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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)

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slide2
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)

The full-text guidelines and executive summary are also available on the Web sites:

ACC (www.acc.org) and,

AHA (www.americanheart.org)

introduction

Introduction

ACC/AHA Guidelines for the Management of Patients with

ST-Elevation Myocardial Infarction

slide4

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

acc aha guidelines for the management of patients with st elevation myocardial infarction

Pathology

ACC/AHA Guidelines for the Management of Patients with

ST-Elevation Myocardial Infarction

slide10

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 2001;104:365, Hamm et al. The Lancet 2001;358:1533 and Davies. Heart 2000;83:361.

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

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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

slide11

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
acc aha guidelines for the management of patients with st elevation myocardial infarction12

Management Before STEMI

ACC/AHA Guidelines for the Management of Patients with

ST-Elevation Myocardial Infarction

slide13

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.

slide14

Identification of Patients at Risk of STEMI

Patients with established CHD or a CHD risk equivalent (diabetes mellitus, chronic kidney disease, > 20% 10-year Framingham risk) should be identified for secondary prevention.

acc aha guidelines for the management of patients with st elevation myocardial infarction15

Onset of STEMI

ACC/AHA Guidelines for the Management of Patients with

ST-Elevation Myocardial Infarction

slide16

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.

slide17

ACT in TIME

If you have any heart attack symptoms,

CALL 9-1-1immediately.

Don’t 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.

slide18

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 9-1-1if symptoms do not improve or worsen 5 minutes after ONE sublingual NTG dose*.

(* Nitroglycerin Dose: 0.4 mg sublingually)

slide19

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 non–enteric-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 non–enteric-coated formulations.

slide20

Patient experiences chest pain/discomfort

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.]

slide21

Patient experiences chest pain/discomfort

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.

No

Yes

See ACC/AHA Guidelines for the Management of Patients with Chronic Stable Angina.

* Nitroglycerin Dose: 0.4 mg sublingually

acc aha guidelines for the management of patients with st elevation myocardial infarction22

Prehospital Issues

ACC/AHA Guidelines for the Management of Patients with

ST-Elevation Myocardial Infarction

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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

slide24
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

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Prehospital Issues

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Prehospital Issues

Prehospital destination protocols

Patients with STEMI who have cardiogenic shock and are <75 yrs old should be brought immediately or secondarily transferred to facilities capable of cardiac catheterization and rapid revascularization with 18 hrs of shock

slide26

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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

slide27

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.

Inter-Hospital

Transfer

Onset of symptoms of STEMI

9-1-1

EMS

Dispatch

EMS Triage Plan

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.

slide28

Options for Transport of Patients With STEMI and Initial Reperfusion Treatment

Fibrinolysis

Noninvasive Risk

Stratification

Late

Hospital Care

and Secondary

Prevention

Not

PCI Capable

Ischemia

driven

Rescue

PCI Capable

PCI or CABG

Primary PCI

  • 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.
acc aha guidelines for the management of patients with st elevation myocardial infarction29

Initial Recognition and Management in the Emergency Department

ACC/AHA Guidelines for the Management of Patients with

ST-Elevation Myocardial Infarction

slide30

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)

slide31

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)

slide32

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

slide33

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

slide34

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.

slide35

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.

laboratory examinations
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
biomarkers of cardiac damage
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.

cardiac biomarkers in stemi
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

URL = 99th %tile of

Reference Control Group

Days After Onset of STEMI

Alpert et al. J Am Coll Cardiol 2000;36:959.

Wu et al. Clin Chem 1999;45:1104.

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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.

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Oxygen

Supplemental oxygen should be administered to patients with arterial oxygen desaturation (SaO2 < 90%).

