This slide set was adapted from the ACC/AHA Guidelines for Management of Patients With ST-Elevation Myocardial Infarction (Journal of the American College of Cardiology 2004;44:671-719, e1-e211 and Circulation 2004;44:671-619, e82-e292) - PowerPoint PPT Presentation

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Title: This slide set was adapted from the ACC/AHA Guidelines for Management of Patients With ST-Elevation Myocardial Infarction (Journal of the American College of Cardiology 2004;44:671-719, e1-e211 and Circulation 2004;44:671-619, e82-e292)


1
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2
  • This slide set was adapted from the ACC/AHA
    Guidelines for Management of Patients With
    ST-Elevation Myocardial Infarction (Journal of
    the American College of Cardiology
    200444671-719, e1-e211 and Circulation
    200444671-619, e82-e292)
  • The full-text guidelines and executive summary
    are also available on the Web sites
  • ACC (www.acc.org) and,
  • AHA (www.americanheart.org)

3
Introduction
  • ACC/AHA Guidelines for the Management of Patients
    with
  • ST-Elevation Myocardial Infarction

4
ACC/AHA Guidelines for the Management of Patients
With ST-Elevation Myocardial Infarction Writing
Committee Members
Elliott M. Antman, MD, FACC, FAHA, Chair
Daniel T. Anbe, MD, FACC, FAHA Paul Wayne
Armstrong, MD, FACC, FAHA Eric R. Bates, MD,
FACC, FAHA Lee A. Green, MD, MPH Mary Hand, MSPH,
RN, FAHA Judith S. Hochman, MD, FACC, FAHA Harlan
M. Krumholz, MD, FACC, FAHA
Frederick G. Kushner, MD, FACC, FAHA Gervasio A.
Lamas, MD, FACC Charles J. Mullany, MB, MS,
FACC Joseph P. Ornato, MD, FACC, FAHA David L.
Pearle, MD, FACC, FAHA Michael A. Sloan, MD,
FACC Sidney C. Smith, Jr., MD, FACC, FAHA
5
Applying Classification of Recommendations and
Level of Evidence
Class I Benefit gtgtgt Risk Procedure/ Treatment SHOULD be performed/ administered Class IIa Benefit gtgt RiskAdditional studies with focused objectives needed IT IS REASONABLE to perform procedure/administer treatment Class IIb Benefit RiskAdditional studies with broad objectives needed Additional registry data would be helpful Procedure/Treatment MAY BE CONSIDERED Class III Risk BenefitNo additional studies needed Procedure/Treatment should NOT be performed/administered SINCE IT IS NOT HELPFUL AND MAY BE HARMFUL
should is recommended is indicated is useful/effective/ beneficial is reasonable can be useful/effective/ beneficial is probably recommended or indicated may/might be considered may/might be reasonable usefulness/effectiveness is unknown /unclear/uncertain or not well established is not recommended is not indicated should not is not useful/effective/beneficial may be harmful
6
Applying Classification of Recommendations and
Level of Evidence
Level A Multiple (3-5) population risk strata evaluated General consistency of direction and magnitude of effect Class I Recommen-dation that procedure or treatment is useful/ effective Sufficient evidence from multiple randomized trials or meta-analyses Class IIa Recommen-dation in favor of treatment or procedure being useful/ effective Some conflicting evidence from multiple randomized trials or meta-analyses Class IIb Recommen-dations usefulness/ efficacy less well established Greater conflicting evidence from multiple randomized trials or meta-analyses Class III Recommen-dation that procedure or treatment not useful/effective and may be harmful Sufficient evidence from multiple randomized trials or meta-analyses
7
Applying Classification of Recommendations and
Level of Evidence
Level B Limited (2-3) population risk strata evaluated Class I Recommen-dation that procedure or treatment is useful/effective Limited evidence from single randomized trial or non-randomized studies Class IIa Recommen-dation in favor of treatment or procedure being useful/ effective Some conflicting evidence from single randomized trial or non-randomized studies Class IIb Recommen-dations usefulness/ efficacy less well established Greater conflicting evidence from single randomized trial or non-randomized studies Class III Recommen-dation that procedure or treatment not useful/effective and may be harmful Limited evidence from single randomized trial or non-randomized studies
8
Applying Classification of Recommendations and
Level of Evidence
Level C Very limited (1-2) population risk strata evaluated Class I Recommen-dation that procedure or treatment is useful/ effective Only expert opinion, case studies, or standard-of-care Class IIa Recommen-dation in favor of treatment or procedure being useful/effective Only diverging expert opinion, case studies, or standard-of-care Class IIb Recommen-dations usefulness/ efficacy less well established Only diverging expert opinion, case studies, or standard-of-care Class III Recommend-ation that procedure or treatment not useful/effective and may be harmful Only expert opinion, case studies, or standard-of-care
9
Pathology
  • ACC/AHA Guidelines for the Management of Patients
    with
  • ST-Elevation Myocardial Infarction

