of ischemia
Recurrent ischemic-type discomfort at rest after STEMI
YES NO
Refer for nonurgent
catheterization
Refer for urgent catheterization (consider
IABP)
YES NO
Refer for nonurgent
catheterization
Refer for urgent catheterization (consider
IABP)
Is ischemia controlled by escalation
of medical therapy?
Is ischemia controlled by escalation
of medical therapy?
YES
Coronary angiography
Revascularization with PCI and/or CABG as dictated by
anatomy
NO
Can catheterization
be performed promptly?*
Can catheterization
be performed promptly?
Modified from Braunwald. Heart Disease: A Textbook of Cardiovascular Medicine. 6th ed. Philadelphia, PA: WB Saunders Co. Ltd. 2001:1195.Consider (re) administration
of fibrinolytic therapy
74
Evidence-Based Approach to Need for Catheterization and Revascularization
After STEMISTEMI
Primary Invasive Strategy Fibrinolytic Therapy No Reperfusion Therapy
Cath Performed
No Cath Performed
EF greater than 0.40
EF less than 0.40
EF less than 0.40
EF greater than 0.40
High-RiskFeatures†
No High-RiskFeatures†
No High-RiskFeatures†
High-RiskFeatures†
Functional Evaluation
ECG Interpretable ECG Uninterpretable
Able to Exercise Unable to Exercise
SubmaximalExercise Test
Before Discharge
Symptom-LimitedExercise Test
Before or After Discharge
Pharmacological Stress
Nuclear ScanDobutamine
Echo
Clinically SignificantIschemia*
No Clinically SignificantIschemia*
MedicalTherapy
Revascularization as Indicated
Catheterization and Revascularization as
Indicated
Catheterization and Revascularization as
Indicated
Able to Exercise
Exercise Echo
Exercise Nuclear
STEMI
Primary Invasive Strategy Fibrinolytic Therapy No Reperfusion Therapy
Cath Performed
No Cath Performed
EF greater than 0.40
EF less than 0.40
EF less than 0.40
EF greater than 0.40
High-RiskFeatures
No High-RiskFeatures
No High-RiskFeatures
High-RiskFeatures
Functional Evaluation
ECG Interpretable ECG Uninterpretable
Able to Exercise Unable to Exercise
SubmaximalExercise Test
Before Discharge
Symptom-LimitedExercise Test
Before or After Discharge
Pharmacological Stress
Adenosineor DipyridamoleDobutamineEcho
Clinically SignificantIschemia
No Clinically SignificantIschemia
MedicalTherapy
Revascularization as Indicated
Catheterization and Revascularization as
Indicated
Catheterization and Revascularization as
Indicated
Able to Exercise
Exercise Echo
Exercise Nuclear
75
Long-Term Antithrombotic Therapy at Hospital Discharge After STEMI
No Stent Implanted
No ASA allergy ASA Allergy
Preferred:ASA 75 to 162 mg
Class I; LOE: A
Preferred:Clopidogrel 75 mg
Class I; LOE: C
Alternative:Warfarin
INR (2.5 to 3.5)
Class I; LOE: B
Alternative:ASA 75 to 162 mg
Warfarin(INR 2.0 to 3.0)
Class: IIa; LOE: B
OR
Warfarin(INR 2.5 to 3.5)
Class IIa; LOE: B
Indicationsfor
Anticoagulation
No Indicationsfor
Anticoagulation
No Indicationsfor
Anticoagulation
Indicationsfor
Anticoagulation
ASA 75 to 162 mg
Warfarin (INR 2.0 to
3.0)Class I; LOE B
OR
Warfarin(INR 2.5 to
3.5)Class I; LOE: B
WarfarinINR (2.5 to
3.5)Class I; LOE: B
STEMI Patient at Discharge
76
Long-Term Antithrombotic Therapy at Hospital Discharge After STEMI
Stent Implanted
No ASA Allergy ASA Allergy
ASA 75 to 162 mgClopidogrel 75 mg
Class: I; LOE: B
ASA 75 to 162 mgClopidogrel 75 mg
Warfarin (INR 2.0 to 3.0)
Class: IIb; LOE: C
Clopidogrel 75 mgClass I; LOE: B
Clopidogrel 75 mgWarfarin
(INR 2.0 to 3.0)Class I; LOE: C
STEMI Patient at Discharge
No Indications
for Anticoagula
tion
Indicationsfor
Anticoagulation
Indicationsfor
Anticoagulation
No Indications
for Anticoagulati
on
77
Long-Term ManagementLong-Term Management
ACC/AHA Guidelines for the Management of Patients with
ST-Elevation Myocardial Infarction
78
Secondary Prevention and Long Term Management
• Assess tobacco use.