It is reasonable to administer supplemental oxygen to all patients with uncomplicated STEMI during the first 6 hours.

nitroglycerin
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.

slide42

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 < 90 mm Hg or ≥ to 30 mm Hg below baseline
  • severe bradycardia (< 50 bpm)
  • tachycardia (> 100 bpm) or
  • suspected RV infarction.
analgesia
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.

aspirin
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 non–enteric-coated formulations.

slide45

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.

slide46

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.

slide47

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
slide48

Reperfusion

The medical system goal is to facilitate rapid recognition and treatment of patients with STEMI such that door-to- needle (or medical contact–to-needle) time for initiation of fibrinolytic therapy can be achieved within 30 minutes or that door-to-balloon (or medical contact–to- balloon) time for PCI can be kept within 90 minutes.

slide49

Reperfusion

Patient

Transport

Inhospital

Reperfusion

Goals

D-N ≤30 min

5min

< 30 min

D-B ≤90 min

Methods of Speeding Time to Reperfusion

Prehospital ECG

Media campaign

Patient education

MI protocol

Critical pathway

Quality improvement program

Bolus lytics

Dedicated PCI team

Greater use of 9-1-1

Prehospital Rx

slide50

Treatment Delayed is Treatment Denied

Cath Lab

Symptom Recognition

Call to Medical System

PreHospital

ED

Increasing Loss of Myocytes

Delay in Initiation of Reperfusion Therapy

slide51

PCI vs Fibrinolysis for STEMI:

Short Term Clinical Outcomes

PCI

P < 0.0001

Fibrinolysis

P < 0.0001

Frequency (%)

P=0.0002

P < 0.0001

P=0.0003

P=0.032

P=0.0004

P < 0.0001

Hemorrh.Stroke

Death

Death, no SHOCKdata

Recurr.

MI

Recurr.Ischemia

Total Stroke

Major Bleed

DeathMICVA

N = 7739

Keeley et al. The Lancet 2003;361:13.

overview of pci vs lysis issues to consider
Sample Size = 7739

Data span 10–15 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

Overview of PCI vs Lysis: Issues to Consider

JACC 2004;44: 671.Circulation 2004;110: 588.

slide53

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.

slide54

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
slide55

Contraindications and Cautions

for Fibrinolysis in STEMI

Relative

Contraindications

  • History of chronic, severe, poorly controlled hypertension
  • Severe uncontrolled hypertension on presentation (SBP > 180 mm Hg or DBP > 110 mm Hg)
  • History of prior ischemic stroke greater than 3 months, dementia, or known intracranial pathology not covered in contraindications
  • Traumatic or prolonged (> 10 minutes) CPR or major surgery (< 3 weeks)
slide56

Contraindications and Cautions

for Fibrinolysis in STEMI

Relative

Contraindications

  • Recent (< 2 to 4 weeks) internal bleeding
  • Noncompressible vascular punctures
  • For streptokinase/anistreplase: prior exposure (> 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
slide57

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 −

  • 40 50 60 70 80

PCI-Related Time Delay (minutes)

Nallamothu and Bates. Am J Cardiol 2003;92:824.

slide58

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 < 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 2004;109:1223.

slide59

Reperfusion Options for STEMI PatientsStep One: Assess Time and Risk.

Risk of Fibrinolysis

Time Since Symptom Onset

Risk of STEMI

Time Required for Transport to a Skilled PCI Lab

slide60

Reperfusion Options for STEMI PatientsStep 2: Select Reperfusion Treatment.

If presentation is < 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
  •  > 1 hour vs fibrinolysis (fibrin-specific agent) now
slide61

Reperfusion Options for STEMI PatientsStep 2: Select Reperfusion Treatment.

If presentation is < 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 < 90 minutes
  • High Risk from STEMI Cardiogenic shock, Killip class ≥ 3
  • Contraindications to fibrinolysis, including

increased risk of bleeding and ICH

  • Late presentation > 3 hours from symptom onset
  • Diagnosis of STEMI is in doubt
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 < 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)

PCI vs Lysis: Additional Data

JACC 2004;44: 671Circ 2004;110: 588

slide63

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).

slide64

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 > 0.1 mV in ≥ 2 contiguous precordial leads or ≥ 2 adjacent limb leads.

slide65

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.

slide66

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 2001;103:2310.

slide67

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 > 75 procedures per year)
  • Appropriate lab environment (lab performs > 200 PCIs/year of which at least 36 are primary PCI for STEMI)
  • Cardiac surgical backup available
slide68

Primary PCI for STEMI:

Specific Considerations

Medical contact–to-balloon or door-to-balloon should be within 90 minutes.