10
Onset of STEMI - Prehospital issues - Initial
recognition and management in the Emergency
Department (ED) - Reperfusion
Hospital Management - Medications -
Arrhythmias - Complications - Preparation for
discharge
Modified from Libby. Circulation 2001104365,
Hamm et al. The Lancet 20013581533 and Davies.
Heart 200083361.
Secondary Prevention/ Long-Term Management
Management Before STEMI
Chronology of the interface between the patient
and the clinician through the progression of
plaque formation and the onset of complications
of STEMI.
1
2
3
4
5
6
4
Presentation
Ischemic Discomfort
Acute Coronary Syndrome
Working Dx
ECG
No ST Elevation
ST Elevation
UA
NSTEMI
Cardiac Biomarker
Unstable Angina
Final Dx
NQMI
QwMI
Myocardial Infarction
11
Prevention of Coronary Heart Disease
(CHD)Campaigns and Statements
  • National Cholesterol Education Program (NCEP)
    Adult Treatment Panel (ATP) III
  • LDL goals, CHD risk equivalent, metabolic
    syndrome
  • Joint National Committee (JNC)-7
  • Hypertension management
  • World Heart Federation (WHF), World Health
    Organization (WHO)
  • Cigarette smoking
  • National Heart, Lung, and Blood Institute
    (NHLBI), Food and Drug Administration (FDA),
    Centers for Disease Control (CDC)
  • Obesity
  • AHA/NHLBI Go Red for Women, AHA Guidelines on
    Prevention of Cardiovascular Disease (CVD) in
    Women
  • Women and CVD

12
Management Before STEMI
  • ACC/AHA Guidelines for the Management of Patients
    with
  • ST-Elevation Myocardial Infarction

13
Identification of Patients at Risk of 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.
14
Identification of Patients at Risk of STEMI
Patients with established CHD or a CHD risk
equivalent (diabetes mellitus, chronic kidney
disease, gt 20 10-year Framingham risk) should be
identified for secondary prevention.
15
Onset of STEMI
  • ACC/AHA Guidelines for the Management of Patients
    with
  • ST-Elevation Myocardial Infarction

16
Patient Education for Early Recognition and
Response to STEMI
Patients should understand their risk of STEMI
and how to recognize symptoms of STEMI.
Patients should understand the advisability of
calling 9-1-1 if symptoms are unimproved or
worsening after 5 minutes.
17
ACT in TIME
If you have any heart attack symptoms, CALL
9-1-1 immediately. Dont wait for more than a
few minutes 5 at most to call 9-1-1.
http//www.nhlbi.nih.gov/actintime/index.htm.
Accessed December 20, 2004.
18
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)
19
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.
20
Instructions for Nitroglycerin Use and EMS
Contact
Has the patient been previously prescribed
nitroglycerin?
No
Is Chest Discomfort/Pain Unimproved or
Worsening 5 Minutes After It Starts?
Yes
No
CALL 9-1-1 IMMEDIATELY.
Notify Physician.
Follow 9-1-1 instructions. Patients may
receive instructions to chew aspirin (162-325 mg)
if not contraindicated or may receive aspirin en
route to the hospital.
21
Instructions for Nitroglycerin Use and EMS
Contact
Has the patient been previously prescribed
nitroglycerin?
Yes
Take ONE Nitroglycerin Dose Sublingually.
Is Chest Discomfort/Pain Unimproved or
Worsening 5 Minutes After Taking ONE
Nitroglycerin Dose Sublingually?
CALL 9-1-1 IMMEDIATELY.
Yes
No
See ACC/AHA Guidelines for the Management of
Patients with Chronic Stable Angina.
Nitroglycerin Dose 0.4 mg sublingually
22
Prehospital Issues
  • ACC/AHA Guidelines for the Management of Patients
    with
  • ST-Elevation Myocardial Infarction

23
Prehospital Issues
  • All public safety first responders trained and
    equipped to provide early defibrillation with
    AEDs.
  • Prehospital aspirin 162 to 325 mg (chewed)
    administration
  • By prehospital providers
  • Advice by dispatchers

24
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

25
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
26
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
27
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.
28
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.

