Referensi STEMI

7/23/2019 Referensi STEMI

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ST Elevation MyocardialST Elevation Myocardial

Infarction (STEMI)Infarction (STEMI)William J. Mosley II, MDWilliam J. Mosley II, MD

Cardiovascular Disease FelloCardiovascular Disease Fello(!"dated from Jo#n $a"" it# %&&'(!"dated from Jo#n $a"" it# %&&'

uidelines)uidelines)


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E"idemoloy of CDE"idemoloy of CD ( %&*+ )( %&*+ )

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In !S3In !S3

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Hospitalizations in the U.S. Due to Acute

Coronary Syndromes (ACS)

3cute CoronarySyndromes6

*./' Millionos"ital 3dmissions 2 3CS

!3-7STEMI STEMI

*.%+ million3dmissions "er year

.88 million3dmissions "er year

eart Disease and Stro9e Statistics : %&&' !"date. Circulation %&&';**/1


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earts conduction systemearts conduction system

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CDCD


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3CS2STEMI3CS2STEMI

ACUTE CORONARY SYNDROMES

No ST elevation ST elevation

Unstable

angina

NSTEMI STEMIStable

angina


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EBG 4ndins in CDEBG 4ndins in CD

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NutlineNutline

OClass-EvidenceClass-EvidenceOGeneral T#era"yGeneral T#era"yOAeta2?loc9ersAeta2?loc9ersO$e"erfusion$e"erfusion

OFacilitated =CIFacilitated =CIOCom"licationsCom"lications


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Class IBenefit >>> Risk

Procedure/Treatment SHOULDbe perormed/administered

Class IIaBenefit >> Risk

Additional studies withfocused objectivesneeded

IT IS REASONABLE toperormprocedure/administertreatment

Class IIbBenefit Risk

Additional studies withbroad objectivesneeded; Additionalregistry data would be

helpful

Procedure/TreatmentMAY BE CONSIDERED

Class IIIRisk BenefitNo additional studiesneeded

Procedure/Treatment

shouldNOT beperormed/administeredSINCE IT IS NOTHELPFUL AND MAYBE HARMFUL

Applyin! Classiication o "ecommendations

and #e$el o %$idence

Level A: "ecommendation based on e$idence rom multiple randomized trials or meta&analyses'ultiple (&) population ris* strata e$aluated+ ,eneral consistency o direction and ma!nitude o eect

Level B: "ecommendation based on e$idence rom a sin!le randomized trial or non&randomized studies#imited (-&) population ris* strata

e$aluated

Level C: "ecommendation based on epert opinion case studies or standard&o&care0ery limited (1&-) population ris* strata e$aluated


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GeneralGeneral

T#era"yT#era"y


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General T#era"yGeneral T#era"y

O MN73MN73: Mor"#ine (Mor"#ine ( /2*/ min C3SS I)

: NPyen (NPyen ("ulse oPQ


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3s"irin3s"irinO 3s"irin s#ould ?e c#eed ?y "atients #o #ave not

ta9en as"irin ?efore "resentation it# STEMI. T#einitial dose s#ould ?e *1% m (Level of Evidence: A) to8%/ m (Level of Evidence: C). Class I

O In a dose of *1% m or more, as"irin "roduces a ra"idclinical antit#rom?otic eRect caused ?y immediate andnear2total in#i?ition of t#rom?oPane 3% "roduction.(ISIS2%22Q3S3 led to %85 reduction in mortality)

1. Antithrombotic Trialists Collaboration. Collaborative meta-analysis of randomised trials ofantiplatelet therapy for prevention of death, myocardial infarction, and stroke in high riskpatients. BMJ. 2002 !2"# $1%&'.

2. ()()-2 *)econd (nternational )t+dy of (nfarct )+rvival Collaborative ro+p. andomised trialof intraveno+s streptokinase, oral aspirin, both, or neither among 1$1&$ cases of s+spectedac+te m ocardial infarction. /ancet 1&& ii#!"-'0.