• Strongly encourage patient and family to stop smoking and to avoid secondhand smoke.
• Provide counseling, pharmacological therapy (including nicotine replacement and bupropion), and formal smoking cessation programs as appropriate.
Smoking Goal: Complete Cessation
Goals Recommendations
79
Secondary Prevention and Long Term Management
If blood pressure is 120/80 mm Hg or greater:
• Initiate lifestyle modification (weight control, physical activity, alcohol moderation, moderate sodium restriction, and emphasis on fruits, vegetables, and low-fat dairy products) in all patients.
If blood pressure is 140/90 mm Hg or greater or 130/80 mm Hg or greater for individuals with chronic kidney disease or diabetes:
• Add blood pressure-reducing medications, emphasizing the use of beta-blockers and inhibitors of the renin-angiotensin-aldosterone system.
Blood pressure control:Goal: < 140/90 mm Hg or <130/80 mm Hg if chronic kidney disease or diabetes
Goals Recommendations
80
Secondary Prevention and Long Term Management
• Assess risk, preferably with exercise test, to guide prescription.
• Encourage minimum of 30 to 60 minutes of activity, preferably daily but at least 3 or 4 times weekly (walking, jogging, cycling, or other aerobic activity) supplemented by an increase in daily lifestyle activities (e.g., walking breaks at work, gardening, household work).
• Cardiac rehabilitation programs are recommended for patients with STEMI.
Physical activity:Minimum goal:30 minutes 3 to 4 days per week;Optimal daily
Goals Recommendations
81
Secondary Prevention and Long Term Management
• Start dietary therapy in all patients (< 7% of total calories as saturated fat and < 200 mg/d cholesterol). Promote physical activity and weight management. Encourage increased consumption of omega-3 fatty acids.
• Assess fasting lipid profile in all patients, preferably within 24 hours of STEMI. Add drug therapy according to the following guide:
Lipid management:(TG less than 200 mg/dL)Primary goal:LDL-C << than 100 mg/dL
Goals Recommendations
LDL-C < 100 mg/dL (baseline or on treatment):Statins should be used to lower LDL-C.
LDL-C ≥ 100 mg/dL (baseline or ontreatment):
Intensify LDL-C–lowering therapy with drug treatment, giving preference to statins.
82
Secondary Prevention and Long Term Management
If TGs are ≥ 150 mg/dL or HDL-C is < 40 mg/dL:Emphasize weight management and physical activity. Advise smoking cessation.
If TG is 200 to 499 mg/dL: After LDL-C–lowering therapy, consider adding fibrate or niacin.
If TG is ≥ 500 mg/dL: Consider fibrate or niacin before LDL-C–lowering therapy.Consider omega-3 fatty acids as adjunct for high TG.
Lipid management:(TG 200 mg/dL or greater)Primary goal:Non–HDL-C << 130 mg/dL
Goals Recommendations
83
Secondary Prevention and Long Term Management
Goals RecommendationsCalculate BMI and measure waist circumference as part of evaluation. Monitor response of BMI and waist circumference to therapy.
Start weight management and physical activity as appropriate. Desirable BMI range is 18.5 to 24.9 kg/m2.
If waist circumference is ≥ 35 inches in women or ≥ 40 inches in men, initiate lifestyle changes and treatment strategies for metabolic syndrome.
Weight management:Goal:BMI 18.5 to 24.9 kg/m2
Waist circumference:Women: < 35 in.Men: < 40 in.
84
Secondary Prevention and Long Term Management
Goals RecommendationsAppropriate hypoglycemic therapy to achieve near-normal
fasting plasma glucose, as indicated by HbA1c.