29
Initial Recognition and Management in the
Emergency Department
  • ACC/AHA Guidelines for the Management of Patients
    with
  • ST-Elevation Myocardial Infarction

30
ED Evaluation of Patients With STEMI
Brief Physical Examination in the ED
1. Airway, Breathing, Circulation (ABC) 2.
Vital signs, general observation 3. Presence or
absence of jugular venous distension 4.
Pulmonary auscultation for rales 5. Cardiac
auscultation for murmurs and gallops 6. Presence
or absence of stroke 7. Presence or absence of
pulses 8. Presence or absence of systemic
hypoperfusion (cool, clammy, pale, ashen)
31
ED Evaluation of Patients With STEMI
Differential Diagnosis of STEMI Life-Threatening
Aortic dissection Pulmonary embolus Perforating
ulcer
Tension pneumothorax Boerhaave syndrome
(esophageal rupture with mediastinitis)
32
ED Evaluation of Patients With STEMI
Differential Diagnosis of STEMI Other
Cardiovascular and Nonischemic
LV hypertrophy with strain Brugada
syndrome Myocarditis Hyperkalemia Bundle-branch
blocks Vasospastic angina Hypertrophic
cardiomyopathy
Pericarditis Atypical angina Early
repolarization Wolff-Parkinson-White
syndrome Deeply inverted T-waves suggestive of a
central nervous system lesion or apical
hypertrophic cardiomyopathy
33
ED Evaluation of Patients With STEMI
Differential Diagnosis of STEMI Other Noncardiac
Gastroesophageal reflux (GERD) and
spasm Chest-wall pain Pleurisy Peptic ulcer
disease Panic attack
Cervical disc or neuropathic pain Biliary or
pancreatic pain Somatization and psychogenic pain
disorder
34
Electrocardiogram
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.
35
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.
36
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

37
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.
38
Cardiac Biomarkers in STEMI
100
50
Cardiac troponin-no reperfusion
20
Cardiac troponin-reperfusion
CKMB-no reperfusion
Multiples of the URL
10
CKMB-reperfusion
5
2
Upper reference limit
1
0 1 2 3 4 5 6 7 8
Days After Onset of STEMI
URL 99th tile of Reference Control Group
Alpert et al. J Am Coll Cardiol 200036959. Wu
et al. Clin Chem 1999451104.
39
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.
40
Oxygen
Supplemental oxygen should be administered to
patients with arterial oxygen desaturation (SaO2
lt 90). It is reasonable to administer
supplemental oxygen to all patients with
uncomplicated STEMI during the first 6 hours.
41
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.
42
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.

43
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.
44
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.
45

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.
46
Summary of Trials of Beta-Blocker Therapy
Phase of Treatment
Total No. Patients
RR (95 CI)
Acute treatment
28,970
0.87 (0.77-0.98)
Secondary prevention
24,298
0.77 (0.70-0.84)
Overall
53,268
0.81 (0.75-0.87)
2
1
0.5
Relative risk (RR) of death
Placebo better
Beta blocker better
Antman E, Braunwald E. Acute Myocardial
Infarction. In Braunwald E, Zipes DP, Libby P,
eds. Heart Disease A textbook of Cardiovascular
Medicine, 6th ed., Philadelphia, PA W.B.
Sanders, 2001, 1168.
47
Reperfusion
  • 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

48
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.
49
Reperfusion
Patient
Transport
Inhospital
Reperfusion
Goals
D-N 30 min
5 min
lt 30 min
D-B 90 min
Methods of Speeding Time to Reperfusion


