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ACCAHA Guidelines for the Management of Patients with ST Elevation Myocardial Infarction 2004

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Title: ACCAHA Guidelines for the Management of Patients with ST Elevation Myocardial Infarction 2004


1
ACC/AHA Guidelines for the Management of Patients
with ST Elevation Myocardial Infarction 2004
  • Ahmad Aslam, M.D.
  • Prasantha Bathini, M.D.
  • Robert Smith, M.D.
  • Cardiac Cath Conference
  • July 13, 2004

2
Participants in Updated Guidelines
3
Evidence Based Medicine Whats the Problem?
There is an unsettling truth about the practice
of medicine. study after study shows that few
physicians systematically apply to everyday
treatment the scientific evidence about what
works best.
Millenson, ML. Demanding Medical Excellence
Doctors and Accountability in the Information
Age. 1997
4
How Should We Be Dealing With This?
5
ACC/AHA Practice Guidelines Classification of
Benefit
  • Class I
  • Conditions for which there is evidence and/or
    general agreement that a given procedure or
    treatment is useful and effective
  • Class IIa
  • Conditions for which there is conflicting
    evidence and/or divergence of opinion about the
    usefulness/efficacy of a procedure or treatment.
    However, the treatment/procedure is reasonable
    and is probably useful and effective
  • Class IIb
  • Conditions for which there is conflicting
    evidence and/or divergence of opinion about the
    usefulness/efficacy of a procedure or treatment.
    However, the treatment/procedure may be
    reasonable. The usefulness and effectiveness is
    not well established
  • Class III
  • Conditions for which there is evidence and/or
    general agreement that the procedure/treatment is
    not useful or effective and in some cases may be
    harmful

6
ACC/AHA Practice Guidelines Level of Evidence
  • A (highest)
  • The data were derived from multiple randomized
    clinical trials that involved large numbers of
    patients
  • B (intermediate)
  • The data were derived from a limited number of
    randomized trials that involved small numbers of
    patients, or from careful analysis of
    non-randomized studies or observational
    registries
  • C (low)
  • A lower rank was given when expert consensus was
    the primary basis for the recommendation

7
Epidemiology
  • In the U.S., there were 1,680,000 discharges for
    ACS in the year 2001
  • Approximately 500,000 of these were STEMIs

8
Prehospital Issues
  • Class I
  • Patients with symptoms of STEMI should be
    transported to the hospital by ambulance rather
    than by friends or relatives. (Level of
    Evidence B)
  • Healthcare providers should instruct patients in
    whom NTG has been prescribed to take ONE NTG dose
    sublingually in response to chest pain. If the
    pain is worsened or unimproved after 5 minutes,
    the patient should be instructed to call 911
    (Level of Evidence C)

9
Initial Recognition and Management in the ED
  • Hospitals should establish multidisciplinary
    teams (including primary care physicians,
    emergency medicine physicians, cardiologists,
    nurses, and laboratorians) to develop
    guideline-based, institution-specific written
    protocols for triaging and managing patients who
    are seen in the prehospital setting or present to
    the ED with symptoms suggestive of STEMI.
  • Class I, Level of Evidence B

10
Targeted History
  • Ascertain whether the patient has had prior
    episodes of myocardial ischemia (stable or
    unstable angina, MI, CABG, or PCI)
  • Focus on chest discomfort and associated symptoms
  • HTN?
  • DM?
  • Assess for possibility of aortic dissection
  • Assess risk of bleeding
  • Assess for clinical cerebrovascular disease
    (amaurosis fugax, face/limb weakness or
    clumsiness, sensory loss, ataxia, vertigo
  • Class I, Level of Evidence C

11
Physical Exam
  • Class I
  • To aid in the diagnosis and assessment of the
    extent, localization, and presence of
    complications of STEMI. (Level of Evidence C)
  • A brief, focused neurologic exam in order to
    look for evidence of prior stroke or cognitive
    defects (before administering fibrinolytics) .
    (Level of Evidence C)

