ACC/AHA Guidelines for the Management of Patients with

1

• ACC/AHA Guidelines for the Management of Patients
  with
• ST-Elevation Myocardial Infarction

2
Applying Classification of Recommendations and
Level of Evidence
3
Patient Education for Early Recognition and
Response to STEMI
Healthcare providers should instruct patients
previously prescribed nitroglycerin (NTG) on use
for chest discomfort or pain and to call 9-1-1 if
symptoms do not improve or worsen 5 minutes after
ONE sublingual NTG dose. ( Nitroglycerin Dose
0.4 mg sublingually)
4
Prehospital Chest Pain Evaluation and 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 nonenteric-coated
formulations.
It is reasonable for all 9-1-1 dispatchers to
advise patients without a history of aspirin
allergy who have symptoms of STEMI to chew
aspirin (162 to 325 mg) while awaiting arrival of
prehospital EMS providers. Although some trials
have used enteric-coated aspirin for initial
dosing, more rapid buccal absorption occurs with
nonenteric-coated formulations.
5
Prehospital Issues

• Prehospital 12-lead ECG by ACLS
• Prehospital fibrinolysis
• Reperfusion checklist by ACLS providers that is
  relayed with the ECG to a predetermined medical
  control facility and/or receiving hospital

6
Prehospital Issues
Prehospital destination protocols Patients with
STEMI who have cardiogenic shock and are lt75 yrs
old should be brought immediately or secondarily
transferred to facilities capable of cardiac
catheterization and rapid revascularization with
18 hrs of shock
7
Prehospital Issues
Prehospital destination protocols Patients with
STEMI who have contraindications to fibrinolytic
therapy should be brought immediately or
secondarily transferred promptly
(primary-receiving hospital door-to-departure
time less than 30 min.) to facilities capable of
cardiac catheterization and rapid
revascularization
8
Options for Transport of Patients With STEMI and
Initial Reperfusion Treatment
Hospital fibrinolysis Door-to-Needle within
30 min.
Not PCI capable
Call 9-1-1 Call fast

• EMS on-scene
• Encourage 12-lead ECGs.
• Consider prehospital fibrinolytic if capable and
  EMS-to-needle within 30 min.

Onset of symptoms of STEMI
9-1-1 EMS Dispatch
EMS Triage Plan
Inter-Hospital Transfer
PCI capable
GOALS
5 min.
8 min.
EMS Transport
Patient
EMS
Prehospital fibrinolysis EMS-to-needle within 30
min.
EMS transport EMS-to-balloon within 90
min. Patient self-transport Hospital
door-to-balloon within 90 min.
Dispatch 1 min.
Golden Hour first 60 min.
Total ischemic time within 120 min.
9
Options for Transport of Patients With STEMI and
Initial Reperfusion Treatment

• 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.

10
Electrocardiogram
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.
11
Laboratory 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

12
Biomarkers of Cardiac Damage
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.
13
Imaging
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.
14
Nitroglycerin
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.
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Nitroglycerin
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 lt 90 mm Hg or to 30 mm Hg
  below baseline
• severe bradycardia (lt 50 bpm)
• tachycardia (gt 100 bpm) or
• suspected RV infarction.

16
Analgesia
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.
17
Aspirin
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 nonenteric-coated
formulations.
18

Beta-Blockers
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.
19
Reperfusion
The medical system goal is to facilitate rapid
recognition and treatment of patients with STEMI
such that door-to- needle (or medical
contactto-needle) time for initiation of
fibrinolytic therapy can be achieved within 30
minutes or that door-to-balloon (or medical
contactto- balloon) time for PCI can be kept
within 90 minutes.
20
Symptom Onset to Balloon Time and Mortality in
Primary PCI for STEMI
6 RCTs of Primary PCI by Zwolle Group 1994
2001N 1791
12 10 8 6 4 2 0
P lt 0.0001
One-year mortality,
RR 1.08 1.01 1.16 for each 30 min delay(P
0.04)
0 60 120 180 240 300 360
Symptoms to balloon inflation (minutes)
DeLuca et al. Circulation 20041091223.
21
PCI vs Fibrinolysis for STEMI Short Term
Clinical Outcomes
PCI
P lt 0.0001
Fibrinolysis
P lt 0.0001
Frequency ()
P0.0002
P lt 0.0001
P0.0003
P0.032
P0.0004
P lt 0.0001
Death
Death, no SHOCKdata
Recurr. MI
Recurr.Ischemia
Total Stroke
Hemorrh.Stroke
Major Bleed
DeathMICVA
N 7739
Keeley et al. The Lancet 200336113.
22
Contraindications and Cautions for Fibrinolysis
in STEMI