Media campaign Patient education
Prehospital ECG
MI protocol Critical pathway Quality improvement
program
Bolus lytics Dedicated PCI team
Greater use of 9-1-1 Prehospital Rx
50
Treatment Delayed is Treatment Denied
Cath Lab
Symptom Recognition
Call to Medical System
ED
PreHospital
Increasing Loss of Myocytes
Delay in Initiation of Reperfusion Therapy
51
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.
52
Overview of PCI vs Lysis Issues to Consider
  • Sample Size 7739
  • Data span 1015 years
  • Selection bias of pts enrolled
  • 2 mortality benefit with PCI depends on lytic
    (not significant vs tPA if SHOCK is excluded)
  • Composite endpoint is driven by reMI potential
    biases against lytic arms Hard to diagnose
    peri-PCI MI UFH used in lytic arms--? Better
    antithrombins Dependent on use of PCI post-lysis

JACC 200444 671.Circulation 2004110 588.
53
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.
54
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

55
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)

56
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

57
PCI versus Fibrinolysis with Fibrin-Specific
Agents Is Timing (Almost) Everything?
10 -
13 RCTs
N 5494
P 0.04
5 -
Absolute Risk Difference in Death ()
Favors PCI
0 -
Favors fibrinolysis with a fibrin-specific agent
-5 -
-
-
-
-
-
-
  1. 40 50
    60 70 80

PCI-Related Time Delay (minutes)
Nallamothu and Bates. Am J Cardiol 200392824.
58
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.
59
Reperfusion Options for STEMI PatientsStep One
Assess Time and Risk.
Risk of Fibrinolysis
Time Since Symptom Onset
Time Required for Transport to a Skilled PCI Lab
Risk of STEMI
60
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

61
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

62
PCI vs Lysis Additional Data
  • Mortality advantage of PCI diminishes As risk
    with lytic decreases PCI Lysis at 3 With
    increasing delay PCI Fibrin spec lytic with
    60 min delay RR 1.08 for every 30 min from
    onset of sx The earlier patient is seen PCI
    Lysis in lt 3 h from sx
  • Outcomes with PCI are influenced by time of day
    and operator/institution volume and experience
  • Trials of transfer for PCI Had very short
    transport and D-B times PCI mortality higher
    than prehospital lysis in pts treated early
    (2h)

JACC 200444 671Circ 2004110 588
63
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).
64
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.
65
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.
66

Evolution of PCI for STEMI
AngioJet
ASA
Clopidogrel
Platelet
GP IIb/IIIa inhibitor
Embolization Protection Device
Thrombus Removal and Distal Embolization
Protection Devices
Balloon
Antiplatelet Rx
Stent
DES
Antman. Circulation 20011032310.
67
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

68
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.
69
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.
70
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.
71
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.
72

Rescue 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.
73

Rescue 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.
IIa
IIb
III
IIa
IIb
III
IIa
IIb
III
IIa
IIb
III
I
IIa
IIb
III
I
IIa
IIb
III
I
IIa
IIb
III
IIa
IIb
III
I
I
IIa
IIb
III
I
I
IIa
IIb
III
I
I
IIa
IIb
III
IIa
IIb
III
74

PCI for Cardiogenic Shock
Primary 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.
75
PCI for Cardiogenic Shock
Cardiogenic Shock
Early Shock, Diagnosed on Hospital Presentation
Fibrinolytic therapy if all of the following are
present 1. Greater than 90 minutes to
PCI 2. Less than 3 hours post STEMI onset 3. No
contraindications Arrange prompt transfer to
invasive procedure-capable center
IABP
76
PCI for Cardiogenic Shock
Cardiogenic Shock
Early Shock, Diagnosed on Hospital Presentation
Delayed Onset Shock Echocardiogram to Rule Out
Mechanical Defects
Fibrinolytic therapy if all of the following are
present 1. Greater than 90 minutes to
PCI 2. Less than 3 hours post STEMI onset 3. No
contraindications Arrange prompt transfer to
invasive procedure-capable center
Arrange rapid transfer to invasive
procedure-capable center
IABP
77
PCI for Cardiogenic Shock
Cardiogenic Shock
Early Shock, Diagnosed on Hospital Presentation
Delayed Onset Shock Echocardiogram to Rule Out
Mechanical Defects
Fibrinolytic therapy if all of the following are
present 1. Greater than 90 minutes to
PCI 2. Less than 3 hours post STEMI onset 3. No
contraindications Arrange prompt transfer to
invasive procedure-capable center
Arrange rapid transfer to invasive
procedure-capable center
IABP
Cardiac Catheterization and Coronary Angiography
1-2 vessel CAD
Moderate 3-vessel CAD
Severe 3-vessel CAD
Left main CAD
PCI IRA
PCI IRA
Immediate CABG
Cannot be performed
Staged Multivessel PCI
Staged CABG
78

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.

