Stemi vs non stemi comparison in admitted management
Download
1 / 40

STEMI VS Non STEMI COMPARISON IN ADMITTED MANAGEMENT - PowerPoint PPT Presentation


  • 220 Views
  • Uploaded on
  • Presentation posted in: General

STEMI VS Non STEMI COMPARISON IN ADMITTED MANAGEMENT. 2004 ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction ACC/AHA 2002 Guideline Update for the Management of Patients With Unstable Angina and Non–ST-Segment Elevation Myocardial Infarction

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha

Download Presentation

STEMI VS Non STEMI COMPARISON IN ADMITTED MANAGEMENT

An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -

Presentation Transcript


STEMI VS Non STEMICOMPARISON IN ADMITTED MANAGEMENT

2004 ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction

ACC/AHA 2002 Guideline Update for the Management of Patients With Unstable Angina and Non–ST-Segment Elevation Myocardial Infarction

Management of acute coronary syndromes: an

Update, Heart 2004;90;698-706

Ri徐子茜/VS柯文哲


Acute coronary syndrome


First step-Triage

  • 1.a typical clinical syndrome +

  • 2.electrocardiographic changes+/-

  • 3.Markers of myocyte injury

    • Unstable angina

    • Non ST-elevation MI

    • ST-elevation MI

  • Decide whether or not to receive acute reperfusion therapy (thrombolytic agent, PCI, emergent CABG )


General measures

  • pain relief

  • Adequate arterial oxygen concentration

  • relief of ischemia

  • assisted ventilation

  • reperfusion of critically ischemic myocardium

  • hemodynamic support (IABP)

  • control hypertension

  • treat acute heart failure and mechanical complications


ACC/AHA guideline

  • Class I:有益之適應症

  • Class II:使用效果有爭議

    • Class IIa:證據偏向有效

    • Class IIb:無有效之證據

  • Class III:該處置無效,甚至有害


ST-elevation MI


Managementinitial therapy

  • a. Oxygen

    • For at least 2-3 hrs after presentation

  • b. Nitroglycerin

    • Class I : ongoing ischemic discomfort → sublingual

      nitroglycerin (0.4 mg) every 5 minutes for a total of

      3 doses →consider iv nitroglycerin

      a.) relief of ongoing ischemic discomfort

      b.) control of hypertension

      c.) management of pulmonary congestion

    • Class III :SBP<90 mmHg

      HR<50 or >100

      suspected RV infarction

      phosphodiesterase inhibitor for erectile dysfunction in

      the past 24 hrs


Managementinitial therapy

  • c. Analgesia

    • Class I: Morphine sulfate 2 to 4 mg IV repeated at 5- to 15-minute intervals

  • d. Aspirin

    • Class I :chewed, 162 mg to 325 mg

  • e. Beta-Blockers

    • Class I : Oral beta-blocker should be administered promptly

      to those patients without a contraindication

    • Class IIa: IV beta-blockers promptly to STEMI patients

      without contraindications ,especially if a

      tachyarrhythmia or hypertension is present.

  • f. ACE Inhibitor


Managementearly therapy

  • Reperfusion: as soon as possible

    • Thrombolytic therapy

    • Primary PCI

    • Emergent CABG

      • Refractory ischemia

      • Cardiogenic shock

      • The coronary vasculature is not amentable to PCI or the procedures has failed

      • Acute mechanical complications of MI(papillary muscle rupture, VSD, ventricular free wall rupture)


Thrombolytic therapy

  • rapid administration

  • the risk of intracranial hemorrage

    • Sudden change in neurologic status

    • DC anticoagulatnt & thrombolytic agent

    • Head CT

    • FFP, platelet transfusion

  • whether the normal flow was restored in the infarct-related area

    • Within 90mins,induce clot lysis in 60-90% patients, but only 30-60% normal flow in the infarct-related area


Thrombolytic therapy

  • Most effective if given within 12hrs,

    not beyond 24 hrs

  • Not indicated if the symptoms resolved or patients with ST-depression on EKG

  • 1.Recombinant tissue-plasminogen activator

    (rt-PA)

  • 2.Reteplase (r-PA)

  • 3.Tenecteplase (TNK)

  • 4.Streptokinase

    • TNK has a lower rate of non-cerebral bleeds and a lesser need for blood transfusion.


Primary PCI

  • With experienced team (door-to-balloon time <90mins), superior to the fibrinolytic therapy

  • Immediate assessment LV function

  • Identification of other diseased vessel

  • Effective when the symptoms persist


  • PCI combined with fibrinolysis

    • fibrinolytic agent is administered followed by PCI.

    • larger scale trials are awaited.

  • PCI combined with Gp IIb/IIIa (abciximab)

    • clear benefit in reducing MI when primary PCI is combined with abciximab.