• 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 hours

Absolute Contraindications
NOTE Age restriction for fibrinolysis has been
removed compared with prior guidelines.
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Contraindications and Cautions for 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 Cautions for Fibrinolysis
in STEMI
Relative Contraindications

• History of chronic, severe, poorly controlled
  hypertension
• Severe uncontrolled hypertension on presentation
  (SBP gt 180 mm Hg or DBP gt 110 mm Hg)
• History of prior ischemic stroke greater than 3
  months, dementia, or known intracranial pathology
  not covered in contraindications
• Traumatic or prolonged (gt 10 minutes) CPR or
  major surgery (lt 3 weeks)

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Contraindications and Cautions for Fibrinolysis
in STEMI
Relative Contraindications

• Recent (lt 2 to 4 weeks) internal bleeding
• Noncompressible vascular punctures
• For streptokinase/anistreplase prior exposure (gt
  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 Patients Step 2
Select Reperfusion Treatment.
If presentation is lt 3 hours and there is no
delay to an invasive strategy, there is no
preference for either strategy.

• 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
• ? gt 1 hour vs fibrinolysis (fibrin-specific
  agent) now

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Reperfusion Options for STEMI Patients Step 2
Select Reperfusion Treatment.
If presentation is lt 3 hours and there is no
delay to an invasive strategy, there is no
preference for either strategy.

• Invasive strategy generally preferred
• Skilled PCI lab available with surgical backup
  ? Door-to-balloon lt 90 minutes
• High Risk from STEMI ? Cardiogenic shock,
  Killip class 3
• Contraindications to fibrinolysis, including
• increased risk of bleeding and ICH
• Late presentation ? gt 3 hours from symptom
  onset
• Diagnosis of STEMI is in doubt

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Fibrinolysis
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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Fibrinolysis
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 gt 0.1 mV in 2
contiguous precordial leads or 2 adjacent limb
leads.
30
Fibrinolysis
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.
31
Primary PCI for STEMI General 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
  gt 75 procedures per year)
• Appropriate lab environment (lab performs gt 200
  PCIs/year of which at least 36 are primary PCI
  for STEMI)
• Cardiac surgical backup available

32
Primary PCI for STEMI Specific Considerations
Medical contactto-balloon or door-to-balloon
should be within 90 minutes.
PCI preferred if gt 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.
33
Primary PCI for STEMI Specific 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 Specific 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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Primary PCI for STEMI Specific Considerations
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.
36

PCI 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.

37

PCI After Fibrinolysis
It is reasonable to perform routine PCI in
patients with left ventricular ejection fraction
(LVEF) 0.40, CHF, or serious ventricular
arrhythmias.
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 gt 0.40).
Routine PCI might be considered as part of an
invasive strategy after fibrinolytic therapy.
38

Assessment 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.

39

Aspirin
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.
40

Thienopyridines
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.

41

Thienopyridines
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.
42

Glycoprotein 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.
43

ACE/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 lt 0.40

An ARB should be given to ACE-intolerant patients
with either clinical or radiological signs of HF
or LVEF lt 0.40.
44

ACE/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 lt 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).
45
Summary of Pharmacologic Rx Ischemia
JACC 200444 671Circulation 2004110 588
46
Summary of Pharmacologic Rx LVD, Sec. Prev.,
JACC 200444671Circ 2004110588
47
What to do at EJCH ?

• RUSH HOUR OR CARDIOGENIC SHOCK 6 10 AM 4
  7 PM
• Drip and ship Give Lytics and Airlift to
  EMORY HOSPITAL
• NON RUSH HOUR e.g. 2 AM
• Drip and ship Give lytics and ship by
  ambulance to EMORY HOSPITAL