12
ECG
  • Class I
  • Should be done within 10 minutes of arrival.
    (Level of Evidence C)
  • If the initial ECG is not diagnostic of STEMI
    but the clinical suspicion is high, serial ECGs
    (5-10 minute intervals) or continuous 12 lead ST
    segment monitoring should be performed. (Level
    of Evidence C)
  • With inferior STEMI, right sided ECG should be
    performed in order to look for ST elevation
    suggestive of RV infarct. (Level of Evidence B)

13
Inferior Infarct
14
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15
Right Sided Leads
16
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17
Inferior/RV Infarct
18
Laboratory Examinations
  • Class I
  • Cardiac-specific troponins should be used as the
    optimum biomarkers for the evaluation of patients
    with STEMI who have coexistent skeletal muscle
    injury. (Level of Evidence C)
  • For patients with STEMI on the ECG and symptoms,
    reperfusion therapy should be initiated
    immediately and is not contingent on a biomarker
    assay. (Level of Evidence C)

19
ECG
  • The 12 lead ECG is the center of the
    therapeutic decision pathway because of the
    strong evidence that ST segment elevation
    identifies patients who benefit from reperfusion
    therapy

20
Imaging
  • Class I
  • Patients with STEMI should have a portable CXR,
    but this should not delay implementation of
    reperfusion therapy unless a contraindication,
    such as aortic dissection, is suspected. (Level
    of Evidence C)
  • High quality pCXR, TTE and or TEE, and contrast
    chest CT or MRI should be used to differentiate
    STEMI from dissection in patients for whom this
    distinction is unclear. (Level of Evidence B)

21
Initial Management Oxygen
  • Class I
  • Supplemental O2 should be administered to
    patients with arterial oxygen desaturation (SaO2
    less than 90). (Level of Evidence B)
  • Class IIa
  • It is reasonable to administer O2 to all
    patients with uncomplicated STEMI during the
    first 6 hours. (Level of Evidence C)

22
Initial Management Nitrates
  • Class I
  • Patients with ongoing ischemic discomfort should
    receive SL NTG (0.4mg) every 5 minutes for a
    total of 3 doses, after which an assessment
    should be made about the need for IV NTG. (Level
    of Evidence C)
  • IV NTG is indicated for relief of ongoing
    ischemic discomfort, control of HTN, or
    management of pulmonary congestion. (Level of
    Evidence C)

23
Initial Management Nitrates
  • Class III
  • Nitrates in all forms should be avoided in
    patients with an initial systolic blood pressure
    less than 90mmHg or greater than or equal to
    30mmHg below baseline, in patients with marked
    bradycardia or tachycardia, and in patients with
    known or suspected RV infarction. In view of
    their marginal treatment benefits, nitrates
    should not be used if hypotension limits the
    administration of Beta Blockers

24
Initial Management Analgesia
  • Class I
  • MSO4 (2-4mg IV with increments of 2-8mg IV
    repeated at 5-15 minute intervals) is the
    analgesic of choice for management of pain
    associated with STEMI. (Level of Evidence C)

25
Initial Management Aspirin
  • Class I
  • Aspirin should be chewed by patients who have
    not taken aspirin before presentation with STEMI.
    The initial dose should be 162mg (Level of
    Evidence A) to 325 mg. (Level of Evidence C)
  • Although some trials have used enteric-coated
    ASA for initial dosing, more rapid buccal
    absorption occurs with non-enteric coated
    formulations

26
Initial Management Beta-Blockers
  • Class I
  • Oral BB therapy should be administered promptly
    to those patients without a contraindication,
    irrespective of concomitant fibrinolytic therapy
    or performance of primary PCI. (Level of
    Evidence A)
  • Class IIa
  • It is reasonable to administer IV BB promptly to
    STEMI patients without contraindications,
    especially if a tachyarrhythmia or HTN is
    present. (Level of Evidence B)