79

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.
80

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.

81
Ancillary 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.

82

Ancillary Therapy to Reperfusion
Platelet counts should be monitored daily in
patients taking UFH.
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.
83

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.
84

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.

85

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.
86

Thienopyridines
Clopidogrel is probably indicated in patients
receiving fibrinolytic therapy who are unable to
take aspirin because of hypersensitivity or
gastrointestinal intolerance.
87

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.
88
Other Pharmacological Measures
  • Angiotensin converting enzyme (ACE)
  • inhibitors
  • Angiotensin receptor blockers (ARB)
  • Aldosterone blockers
  • Glucose control
  • Magnesium
  • Calcium channel blockers

Inhibition of the renin -angiotensin -aldosterone
system
89
All-Cause Mortality
TRACEEchocardiographicEF 35
AIREClinical and/or radiographic signs of HF
SAVERadionuclideEF 40
Probability of Event
Placebo 866/2971 (29.1)
ACE-I 702/2995 (23.4)
OR 0.74 (0.660.83)
Years
ACE-I 2995 2250 1617 892 223
Placebo 2971 2184 1521 853 138
Flather MD, et al. Lancet. 200035515751581
90
Mortality by Treatment
0.3
0.25
0.2
0.15
Probability of Event
0.1
0.05
Valsartan vs. Captopril HR 1.00 P 0.982
Valsartan Captopril vs. Captopril HR 0.98 P
0.726
0
Months
0
6
12
18
24
30
36
Captopril 4909 4428 4241 4018 2635 1432 364

Valsartan 4909 4464 4272 4007 2648 1437 357
Valsartan Cap 4885 4414 4265 3994 2648 1435 382
Pfeffer, McMurray, Velazquez, et al. N Engl J Med
2003349
91
EPHESUS All-Cause Mortality
P 0.008RR 0.85 (95 CI, 0.750.96)
Eplerenone 3319 3044 2463 1260 336 0 0
Placebo 3313 2983 2418 1213 323 2 0
Pitt et al. N Engl J Med 20033481309-1321
92

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.
93

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).
94

Strict 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.
95
Hospital Management
  • ACC/AHA Guidelines for the Management of Patients
    with
  • ST-Elevation Myocardial Infarction

96
Sample Admitting Orders for the Patient 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
97
Sample Admitting Orders for the Patient 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 lt 90). Consider discontinuing if O2
saturation is gt 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
98
Emergency Management of Complicated STEMI
Clinical signs Shock, hypoperfusion, congestive
heart failure, acute pulmonary edema Most likely
major underlying disturbance?
Arrhythmia
Low Output - Cardiogenic Shock
Hypovolemia
Acute Pulmonary Edema
  • 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

Bradycardia
Tachycardia
  • Administer
  • Fluids
  • Blood transfusions
  • Cause-specific interventions
  • Consider vasopressors

