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Introduction

Introduction

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  1. 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)

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

  3. 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

  4. Applying Classification of Recommendations and Level of Evidence

  5. Applying Classification of Recommendations and Level of Evidence

  6. Applying Classification of Recommendations and Level of Evidence

  7. Applying Classification of Recommendations and Level of Evidence

  8. Pathology ACC/AHA Guidelines for the Management of Patients with ST-Elevation Myocardial Infarction

  9. 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 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

  10. 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

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

  12. 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.

  13. 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.

  14. Onset of STEMI ACC/AHA Guidelines for the Management of Patients with ST-Elevation Myocardial Infarction

  15. 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.

  16. 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.

  17. 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)

  18. 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.

  19. 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.]

  20. 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

  21. Prehospital Issues ACC/AHA Guidelines for the Management of Patients with ST-Elevation Myocardial Infarction

  22. 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 B 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 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

  23. 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 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 B 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 C Prehospital Issues

  24. 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 A 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

  25. 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 B 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

  26. 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.

  27. 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.

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

  29. 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)

  30. 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)

  31. 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

  32. 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

  33. 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.

  34. 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.

  35. 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

  36. 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.

  37. 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.

  38. 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 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.

  39. 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 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.

  40. 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.

  41. 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.

  42. 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.

  43. 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.

  44. 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.

  45. 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.

  46. 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

  47. 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.

  48. 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

  49. 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