Treatment of other risk factors (e.g., physical activity, weight management, blood pressure, and cholesterol management).
Diabetes management: Goal: HbA1c < 7%
85
Secondary Prevention and Long Term Management
Goals Recommendations
• In the absence of contraindications, start aspirin 75 to 162 mg/d and continue indefinitely.• If aspirin is contraindicated, consider clopidogrel 75 mg/day or warfarin. • Manage warfarin to INR 2.5 to 3.5 in post-STEMI patients when clinically indicated or for those not able to take aspirin or clopidogrel.
Antiplatelet agents/ anticoagulants
86
Secondary Prevention and Long Term Management
Goals Recommendations
ACE inhibitors in all patients indefinitely; start early in stable, high-risk patients (ant. MI, previous MI, Killip class ≥ 2 [S3 gallop, rales, radiographic CHF], LVEF < 0.40).
Angiotensin receptor blockers in patients who are intolerant of ACE inhibitors and with either clinical or radiological signs of heart failure or LVEF < 0.40.
Aldosterone blockade in patients without significant renal dysfunction or hyperkalemia who are already receiving therapeutic doses of an ACE inhibitor, have LVEF ≤ 0.40, and have either diabetes or heart failure.
Renin-Angiotensin-Aldosterone System Blockers
87
Secondary Prevention and Long Term Management
Goals Recommendations
Start in all patients. Continue indefinitely. Observe usual contraindications.
Beta- Blockers
88
1st 1st 24 h24 h
During During HospHosp
Hosp DC Hosp DC + Long + Long TermTerm
Aspirin 162-325 mgchewed
75-162 mg/d p.o.
75-162 mg/d p.o.
Fibrinolytic tPA,TNK,rPA, SK
UFH60U/kg (4000)12 U/kg/h (1000)
aPTT 1.5 - 2 x C
aPTT1.5 - 2 x C
Beta-blocker Oral daily Oral daily
Oral daily
Summary of Pharmacologic Rx:Summary of Pharmacologic Rx: Ischemia Ischemia
JACC 2004;44: 671Circulation 2004;110: 588
89
1st 1st 24 h24 h
During HospDuring Hosp Hosp DC + Hosp DC + Long TermLong Term
ACEI Anterior MI,Pulm Cong., EF <
40Oral Daily
Oral Daily
IndefinitelyARB ACEI intol.,
HF, EF < 40Aldo
BlockerNo renal dysf, K+ < 5.0 mEq/LOn ACEI, HF or DM
Same as during Hosp.
Statin Start w/o lipid profile
Indefinitely,LDL << 100
Summary of Pharmacologic Rx: Summary of Pharmacologic Rx: LVD, Sec. Prev.,LVD, Sec. Prev.,
JACC 2004;44:671JACC 2004;44:671Circ 2004;110:588Circ 2004;110:588
90
Hormone TherapyHormone Therapy
Hormone therapy with estrogen plus progestin should not be given de novo to postmenopausal women after STEMI for secondary prevention of coronary events.
91
Hormone TherapyHormone Therapy
Postmenopausal women who are already taking estrogen plus progestin at the time of STEMI should not continue hormone therapy.
However, women who are beyond 1 to 2 years after initiation of hormone therapy who wish to continue such therapy for another compelling indication should weigh the risks and benefits.
92
AntioxidantsAntioxidants
Antioxidant vitamins such as vitamin E and/or vitamin C supplements should not be prescribed to patients recovering from STEMI to prevent cardiovascular disease.
93
Psychosocial Impact of STEMIPsychosocial Impact of STEMI
The psychosocial status of the patient should be evaluated, including inquiries regarding symptoms of depression, anxiety, or sleep disorders and the social support environment.
Treatment with cognitive-behavioral therapy and selective serotonin reuptake inhibitors can be useful for STEMI patients with depression that occurs in the year after hospital discharge.
94
Cardiac RehabilitationCardiac Rehabilitation
Cardiac rehabilitation/secondary prevention programs, when available, are recommended for patients with STEMI, particularly those with multiple modifiable risk factors and/or those moderate- to high-risk patients in whom supervised exercise training is warranted.