Check Blood Pressure
First line of action
See Section 7.7 in the ACC/AHA Guidelines for
Patients With ST-Elevation Myocardial Infarction
Check Blood Pressure
Systolic BP Greater than 100 mm Hg
Systolic BP 70 to 100 mm Hg NO signs/symptoms of
shock
Systolic BP 70 to 100 mm Hg Signs/symptoms of
shock
Systolic BP less than 70 mm Hg Signs/symptoms of
shock
Systolic BP Greater than 100 mm Hg and not less
than 30 mm Hg below baseline
Second line of action
Norepinephrine 0.5 to 30 mcg/min IV
Dobutamine 2 to 20 mcg/kg per minute IV
Nitroglycerin 10 to 20 mcg/min IV
Dopamine 5 to 15 mcg/kg per minute IV
ACE Inhibitors Short-acting agent such as
captopril (1 to 6.25 mg)
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
Circulation 2000102(suppl I)I-172-I-216.
Third line of action
99
Right Ventricular Infarction
Clinical findingsShock with clear lungs,
elevated JVPKussmaul sign Hemodynamics
Increased RA pressure (y descent)Square root
sign in RV tracing ECGST elevation in R sided
leads EchoDepressed RV function RxMaintain RV
preloadLower RV afterload (PA---PCW)Inotropic
supportReperfusion
V4R
Modified from Wellens. N Engl J Med 1999340381.
100
Ventricular Septal Rupture
Mitral Regurgitation(Pap. M. dysfunction)
Free WallRupture
Incidence 1-2 1-6 1-2Timing 3-5 d p
MI 3-6 d p MI 3-5 d p MIPhy Exam murmur
90 JVD, EMD murmur 50Thrill Common
No RareEcho Shunt Peric.
Effusion Regurg. JetPA cath O2 step up
Diast Press Equal. c-v wave in PCW
ImagesCourtesy of W D Edwards (Mayo
Foundation)Data Lavocitz. CV Rev Rpt
19845948 Birnbaum. NEJM 20023471426.
101
Warning Arrhythmias
Antman and Rutherford. Coronary Care Medicine.
Boston, MA Martinus Nijhoff Publishing198681.
102
Arrhythmias During Acute Phase of STEMI
Electrical Instability
Arrhythmia Treatment
VPBs K , Mg, beta blocker VT Antiarrhythmics,
DC shock AIVR Observe unless hemodynamic compromis
e NPJT Search for cause (e.g., dig toxicity)
103
Arrhythmias During Acute Phase of STEMI Pump
Failure / Excess Sympathetic Tone
Arrhythmia Treatment
Sinus Tach Treat cause beta blocker Afib /
Flutter Treat cause slow ventricular rate DC
shock PSVT Vagal maneuvers beta blocker,
verapamil / diltiazem DC shock
104
Arrhythmias During Acute Phase of STEMI
Bradyarrhythmias
Arrhythmia Treatment
Sinus Brady Treat if hemodynamic
compromise atropine / pacing Junctional Treat
if hemodynamic compromise atropine / pacing

105
Arrhythmias During Acute Phase of STEMI AV
Conduction Disturbances
Proximal Distal
Escape Rhythm His Bundle Distal lt 120 ms gt 120
ms 45 - 60 Often lt 30 Duration of AVB 2 - 3
days Transient Mortality Low High (CHF,
VT) Rx Observe PM (ICD)
106
Recommendations for Treatment of Atrioventricular
and Intraventricular Conduction Disturbances
During STEMI
107
ICD Trials in Post-MI Patients
NEJM 19963351933-40. NEJM 19993411882-90. NEJM
2002346877-93.
108
ICD Implantation After STEMI
One Month After STEMI No Spontaneous VT or VF
48 hours post-STEMI
EF lt 0.30
EF 0.31 - 0.40

EF gt 0.40
No
Yes
EPS

-
NEJM 349 1836,2003
109
Algorithm for Management of Recurrent
Ischemia/Infarction After STEMI
Recurrent ischemic
-
type discomfort at rest after STEMI
Recurrent ischemic
-
type discomfort at rest after STEMI

Escalation of medical therapy (nitrates, beta
-

Escalation of medical therapy (nitrates, beta
-
blockers)
blockers)

Anticoagulation if not already given

Anticoagulation if not already given

Consider IABP for hemodynamic instability,

Consider IABP for hemodynamic instability,
poor LV function, or a large area of
poor LV function, or a large area of
Obtain 12
-
lead ECG
Obtain 12
-
lead ECG
myocardium at risk
myocardium at risk

Correct secondary causes of ischemia

Correct secondary causes of ischemia
ST
-
segment elevation?
ST
-
segment elevation?
ST
-
segment elevation?
110
Algorithm for Management of Recurrent
Ischemia/Infarction After STEMI
Recurrent ischemic
-
type discomfort at rest after STEMI
Recurrent ischemic
-
type discomfort at rest after STEMI

Escalation of medical therapy (nitrates, beta
-

Escalation of medical therapy (nitrates, beta
-
blockers)
blockers)

Anticoagulation if not already given

Anticoagulation if not already given

Consider IABP for hemodynamic instability,

Consider IABP for hemodynamic instability,
poor LV function, or a large area of
poor LV function, or a large area of
Obtain 12
-
lead ECG
Obtain 12
-
lead ECG
myocardium at risk
myocardium at risk