PCI preferred if > 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.

slide69

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.

slide70

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.

slide71

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.

slide72

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.

slide73

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

IIa

IIa

IIa

IIb

IIb

IIb

IIb

III

III

III

III

I

I

I

IIa

IIa

IIa

IIa

IIb

IIb

IIb

IIb

III

III

III

III

I

I

I

IIa

IIa

IIa

IIa

IIb

IIb

IIb

IIb

III

III

III

III

I

I

I

slide74

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.

slide75

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

slide76

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

slide77

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

slide78

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.

slide79

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 > 0.40).

Routine PCI might be considered as part of an invasive strategy after fibrinolytic therapy.

slide80

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.
slide81

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.
slide82

IIa

IIa

IIa

IIa

IIb

IIb

IIb

IIb

III

III

III

III

I

I

I

IIa

IIa

IIa

IIa

IIb

IIb

IIb

IIb

III

III

III

III

I

I

I

IIa

IIa

IIa

IIa

IIb

IIb

IIb

IIb

III

III

III

III

I

I

I

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.

slide83

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.

slide84

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.
slide85

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.

slide86

Thienopyridines

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

slide87

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.

slide88

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

all cause mortality

0.4

ACE-I

0.35

Placebo

0.3

0.25

0.2

0.15

0.1

0.05

0

4

0

1

2

3

SAVERadionuclideEF £ 40%

AIREClinical and/or radiographic signs of HF

TRACEEchocardiographicEF £ 35%

All-Cause Mortality

Probability of Event

Placebo: 866/2971 (29.1%)

ACE-I: 702/2995 (23.4%)

OR: 0.74 (0.66–0.83)

Years

ACE-I 2995 2250 1617 892 223

Placebo 2971 2184 1521 853 138

Flather MD, et al. Lancet. 2000;355:1575–1581

mortality by treatment

Valsartan

Valsartan + Captopril

Captopril

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 2003;349

ephesus all cause mortality

25

Eplerenone

Placebo

20

15

Cumulative Incidence (%)

10

5

0

0

Month

6

12

18

24

30

36

EPHESUS: All-Cause Mortality

P = 0.008RR = 0.85 (95% CI, 0.75–0.96)

Eplerenone 3319 3044 2463 1260 336 0 0

Placebo 3313 2983 2418 1213 323 2 0

Pitt et al. N Engl J Med 2003;348:1309-1321

slide92

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 < 0.40

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

slide93

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 < 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).

slide94

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.

hospital management

Hospital Management

ACC/AHA Guidelines for the Management of Patients with

ST-Elevation Myocardial Infarction

slide96

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

slide97

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 < 90%). Consider discontinuing if O2 saturation is > 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

slide98

Emergency Management of Complicated STEMI

Clinical signs: Shock, hypoperfusion, congestive heart failure, acute pulmonary edema

Most likely major underlying disturbance?

Hypovolemia

Low Output -

Cardiogenic Shock

Arrhythmia

AcutePulmonary 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

Nitroglycerin

10 to 20 mcg/min IV

Dobutamine

2 to 20 mcg/kg per minute 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 2000;102(suppl I):I-172-I-216.