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Aeta2Aloc9ersAeta2Aloc9ers


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I7C!SIN7I7C!SIN7 Q+/,&&& "atients it# sus"ected acuteQ+/,&&& "atients it# sus"ected acuteMI (ST c#ane or AAA) it#in %+ # ofMI (ST c#ane or AAA) it#in %+ # ofsym"tom onsetsym"tom onset

T$E3TME7TT$E3TME7T Meto"rolol */ m iv over */ mins, t#enMeto"rolol */ m iv over */ mins, t#en%&& m oral daily vs matc#in "lace?o%&& m oral daily vs matc#in "lace?o

EC!SIN7EC!SIN7 S#oc9, systolic A= *&& mm, #eartS#oc9, systolic A= *&& mm, #eart

rate /&-min or II-III 3K ?loc9rate /&-min or II-III 3K ?loc9

**N!TCNMESN!TCNMES Deat# U deat#, re2MI or KF-arrest u" toDeat# U deat#, re2MI or KF-arrest u" to+ ee9s in #os"ital (or "rior disc#are)+ ee9s in #os"ital (or "rior disc#are)

Mean treatment and follo2u" *1 daysMean treatment and follo2u" *1 days

COMMITCOMMIT Study desin Study desin


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ERects of Meto"rololERects of Meto"rolol

Lancet !""#$%&&:'&!!

Deat(

'%)

P*""""&

ReMI

!!)

P*""""!

+F'#)

P*"""!

Totality of Evidence (N = 52,411)COMMIT (N = 45,852)

%") ,elative

in-,ease in

.-a,/iogeni-

s(o-0

.Ris0 1a-to,s 1o, -a,/iogeni- s(o-0 :(ea,t 1ail2,e3 age 4 5" 3 s6stoli- bloo/7,ess2,e 8 '!"3 sin2s ta-(6-a,/ia 4 ''" o, (ea,t ,ate 8 &"3 in-,ease/ ti9e

sin-e onset o1 STEMI s697to9s


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$ecommendations 2 Class (a*

O A/?eta2?loc9er t#era"y )34/5 6initiatedin t#e 4rst %+ #ours for "atients #o 5 7T

#ave any of t#e folloin*) sins of #eart failure,%) evidence of a lo out"ut state,8) increased ris9 for cardioenic s#oc9, or+) relative contraindications to ?eta ?loc9ade

*3KA Q &.%+ sec, %nd2 or 8rd2deree #eart ?loc9

reactive airay disease88 T#ere is no study evaluatin oral ?eta ?loc9ers

alone

2eta&2loc*ers

.Ris0 1a-to,s 1o, -a,/iogeni- s(o-0 :(ea,t 1ail2,e3 age 4 5" 3 s6stoli- bloo/ 7,ess2,e 8 '!"3

sin2s ta-(6-a,/ia 4 ''" o, (ea,t ,ate 8 &"3 in-,ease/ ti9e sin-e onset o1 STEMI s697to9s


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$ecommendations 2 Class ((a*

O It is reasona?le to administer an (9 6TA/C:6at t#e time of "resentation to STEMI

"atients #o are 3;


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$ecommendations 2 Class (((*A

O IK ?eta ?loc9ers )34/5 7T?e administeredto STEMI "atients #o #ave any of t#e folloin

*) sins of #eart failure

%) evidence of a lo out"ut state

8) increased ris96 for cardioenic s#oc9+) relative contraindications to ?eta ?loc9ade

*3KA Q &.%+ sec, %nd2 or 8rd2deree #eart ?loc9 reactive airay disease

2eta&2loc*ers

.Ris0 1a-to,s 1o, -a,/iogeni- s(o-0 :(ea,t 1ail2,e3 age 4 5" 3 s6stoli- bloo/

7,ess2,e 8 '!"3 sin2s ta-(6-a,/ia 4 ''" o, (ea,t ,ate 8 &"3 in-,ease/ ti9e

sin-e onset o1 STEMI s697to9s


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$e"erfusion$e"erfusion


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VVTime is MuscleTime is Muscle