Correct secondary causes of ischemia

Correct secondary causes of ischemia
ST
-
segment elevation?
ST
-
segment elevation?
ST
-
segment elevation?
YES
YES
Is patient
Is patient
Is patient
a candidate for
a candidate for
a candidate for
revascularization
?
revascularization
?
revascularization
?
YES
NO
YES
NO
Can
Can
Can
Consider (re)
Consider (re) administration
catheterization
catheterization
catheterization
administration of
of fibrinolytic therapy
be performed promptly?
be performed promptly?
be performed promptly?
Modified from Braunwald. Heart Disease A
Textbook of Cardiovascular Medicine. 6th ed.
Philadelphia, PA WB Saunders Co. Ltd. 20011195.
YES
YES
NO
NO
Coronary
Coronary
Consider (re) administration
angiography
angiography
of fibrinolytic therapy
Revascularization with PCI
Revascularization with PCI
and/or CABG as dictated by
and/or CABG as dictated by
anatomy
anatomy
111
Algorithm for Management of Recurrent
Ischemia/Infarction After STEMI
Recurrent ischemic
-
type discomfort at rest after STEMI
Recurrent ischemic
-
type discomfort at rest after STEMI

Escalation of medical therapy (nitrates, beta
-

Escalation of medical therapy (nitrates, beta
-
blockers)
blockers)

Anticoagulation if not already given

Anticoagulation if not already given

Consider IABP for hemodynamic instability,

Consider IABP for hemodynamic instability,
poor LV function, or a large area of
poor LV function, or a large area of
Obtain 12
-
lead ECG
Obtain 12
-
lead ECG
myocardium at risk
myocardium at risk

Correct secondary causes of ischemia

Correct secondary causes of ischemia
ST
-
segment elevation?
ST
-
segment elevation?
ST
-
segment elevation?
YES
NO
YES
NO
Is patient
Is ischemia
Is patient
Is patient
Is ischemia
Is ischemia
a candidate for
controlled by escalation
a candidate for
a candidate for
controlled by escalation
controlled by escalation
revascularization
?
of medical therapy?
revascularization
?
revascularization
?
of medical therapy?
of medical therapy?
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
Refer for
Refer for urgent
Refer for
Refer for urgent
Refer for
Refer for urgent
nonurgent
catheterization (consider
Can
nonurgent
catheterization (consider
nonurgent
catheterization (consider
Can
Can
Consider (re)
Consider (re) administration
catheterization
IABP)
catheterization
catheterization
IABP)
catheterization
IABP)
catheterization
catheterization
administration of
of fibrinolytic therapy
be performed promptly?
be performed promptly?
be performed promptly?
Modified from Braunwald. Heart Disease A
Textbook of Cardiovascular Medicine. 6th ed.
Philadelphia, PA WB Saunders Co. Ltd. 20011195.
YES
YES
NO
NO
Coronary
Coronary
Consider (re) administration
angiography
angiography
of fibrinolytic therapy
Revascularization with PCI
Revascularization with PCI
and/or CABG as dictated by
and/or CABG as dictated by
anatomy
anatomy
112
Evidence-Based Approach to Need for
Catheterization and Revascularization After STEMI
STEMI
STEMI
Primary Invasive Strategy
Fibrinolytic Therapy
No Reperfusion Therapy
Primary Invasive Strategy
Fibrinolytic Therapy
No Reperfusion Therapy
Cath
No Cath
Cath
No Cath
EF less
EF greater
EF less
EF greater
Performed
Performed
Performed
Performed
than 0.40
than 0.40
than 0.40
than 0.40
EF greater
EF less
EF greater
EF less
High
-
Risk
No High
-
Risk
High
-
Risk
No High
-
Risk
than 0.40
than 0.40
than 0.40
than 0.40
Features

Features
Features

Features
Catheterization and
Catheterization and
Revascularization as
Revascularization as
No High
-
Risk
High
-
Risk
No High
-
Risk
High
-
Risk
Indicated
Indicated
Features