Third line of action

right ventricular infarction
Right Ventricular Infarction

Clinical findings:Shock with clear lungs, elevated JVPKussmaul sign

Hemodynamics: Increased RA pressure (y descent)Square root sign in RV tracing

ECG:ST elevation in R sided leads

Echo:Depressed RV function

Rx:Maintain RV preloadLower RV afterload (PA---PCW)Inotropic supportReperfusion

V4R

Modified from Wellens. N Engl J Med 1999;340:381.

ventricular septal rupture

Mitral Regurgitation(Pap. M. dysfunction)

Free WallRupture

Ventricular Septal Rupture

Incidence 1-2% 1-6% 1-2%Timing 3-5 d p MI 3-6 d p MI 3-5 d p MIPhy Exam murmur 90% JVD, EMD murmur 50%Thrill Common No RareEcho Shunt Peric. Effusion Regurg. JetPA cath O2 step up Diast Press Equal. c-v wave in PCW

Images:Courtesy of W D Edwards (Mayo Foundation)Data: Lavocitz. CV Rev Rpt 1984;5:948; Birnbaum. NEJM 2002;347:1426.

slide101

“Warning Arrhythmias”

Antman and Rutherford. Coronary Care Medicine. Boston, MA: Martinus Nijhoff Publishing;1986:81.

slide102

Arrhythmias During Acute Phase of STEMI: Electrical Instability

Arrhythmia Treatment

VPBs K+ , Mg++, beta blocker

VT Antiarrhythmics, DC shock

AIVR Observe unless hemodynamic compromise

NPJT Search for cause (e.g., dig toxicity)

slide103

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

slide104

Arrhythmias During Acute Phase of STEMI: Bradyarrhythmias

Arrhythmia Treatment

Sinus Brady Treat if hemodynamic compromise;

atropine / pacing

Junctional Treat if hemodynamic compromise;

atropine / pacing

arrhythmias during acute phase of stemi av conduction disturbances
Arrhythmias During Acute Phase of STEMI: AV Conduction Disturbances

Proximal Distal

Escape Rhythm His Bundle Distal < 120 ms > 120 ms 45 - 60 Often < 30

Duration of AVB 2 - 3 days Transient

Mortality Low High (CHF, VT)

Rx Observe PM (ICD)

slide106

Recommendations for Treatment of Atrioventricular and Intraventricular Conduction Disturbances During STEMI

slide107

EF

Study

Year

Number

Days

Qualifying

EPS

Mortality hazard

Upper limit,

Name

of

post-MI

arrhythmia

ICD versus no

mean

patients

ICD (95%CI)

3-30 VPBs

MADIT

1996

196

Greater

35%, 26%

Yes

0.46 (0.26-0.82)

rate greater

than 20

than 120

MUSTT

1999

704

Greater

Greater than 2

40%, 30%

Yes

0.42 (0.28-0.62)

than 3

VPS

rate greater

than 100

MADIT 2

2002

1232

Greater

30%, 23%

No

0.69 (0.51-0.93)

None necessary

than 29

ICD Trials in Post-MI Patients

NEJM 1996;335:1933-40.

NEJM 1999;341;1882-90.

NEJM 2002;346:877-93.

slide108

ICD Implantation After STEMI

Additional Marker of Electrical Instability?

No ICD.

Medical Rx

One Month After STEMI; No Spontaneous VT or VF 48 hours post-STEMI

EF < 0.30

EF 0.31 - 0.40

EF > 0.40

No

Yes

EPS

+

-

NEJM 349: 1836,2003

slide109

Algorithm for Management of Recurrent Ischemia/Infarction After STEMI

Recurrent ischemic

Recurrent ischemic

-

-

type discomfort at rest after STEMI

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

Obtain 12

-

-

lead ECG

lead ECG

myocardium at risk

myocardium at risk

Correct secondary causes of ischemia

Correct secondary causes of ischemia

ST

ST

ST

-

-

-

segment elevation?

segment elevation?

segment elevation?

slide110

Algorithm for Management of Recurrent Ischemia/Infarction After STEMI

Recurrent ischemic

Recurrent ischemic

-

-

type discomfort at rest after STEMI

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

Obtain 12

-

-

lead ECG

lead ECG

myocardium at risk

myocardium at risk

Correct secondary causes of ischemia

Correct secondary causes of ischemia

ST

ST

ST

-

-

-

segment elevation?

segment elevation?

segment elevation?

