Title: ACCAHA Guidelines for the Management of Patients with ST Elevation Myocardial Infarction 2004
1ACC/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
2Participants in Updated Guidelines
3Evidence 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
4How Should We Be Dealing With This?
5ACC/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 -
6ACC/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
7Epidemiology
- In the U.S., there were 1,680,000 discharges for
ACS in the year 2001 - Approximately 500,000 of these were STEMIs
8Prehospital 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)
9Initial 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
10Targeted 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
11Physical 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)
12ECG
- 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)
13Inferior Infarct
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15Right Sided Leads
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17Inferior/RV Infarct
18Laboratory 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)
19ECG
- 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
20Imaging
- 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)
21Initial 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)
22Initial 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)
23Initial 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
24Initial 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)
25Initial 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
26Initial 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)
27Reperfusion
- 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)
28Reperfusion
- 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
29Reperfusion
- 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
30Selection 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
31Time 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
32Time 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
33Risk 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
34Risk 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
35Transport 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
36PCI vs. Fibrinolysis 4-6 Weeks
37PCI vs. Fibrinolysis Long Term
38Reperfusion 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
39Reperfusion 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
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41Fibrinolytic 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)
42Fibrinolytic 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)
43True Posterior MI
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45True Posterior MI
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47True Posterior MI
48Fibrinolytic 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) -
-
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50Percutaneous 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)
51Percutaneous 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)
52Percutaneous 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)
53Percutaneous 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) -