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Evidence Based Strategies for Acute Myocardial Infarction Care: STEMI. Scott A. Sample DO, FACC Cardiovascular Interventionist April 2010. Why a Systems Approach to Acute Coronary Syndrome Care?.

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Evidence based strategies for acute myocardial infarction care stemi l.jpg

Evidence Based Strategies for Acute Myocardial Infarction Care:STEMI

Scott A. Sample DO, FACC

Cardiovascular Interventionist

April 2010


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Why a Systems Approach to Acute Coronary Syndrome Care?

  • Therapy for ACS has been well studied and validated. Standardized protocols for treatment are evidence based and readily available.

  • A systems approach results in improved adherence to evidence based treatment strategies. These strategies improve patient outcomes and survival.

  • A systems approach provides a scaffold for program development and real time feedback measurements that can be used to improve care.

  • A systems approach encourages providers across the entire continuum of care to place focus on the patient.


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Evidence Based Strategies for Acute Myocardial Infarction Care

Pre-hospital Care/Diagnosing Acute Coronary Syndromes

Acute Myocardial Infarction in the rural hospital setting

STEMI Treatment/Transfer Thrombolytics/Anticoagulants/Beta Blockers

American College of Cardiology Website

ACC/AHA STEMI and non-STEMI guidelines


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Pre-Hospital Care

Patients with chest pain suspicious for acute coronary syndromes should undergo the following:

Activation of EMS LOE* B

Aspirin 162-325mg chewed and swallowed (Unless already self administered by patient) LOE A

12 Lead EKG, if available in the field LOE B

Rapid stabilization and transfer to Emergency Department (Unless care pathways for Acute MI PCI direct to the catheterization laboratory are in place) LOE A

* LOE = Level of Evidence


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ACS Recognition

Upon arrival to the Emergency Department, 12 lead EKG (10 minutes) LOE B

Initiate continuous EKG monitoring, oximetry, and frequent vital sign monitoring LOE B

Establish IV access with two large bore peripheral IVs

Once ACS is suspected/established, initiate aspirin, oxygen, nitrates and morphine


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ACS Risk Stratification

Obtain Baseline laboratory markers including a CBC, Metabolic Panel and Cardiac Markers

If the initial EKG is nondiagnostic, repeat every 15-30 minutes

Assess cardiac risk factors


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Assessment of Risk

Identify chest pain into 4 groups

Non-cardiac Pain

Stable Angina

Possible Acute Coronary Syndrome

Definite Acute Coronary Syndrome


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Evidence Based Strategies for Acute Myocardial Infarction Care

Pre-hospital Care/Diagnosing Acute Coronary Syndromes

Acute Myocardial Infarction in the rural hospital setting

STEMI Treatment/Transfer Thrombolytics/Anticoagulants/Beta Blockers

American College of Cardiology Website

ACC/AHA STEMI and non-STEMI guidelines


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Approach For Acute Coronary Syndrome for Critical Access Hospitals: STEMI


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Thrombolytic Therapy Indications

Presentation consistent with signs and symptoms of AMI

Time of symptom onset 12 hours or less

ST elevation > 1mm in 2 or more contiguous leads

New Left Bundle Branch Block

True Posterior Wall MI


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Contraindications to Thrombolytics

Known prior hemorrhagic CVA

IC trauma

Active internal bleeding

Suspected aortic dissection


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Cautions to Thrombolytics

Persistent BP ≥ 180/110mmHG

Prior cerebrovascular accident/intracerebral pathology

Current use of anticoagulants in therapeutic doses

Trauma or surgery within 2 weeks


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Noncompressible vascular punctures

Recent (within 2-4 weeks) internal bleeding

Pregnancy

Active peptic ulcer disease

History of chronic severe hypertension

Cautions to Thrombolytics cont.


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Thrombolytic Agents

Alteplase

15mg bolus

Then 0.75mg/kg IV drip over 30 minutes (not to exceed 50mg)

Then 0.5mg/kg over next 60 minutes (not to exceed 35mg)

Maximum dose 100mg

This agent requires concurrent administration of heparin or alternative agent


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Thrombolytic Agents

Reteplase

First bolus 10U over 2 minutes

30 minutes later, second bolus 10U over 2 minutes

Heparin (or alternative agent) and aspirin required adjuncts


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Thrombolytic Agents

Tenecteplase

30-50mg weight adjusted IV bolus; see package insert for dosing scale

Heparin (or alternative agent) and aspirin are required adjuncts


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STEMI Unfractionated Heparin Adjunctive Therapy

Initial bolus 60 IU/kg, Maximum 4,000 IU

12 IU/kg/hr drip, Maximum 1,000 IU/hr

Monitor PTT, Hemoglobin, Hematocrit and Platelet count per institutional protocol


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STEMI Low Molecular Weight Heparin Adjunctive Therapy

Enoxaparin

Age <75 with normal creatinine clearance: bolus 30mg IV; 15 minutes later, 1mg/kg SQ every 12 hours

Age >75 no IV bolus; 0.75mg/kg SQ every 12 hours

Creatinine Clearance <30mL/min, regardless of age, 1mg/kg SQ every 24 hours

Monitor Hemoglobin, Hematocrit and Platelets


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STEMI Fondaparinux Adjunctive Therapy

Initial Dose 2.5mg/kg IV

Subsequent dose 2.5mg/kg SQ every 24 hours for up to 8 days

Do not use in patients with creatinine clearance of less than 30mL/min

Do not use as monotherapy in patients undergoing PCI


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STEMI Beta Blocker Use

  • Class Ib

    • Oral beta blocker (ie metoprolol 25 mg po) unless contraindicated by the following

      • Acute heart failure

      • Low cardiac output state

      • Increased risk of cardiogenic shock

      • PR interval >0.24 seconds, second degree or third degree heart block

  • Class II

    • IV beta blocker for hypertensive patients that do not have the above exclusion criteria


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Additional Therapeutics

  • Aspirin 162-325mg, if not already given

  • Nitrates, preferably IV

  • Antiarrhythmics, if indicated

  • Transport with defibrillator patches attached, if possible

  • Clopidogrel can be given with high level of evidence to support use; however, if surgical disease is present, surgery will be delayed


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Transfer Considerations

  • Establish contact with accepting hospital

    • Accepting Physician

    • Administrative Acceptance

  • Establish safest method of transfer

  • Arrange for copies of transfer documents

  • Copies of all pertinent clinical material


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Summary:Evidence Based Strategies for Acute Myocardial Infarction Care

Pre-hospital Care/Diagnosing Acute Coronary Syndromes

Acute Myocardial Infarction in the rural hospital setting

STEMI Treatment/Transfer Thrombolytics/Anticoagulants/Beta Blockers

American College of Cardiology Website

ACC/AHA STEMI and non-STEMI guidelines


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