YES

YES

Is patient

Is patient

Is patient

a candidate for

a candidate for

a candidate for

?

revascularization

revascularization

revascularization

?

?

YES

YES

NO

NO

Can

Can

Can

Consider (re) administration

Consider (re)

catheterization

catheterization

catheterization

of fibrinolytic therapy

administration of

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. 2001:1195.

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

slide111

Algorithm for Management of Recurrent Ischemia/Infarction After STEMI

Recurrent ischemic

Recurrent ischemic

-

-

type discomfort at rest after STEMI

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

Obtain 12

-

-

lead ECG

lead ECG

myocardium at risk

myocardium at risk

Correct secondary causes of ischemia

Correct secondary causes of ischemia

ST

ST

ST

-

-

-

segment elevation?

segment elevation?

segment elevation?

YES

YES

NO

NO

Is patient

Is patient

Is patient

Is ischemia

Is ischemia

Is ischemia

a candidate for

a candidate for

a candidate for

controlled by escalation

controlled by escalation

controlled by escalation

?

revascularization

revascularization

revascularization

?

?

of medical therapy?

of medical therapy?

of medical therapy?

NO

NO

NO

YES

YES

YES

YES

YES

NO

NO

Refer for urgent

Refer for urgent

Refer for urgent

Refer for

Refer for

Refer for

Can

Can

Can

catheterization (consider

catheterization (consider

catheterization (consider

nonurgent

nonurgent

nonurgent

Consider (re) administration

Consider (re)

catheterization

catheterization

catheterization

IABP)

IABP)

IABP)

catheterization

catheterization

catheterization

of fibrinolytic therapy

administration of

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. 2001:1195.

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

slide112

Evidence-Based Approach to Need for

Catheterization and Revascularization After STEMI

STEMI

STEMI

Primary Invasive Strategy

Primary Invasive Strategy

Fibrinolytic Therapy

Fibrinolytic Therapy

No Reperfusion Therapy

No Reperfusion Therapy

Cath

Cath

No Cath

No Cath

EF less

EF less

EF greater

EF greater

Performed

Performed

Performed

Performed

than 0.40

than 0.40

than 0.40

than 0.40

EF greater

EF greater

EF less

EF less

High

High

-

-

Risk

Risk

No High

No High

-

-

Risk

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

No High

-

-

Risk

Risk

High

High

-

-

Risk

Risk

Indicated

Indicated

Features

Features

Features

Features

Revascularization as

Revascularization as

Functional

Functional

Indicated

Indicated

Evaluation

Evaluation

ECG Interpretable

ECG Interpretable

ECG Uninterpretable

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

Symptom

-

-

Limited

Limited

Adenosine

Exercise

Exercise

Exercise

Exercise

Dobutamine

Dobutamine

Exercise Test

Exercise Test

Exercise Test

Exercise Test

or Dipyridamole

Echo

Echo

Nuclear

Nuclear

Echo

Echo

Before Discharge

Before Discharge

Before or After Discharge

Before or After Discharge

Nuclear Scan

Catheterization and

Catheterization and

Medical

Medical

Clinically Significant

Clinically Significant

No Clinically Significant

No Clinically Significant

Revascularization as

Revascularization as

Therapy

Therapy

Ischemia

Ischemia*

Ischemia

Ischemia*

Indicated

Indicated

slide113

Long-Term Antithrombotic Therapy at

Hospital Discharge After STEMI

STEMI Patient at Discharge

No Stent Implanted

No ASA allergy

ASA Allergy

No Indications

for Anticoagulation

Indications

for Anticoagulation

No Indications

for Anticoagulation

Indications

for Anticoagulation

Preferred:

ASA 75 to 162 mg

Class I; LOE: A

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

Preferred:

