Aha guidelines stemi

1

ACC/AHA Guidelines for the Management of Patients with

ST-Elevation Myocardial Infarction

2

Management Before Management Before STEMISTEMI



3

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.

4

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.

5

Onset of STEMIOnset of STEMI



6

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.

7

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.

8

• 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

9

Initial Recognition Initial Recognition and Management in the and Management in the Emergency DepartmentEmergency Department



10

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

11


Aortic dissectionPulmonary embolusPerforating ulcer

Tension pneumothoraxBoerhaave syndrome (esophageal rupture with mediastinitis)

Differential Diagnosis of STEMI: Life-Threatening

12


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

13

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


Differential Diagnosis of STEMI: Other Noncardiac

14

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.

15

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.

16

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

17

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

18

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

19

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

20

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

21

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

22

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.

23

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.

24

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

25

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

26


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.

27

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


28

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

29

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.

30


Absolute Contraindications

• Suspected aortic dissection• Active bleeding or bleeding diathesis (excluding menses)

• Significant closed-head or facial trauma within 3 months

31


• 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

32


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

33

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

34

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.

35

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.

36

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).

37


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.

38


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.

39

Evolution of PCI for STEMIEvolution of PCI for STEMI

40

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

41

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.

42


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.

43


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.

44

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.


45

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.

46

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.

47

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.

48

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

49

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.

50

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).

51

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.

52

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.

53

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.

54

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.

55

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.

56


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.

57


Clopidogrel is probably indicated in patients receiving fibrinolytic therapy who are unable to take aspirin because of hypersensitivity or gastrointestinal intolerance.

58

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.

59

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.

61

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).

62

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.

63

Hospital ManagementHospital Management



64

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

65

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

66

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.

67

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

68

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

69

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

70

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

71

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

72

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?

73

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


revascularization?


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


IABP)

YES NO

Refer for nonurgent

catheterization


IABP)


of medical therapy?


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


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


Indicated

Able to Exercise

Exercise Echo

Exercise Nuclear

STEMI

Primary Invasive Strategy Fibrinolytic Therapy No Reperfusion Therapy

Cath Performed

No Cath Performed


EF less than 0.40

EF less 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


Indicated


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

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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

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Long-Term ManagementLong-Term Management



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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

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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


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• 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


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• 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


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.

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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


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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.

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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%

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• 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

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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

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Start in all patients. Continue indefinitely. Observe usual contraindications.

Beta- Blockers

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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

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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

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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.

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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.

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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.

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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.

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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.

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