    • Death or MI at 30 days was 3.2% (59/1843) with

      abciximab versus 4.8% (88/1823) without

    • modern reference standard


  • Rescue PCI

    • PCI procedure performed in patients without evidence of a response to thrombolysis (,50% ST segment resolution)

    • No insufficient data to demonstrate the improvement in mortality or further MI


Non ST-elevation MI


Risk profile

  • 1.TIMI score

    • Age>65 y/o

    • >= 3 coronary risk factor

    • Angiographically documented prior CAD

    • >2 angina episodes within 24 hrs

    • ST deviation on the EKG

    • Aspirin use within in 7 days

    • Elevated cardiac enzymes


Management

  • 1.antiischemia therapy

    • Bed rest

    • O2

    • Morphine Sulfate

    • Nitroglyceride

    • Beta-Blockers

  • 2.antiplatelet therapy


Management

  • 3.antithrombic treatment

  • 4.early conservative VS

    early invasive strategy

  • 5.Coronary revascularization

    • PCI

    • CABG


Antiplatelet therapy

  • highly significant reduction in the risk of MI/ stroke/vascular death

  • ASA

  • Thienopyridine (ADP antagonist)

  • GP IIb/IIIa antagonist


Antiplatelet therapy

  • Class I

    • 1.ASA should be administered as soon as possible after

      presentation and continued indefinitely.

    • 2.Clopidogrel should be administered to hospitalized

      patients who are unable to take ASA

    • * 3.early noninterventional approach is planned, clopidogrel

      should be added to ASA as soon as possible on

      admission and administered for at least 1 month and for

      up to 9 months.

    • * 4.A platelet GP IIb/IIIa antagonist should be administered,

      in addition to ASA and heparin, to patients in whom

      catheterization and PCI are planned. The GP IIb/IIIa

      antagonist may also be administered just prior to PCI.


Antiplatelet therapy

  • Class I

    • * 5.In patients for whom a PCI is planned and who are not at

      high risk for bleeding, clopidogrel should be started and

      continued for at least 1 month and for up to 9 months.

    • * 6.In patients taking clopidogrel in whom elective

      CABG is planned, the drug should be withheld for

      5 to 7 days

  • Class IIa

    • * 1. Eptifibatide or tirofiban should be administered, in

      addition to ASA and LMWH or UFH, to patients

      with continuing ischemia, an elevated troponin, or

      with other high-risk features in whom an invasive

      management strategy is not planned.


Antiplatelet therapy

  • Class IIa

    • * 2.A platelet GP IIb/IIIa antagonist should be

      administered to patients already receiving

      heparin, ASA, and clopidogrel in whom

      catheterization and PCI are planned. The GP

      IIb/IIIa antagonist may also be administered

      just prior to PCI.

  • Class IIb

    • *1. Eptifibatide or tirofiban, in addition to ASA and

      LMWH or UFH, to patients without continuing

      ischemia who have no other high-risk features

      and in whom PCI is not planned.


Antiplatelet therapy

  • Class III

    • 1. Intravenous fibrinolytic therapy in

      patients without acute ST-segment

      elevation, a true posterior MI, or a

      presumed new left bundle-branch block.

    • *2. Abciximabadministration in patients in

      whom PCI is not planned.


Anticoagulation treatment

  • Enoxaperin (LMWH)

  • UFH (unfractionated heparin)


Anticoagulant Therapy

  • Class I

    • *1. Anticoagulation with subcutaneous LMWH or iv UFH should be added to antiplatelet therapy with ASA and/or clopidogrel.


Early Conservative vs EarlyInvasive Strategies

  • 1.medium- and high-risk patients :

    • troponin T> 0.01 ng/mL or troponin I > 0.1ng/mL, the presence of ST-segment deviation, or a TIMI risk>=3

    • The beneficial effects : I>C

  • 2.low-risk patients:

    • outcomes I=C

  • Rates of major bleeding were similar, and lengths of hospital stay were reduced in patients assigned to the invasive strategy.


  • Class I

    • †1. An early invasive strategy in patients with UA/

      NSTEMI without serious comorbidity and who

      have any of the following high-risk indicators:

      • *(a) Recurrent angina/ischemia at rest or with low-level

        activities despite intensive anti-ischemictherapy.

      • *(b) Elevated TnT or TnI

      • *(c) New or presumably new ST-segment depression

      • (d) Recurrent angina/ischemia with CHF symptoms, an

        S3 gallop, pulmonary edema, worsening rales, or new

        or worsening MR


  • (e) High-risk findings on noninvasive stress testing

  • (f) Depressed LV systolic function (eg, EF <0.40 on

    noninvasive study)

  • (g) Hemodynamic instability

  • (h) Sustained ventricular tachycardia

  • (i) PCI within 6 months

  • (j) Prior CABG

  • 2. In the absence of any of these findings, either an

    early conservative or an early invasive strategy

    may be offered in hospitalized patients without

    contraindications for revascularization.


  • Coronary revascularization

    • PCI

    • CABG

      • Significant left main CAD

      • 3 vessel disease and abnormal LV function (LVEF<50%)

      • 2 vessel disease with a significant proximal left ant. descending artery stenosis and abnormal LV function

      • DM and multivessel disease


    Coronary revascularization


    Coronary revascularization


    Comparison of different revascularization stragies

    • Lack of long term outcome

    • PCI

      • Coronary stenting

      • The adjuvant use of platelet inhibitors

    • CABG

      • Refinement of surgical management with right internal mammary artery grafts, radial artery grafts

      • less invasive methodology


    Take home message


    THANK YOU FOR

    YOUR ATTENEION!!


    ad
  • Login