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"eperusion

O STEMI "atients "resentin to a #os"ital it# =CIca"a?ility s#ould ?e treated it# "rimary =CI=ithin 0 minof 4rst medical contact as asystems oal. Class (a

O STEMI "atients "resentin to a #os"ital it#out=CI ca"a?ility, and #o cannot ?e transferred to a=CI center and undero =CI it#in


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PC3 $s 4ibrinolysis or ST%'35

Short&Term Clinical 6utcomesPCI

F,e:2en-

6;)cacy *thro+gh !0 d6>cacy *thro+gh !0 d )afety)afety 4se 5+ring

7o data on revi"arin alone7o data on revi"arin alone

durin =CI. 3dditionaldurin =CI. 3dditionalanticoaulant it# anti2IIaanticoaulant it# anti2IIaactivity, suc# as !F oractivity, suc# as !F or?ivalirudin, recommended.?ivalirudin, recommended.

Fonda"arinuPFonda"arinuP Fi?rinolysis a""ears su"erior toFi?rinolysis a""ears su"erior tocontrol rP ("lace?o-!F). $elativecontrol rP ("lace?o-!F). $elative?ene4t vs "lace?o and !F?ene4t vs "lace?o and !Fse"arately cannot ?e relia?lyse"arately cannot ?e relia?ly

determined from availa?le data.6determined from availa?le data.6

=rimary =CI #en used alone, no=rimary =CI #en used alone, noadvantae over !F and trendadvantae over !F and trendtoard orse outcome.toard orse outcome.

7o re"erfusion a""ears su"erior to7o re"erfusion a""ears su"erior tocontrol t#era"y ("lace?o-!F).control t#era"y ("lace?o-!F).

$elative ?ene4t versus "lace?o and$elative ?ene4t versus "lace?o and!F se"arately cannot ?e relia?ly!F se"arately cannot ?e relia?lydetermined from availa?le data.6determined from availa?le data.6

Trend toard [Trend toard [ris9 of seriousris9 of serious?leeds>?leeds>

ZZ ris9 of cat#eter t#rom?osisris9 of cat#eter t#rom?osis#en fonda"arinuP used#en fonda"arinuP usedalone. 3dditionalalone. 3dditionalanticoaulant it# anti2IIaanticoaulant it# anti2IIa

activity, suc# as !F oractivity, suc# as !F or?ivalirudin, recommended.?ivalirudin, recommended.

EnoPa"arinEnoPa"arin Fi?rinolysis a""ears su"erior to !FFi?rinolysis a""ears su"erior to !F ZZ ris9 of seriousris9 of serious?leeds>?leeds>

EnoPa"arin can ?e used toEnoPa"arin can ?e used tosu""ort =CI after 4?rinolysis.su""ort =CI after 4?rinolysis.7o additional anticoaulant7o additional anticoaulantneeded.needed.

Summary o 6bser$ations rom Trials o Anticoa!ulants or ST%'3

Antman %' et al. A! "oll "ardiol #$$%& Published ahead o print on December 18 -88. A$ailable at

http5//content.onlineBacc.or!/c!i/content/ull/B.Bacc.-88.18.881.Table 18.
http://content.onlinejacc.org/cgi/content/full/j.jacc.2007.10.001http://content.onlinejacc.org/cgi/content/full/j.jacc.2007.10.001


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Facilitated =CIFacilitated =CI


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Meta2analysis Facilitated =CI vsMeta2analysis Facilitated =CI vs

=rimary =CI=rimary =CI

1.0!1.0!

*0.1?-$.1!*0.1?-$.1!!.0$!.0$

*0.1&-?2.0*0.1&-?2.0

1."!1."!

*1.01-2.02*1.01-2.02

1.0!1.0!*0."-2.1$*0."-2.1$

Mo,talit6 Rein1a,-tion Ma>o, Blee/ing

Fa- PCI

Bette,

PPCI

Bette,

Fa- PCI

Bette,

PPCI

Bette,

Fa- PCI

Bette,

PPCI

Bette,

7eeley % et al. Lancet -889+95.

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Referensi STEMI

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