27
Reperfusion
  • Class I
  • All STEMI patients should undergo rapid
    evaluation for reperfusion and have a reperfusion
    strategy implemented promptly after contact with
    the medical system. (Level of Evidence A)

28
Reperfusion
  • For fibrinolytic therapy, goal is door to needle
    time of 30 minutes
  • For PCI, goal is door to balloon inflation time
    of 90 minutes
  • These goals may not be relevant for patients with
    an appropriate reason for delay such as
    uncertainty about the diagnosis, life threatening
    conditions (e.g., respiratory failure), or delays
    associated with patients informed failure to
    consent

29
Reperfusion
  • These goals should not be understood as ideal
    times, but the rather the longest times that
    should be considered acceptable
  • Systems that are able to achieve more rapid times
    should be encouraged

30
Selection of Reperfusion Strategy
  • Several issues should be considered in selecting
    the type of reperfusion therapy
  • Time From Onset of Symptoms
  • Risk from STEMI
  • Risk of Bleeding
  • Time Required for Transport to a Skilled PCI
    laboratory

31
Time From Onset of Symptoms
  • Time from onset of symptoms to fibrinolytic
    therapy is an important predictor of MI size and
    patient outcome1
  • The efficacy of fibrinolytic agents for lysing
    thrombus diminishes with time2
  • Fibrinolytic therapy administered within the
    first 2 hours (especially the first hour) can
    occasionally abort MI and dramatically reduce
    mortality3,4
  • 1Boersma, E., et al. Lancet, 1996348771-775
  • 2Zeymer et al. Am Heart J, 199913734-38
  • 3FTT Collaborative Group. Lancet,
    1994343311-322
  • 4Weaver, WD et al. JAMA, 19932701211-1216

32
Time From Onset of Symptoms
  • Conversely, the ability to produce a patent
    infarct artery is much less dependent on symptom
    duration in patients undergoing PCI
  • Several reports claim no influence of time delay
    on mortality rates when PCI is performed after
    2-3 hours of symptom duration1,2
  • However, after adjustment for baseline
    characteristics, time from symptom onset to
    balloon inflation is significantly correlated
    with 1 year mortality in patients undergoing
    primary PCI for STEMI3
  • 1FTT Collaborative Group. Lancet,
    1994343311-322
  • 2Brodie et al. Am J Cardiol, 2001881085-1090
  • 3Williams, D. Circ, 20041091806-1808

33
Risk From STEMI
  • In patients at high risk for adverse outcome from
    STEMI, such as those with cardiogenic shock or
    high TIMI risk score1, compelling evidence exists
    that favors a PCI strategy
  • 1Morrow et al. Circ. 20001022031-2037

34
Risk of Bleeding
  • If both types of reperfusion therapy are
    available, PCI is favored in patients at high
    risk for bleeding
  • If PCI is not available, the risks and benefits
    of fibrinolysis must be weighed

35
Transport Time to PCI Lab
  • For facilities that can offer PCI, the literature
    suggests that this approach is superior to
    fibrinolysis1
  • The trials comparing fibrinolysis to PCI,
    however, were conducted prior to the advent of
    more recent PCI and pharmacologic therapies
  • When a composite end point of death, nonfatal
    recurrent MI, or stroke is analyzed, much of the
    superiority of PCI is driven by the reduction of
    nonfatal recurrent MI2
  • 1Magid et al. JAMA. 20002843131-3138
  • 2Boersma, E., et al. Lancet, 1996348771-775

36
PCI vs. Fibrinolysis 4-6 Weeks
37
PCI vs. Fibrinolysis Long Term
38
Reperfusion Strategy (cont.)
  • As the time delay for performing PCI increases,
    the mortality benefit of PCI over fibrinolysis
    decreases1
  • Compared with a fibrin-specific lytic agent, a
    PCI strategy may not reduce mortality when a
    delay greater than 60 minutes is anticipated vs.
    immediate lytic therapy
  • 1Nallamothu et al. Am J. Cardiol. 200392824-826