Clopidogrel 75 mg

Class I; LOE: C

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

slide114

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

No Indications

for Anticoagulation

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

long term management

Long-Term Management

ACC/AHA Guidelines for the Management of Patients with

ST-Elevation Myocardial Infarction

slide116

Secondary Prevention and Long Term Management

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

slide117

Secondary Prevention and Long Term Management

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: < 140/90 mm Hg or <130/80 mm Hg if chronic kidney disease or diabetes

slide118

Secondary Prevention and Long Term Management

GoalsRecommendations

  • 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

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Secondary Prevention and Long Term Management

Goals Recommendations

  • Start dietary therapy in all patients (< 7% of total calories as saturated fat and < 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 << than 100 mg/dL

LDL-C < 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-C–lowering therapy with drug treatment, giving preference to statins.

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Secondary Prevention and Long Term Management

Goals Recommendations

If TGs are ≥ 150 mg/dL or HDL-C is < 40 mg/dL:

Emphasize weight management and physical activity. Advise smoking cessation.

If TG is 200 to 499 mg/dL:

After LDL-C–lowering therapy, consider adding fibrate or niacin.

If TG is ≥ 500 mg/dL:

Consider fibrate or niacin before LDL-C–lowering therapy.

Consider omega-3 fatty acids as adjunct for high TG.

Lipid management:

(TG 200 mg/dL or greater)

Primary goal:

Non–HDL-C << 130 mg/dL

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Secondary Prevention and Long Term Management

Goals Recommendations

Weight management:

Goal:

BMI 18.5 to 24.9 kg/m2

Waist circumference:

Women: < 35 in.

Men: < 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.

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Secondary Prevention and Long Term Management

Goals Recommendations

Diabetes management:

Goal:

HbA1c < 7%

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).

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Secondary Prevention and Long Term Management

Goals Recommendations

Antiplatelet agents/ anticoagulants

  • 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.
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Secondary Prevention and Long Term Management

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 < 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 < 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.

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Secondary Prevention and Long Term Management

Goals Recommendations

Beta- Blockers

Start in all patients. Continue indefinitely. Observe usual contraindications.

slide126

Summary of Pharmacologic Rx: Ischemia

JACC 2004;44: 671Circulation 2004;110: 588

slide127

Summary of Pharmacologic Rx: LVD, Sec. Prev.,

JACC 2004;44:671Circ 2004;110:588

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Hormone Therapy

Hormone therapy with estrogen plus progestin should not be given de novo to postmenopausal women after STEMI for secondary prevention of coronary events.

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Hormone Therapy

Postmenopausal women who are already taking estrogen plus progestin at the time of STEMI should not continue hormone therapy.

However, women who are beyond 1 to 2 years after initiation of hormone therapy who wish to continue such therapy for another compelling indication should weigh the risks and benefits.

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Antioxidants

Antioxidant vitamins such as vitamin E and/or vitamin C supplements should not be prescribed to patients recovering from STEMI to prevent cardiovascular disease.

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Psychosocial Impact of STEMI

The psychosocial status of the patient should be evaluated, including inquiries regarding symptoms of depression, anxiety, or sleep disorders and the social support environment.

Treatment with cognitive-behavioral therapy and selective serotonin reuptake inhibitors can be useful for STEMI patients with depression that occurs in the year after hospital discharge.

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Cardiac Rehabilitation

Cardiac rehabilitation/secondary prevention programs, when available, are recommended for patients with STEMI, particularly those with multiple modifiable risk factors and/or those moderate- to high-risk patients in whom supervised exercise training is warranted.

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Follow-Up Visit With Medical Provider

  • Delineate cardiovascular symptoms and functional class.
  • Evaluate current medications and titrate if needed.
  • Review and continue predischarge risk assessment.
  • Review secondary prevention principles.
  • Check psychosocial status.
  • Discuss resumption of daily activities.
  • Address plan for recognizing and responding to potential cardiac event.
  • Referto a cardiac rehabilitation program.