Stemi vs non stemi comparison in admitted management
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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

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STEMI VS Non STEMI COMPARISON IN ADMITTED MANAGEMENT

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Stemi vs non stemi comparison in admitted management

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

Acute coronary syndrome


First step triage

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

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

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

ST-elevation MI


Management initial therapy

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


Management initial therapy1

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


Management early therapy

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

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 therapy1

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

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


Stemi vs non stemi comparison in admitted management

  • 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


Stemi vs non stemi comparison in admitted management

  • 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

Non ST-elevation MI


Risk profile

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

Management

  • 1.antiischemia therapy

    • Bed rest

    • O2

    • Morphine Sulfate

    • Nitroglyceride

    • Beta-Blockers

  • 2.antiplatelet therapy


Management1

Management

  • 3.antithrombic treatment

  • 4.early conservative VS

    early invasive strategy

  • 5.Coronary revascularization

    • PCI

    • CABG


Antiplatelet therapy

Antiplatelet therapy

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

  • ASA

  • Thienopyridine (ADP antagonist)

  • GP IIb/IIIa antagonist


Antiplatelet therapy1

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 therapy2

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 therapy3

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 therapy4

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

Anticoagulation treatment

  • Enoxaperin (LMWH)

  • UFH (unfractionated heparin)


Anticoagulant therapy

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 early invasive strategies

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.


Stemi vs non stemi comparison in admitted management

  • 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


Stemi vs non stemi comparison in admitted management

  • (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

    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 revascularization1

    Coronary revascularization


    Coronary revascularization2

    Coronary revascularization


    Comparison of different revascularization stragies

    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

    Take home message


    Stemi vs non stemi comparison in admitted management

    THANK YOU FOR

    YOUR ATTENEION!!


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