39
Reperfusion Strategy (cont.)
  • Given the current literature, it is not possible
    to say definitively that a particular reperfusion
    approach is superior for all patients 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
    patients with suspected STEMI
  • The appropriate and timely use of some
    reperfusion therapy is likely more important than
    the choice of therapy

40
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41
Fibrinolytic Therapy
  • Class I
  • STEMI patients presenting to a facility without
    the capacity for expert, prompt intervention
    (primary PCI with 90 minutes of first medical
    contact) should undergo fibrinolytic therapy.
    (Level of Evidence A)
  • In the absence of contraindications,
    fibrinolytic therapy should be administered to
    STEMI patients with symptom onset within the
    prior 12 hours and ST elevation greater than
    0.1mV in at least 2 contiguous precordial leads
    or at least 2 adjacent limb leads. (Level of
    Evidence A)
  • In the absence of contraindications,
    fibrinolytic therapy should be administered to
    patients with symptom onset within the prior 12
    hours and new or presumably new LBBB. (Level of
    Evidence A)

42
Fibrinolytic Therapy
  • Class IIa
  • In the absence of contraindications, it is
    reasonable to administer fibrinolytic therapy to
    STEMI patients with symptom onset within the
    prior 12 hours and ECG findings consistent with
    true posterior MI. (Level of Evidence C)
  • In the absence of contraindications, it is
    reasonable to administer fibrinolytic therapy to
    patients with symptoms of STEMI beginning within
    the prior 12-24 hours who have continuing
    ischemic symptoms and ST elevation greater than
    0.1mV in at least 2 contiguous precordial leads
    or at least 2 adjacent limb leads. (Level of
    Evidence B)

43
True Posterior MI
44
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45
True Posterior MI
46
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47
True Posterior MI
48
Fibrinolytic Therapy
  • Class III
  • Fibrinolytic therapy should not be administered
    to asymptomatic patients whose initial symptoms
    of STEMI began more than 24 hours earlier. (Level
    of Evidence C)
  • Fibrinolytic therapy should not be administered
    to patients whose ECG shows only ST segment
    depression unless true posterior MI is suspected.
    (Level of Evidence A)

49
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50
Percutaneous Coronary Intervention
  • Class I
  • If immediately available, primary PCI should be
    performed in patients with STEMI (including
    posterior MI), or in patients with new LBBB who
    can undergo PCI of the infarct artery within 12
    hours of onset of symptoms. (Level of evidence
    A)
  • PCI must be performed in a timely fashion (door
    ? balloon time 90 minutes) by persons skilled in
    the procedure (greater than 75/year). (Level of
    evidence A)

51
Percutaneous Coronary Intervention
  • Class I
  • Primary PCI should be performed for patients
    younger than 75 years with STEMI or LBBB who
    develop shock within 36 hours of MI and are
    suitable for revascularization that can be
    performed within 18 hours of shock. (Level of
    Evidence A)
  • Primary PCI should be performed in patients with
    severe CHF and/or pulmonary edema (Killip class
    III) and onset of symptoms within 12 hours. Door
    ? balloon should be within 90 minutes. (Level of
    Evidence B)

52
Percutaneous Coronary Intervention
  • Class IIa
  • Primary PCI is reasonable for patients gt75 yrs
    who develop shock within 36 hours of MI and are
    suitable for revascularization that can be
    performed within 18 hours of shock. (Level of
    Evidence B)
  • It is reasonable to perform primary PCI for
    patients with onset of symptoms in prior 12-24
    hours and severe CHF (Level of Evidence C),
    hemodynamic or electrical instability (Level of
    Evidence C), or persistent ischemic symptoms
    (Level of Evidence C)

53
Percutaneous Coronary Intervention
  • Class III
  • PCI should not be performed in a non-infarct
    artery at the time of PCI in patients without
    hemodynamic compromise. (Level of Evidence C)
  • Primary PCI should not be performed in
    asymptomatic patients more than 12 hours after
    onset of STEMI if they are hemodynamically and
    electrically stable. (Level of Evidence C)
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