Features

Features
Features
Revascularization as
Revascularization as
Functional
Functional
Indicated
Indicated
Evaluation
Evaluation
ECG Interpretable
ECG Uninterpretable
ECG Interpretable
ECG Uninterpretable
Unable to Exercise
Unable to Exercise
Able to Exercise
Able to Exercise
Able to Exercise
Able to Exercise
Pharmacological Stress
Pharmacological Stress
Submaximal
Submaximal
Symptom
-
Limited
Symptom
-
Limited
Adenosine
Exercise
Exercise
Exercise
Exercise
Dobutamine
Dobutamine
Exercise Test
Exercise Test
Exercise Test
Exercise Test
or Dipyridamole
Echo
Nuclear
Echo
Nuclear
Echo
Echo
Before Discharge
Before or After Discharge
Before Discharge
Before or After Discharge
Nuclear Scan
Catheterization and
Catheterization and
Clinically Significant
No Clinically Significant
Medical
Clinically Significant
No Clinically Significant
Medical
Revascularization as
Revascularization as
Ischemia
Ischemia
Therapy
Ischemia
Ischemia
Therapy
Indicated
Indicated
113
Long-Term Antithrombotic Therapy at Hospital
Discharge After STEMI
STEMI Patient at Discharge
No Stent Implanted
No ASA allergy
ASA Allergy
Indications for Anticoagulation
No Indications for Anticoagulation
No Indications for Anticoagulation
Indications for Anticoagulation
Preferred ASA 75 to 162 mg Class I LOE A
Preferred Clopidogrel 75 mg Class I LOE C
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
Warfarin INR (2.5 to 3.5) Class I LOE B
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
114
Long-Term Antithrombotic Therapy at Hospital
Discharge After STEMI
STEMI Patient at Discharge
Stent Implanted
No ASA Allergy
ASA Allergy
No Indications for Anticoagulation
Indications for Anticoagulation
Indications for Anticoagulation
No Indications for Anticoagulation
ASA 75 to 162 mg Clopidogrel 75 mg Class I LOE
B
ASA 75 to 162 mg Clopidogrel 75 mg Warfarin (INR
2.0 to 3.0) Class IIb LOE C
Clopidogrel 75 mg Class I LOE B
Clopidogrel 75 mg Warfarin (INR 2.0 to
3.0) Class I LOE C
115
Long-Term Management
  • ACC/AHA Guidelines for the Management of Patients
    with
  • ST-Elevation Myocardial Infarction

116
Goals Recommendations
  • 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
117
Goals Recommendations
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 lt 140/90 mm Hg or
lt130/80 mm Hg if chronic kidney disease or
diabetes
118
Goals Recommendations
  • 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
119
Goals Recommendations
  • Start dietary therapy in all patients (lt 7 of
    total calories as saturated fat and lt 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 ltlt than 100 mg/dL
LDL-C lt 100 mg/dL (baseline or on
treatment) Statins should be used to lower
LDL-C. LDL-C 100 mg/dL (baseline or
on treatment) Intensify LDL-Clowering therapy
with drug treatment, giving preference to statins.
120
If TGs are 150 mg/dL or HDL-C is lt 40
mg/dL Emphasize weight management and physical
activity. Advise smoking cessation. If TG is 200
to 499 mg/dL After LDL-Clowering therapy,
consider adding fibrate or niacin. If TG is
500 mg/dL Consider fibrate or niacin before
LDL-Clowering therapy. Consider omega-3 fatty
acids as adjunct for high TG.
Lipid management (TG 200 mg/dL or
greater) Primary goal NonHDL-C ltlt 130 mg/dL
121
Weight management Goal BMI 18.5 to 24.9
kg/m2 Waist circumference Women lt 35 in. Men
lt 40 in.
Calculate 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.
122
Goals Recommendations
Appropriate 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 lt 7
123
Goals Recommendations
  • 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
124
Goals Recommendations
Renin-Angiotensin-Aldosterone System Blockers
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 lt 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 lt 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.
125
Goals Recommendations
Start in all patients. Continue indefinitely.
Observe usual contraindications.
Beta- Blockers
126
Summary of Pharmacologic Rx Ischemia
1st 24 h During Hosp Hosp DC Long Term
Aspirin 162-325 mgchewed 75-162 mg/d p.o. 75-162 mg/d p.o.
Fibrinolytic tPA,TNK,rPA, SK
UFH 60U/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
JACC 2004
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