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

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evidence based strategies for acute myocardial infarction care stemi

Evidence Based Strategies for Acute Myocardial Infarction Care:STEMI

Scott A. Sample DO, FACC

Cardiovascular Interventionist

April 2010

why a systems approach to acute coronary syndrome care
Why a Systems Approach to Acute Coronary Syndrome Care?
  • Therapy for ACS has been well studied and validated. Standardized protocols for treatment are evidence based and readily available.
  • A systems approach results in improved adherence to evidence based treatment strategies. These strategies improve patient outcomes and survival.
  • A systems approach provides a scaffold for program development and real time feedback measurements that can be used to improve care.
  • A systems approach encourages providers across the entire continuum of care to place focus on the patient.
evidence based strategies for acute myocardial infarction care
Evidence Based Strategies for Acute Myocardial Infarction Care

Pre-hospital Care/Diagnosing Acute Coronary Syndromes

Acute Myocardial Infarction in the rural hospital setting

STEMI Treatment/Transfer Thrombolytics/Anticoagulants/Beta Blockers

American College of Cardiology Website

ACC/AHA STEMI and non-STEMI guidelines

pre hospital care
Pre-Hospital Care

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

Activation of EMS LOE* B

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

12 Lead EKG, if available in the field LOE B

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

* LOE = Level of Evidence

acs recognition
ACS Recognition

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

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

Establish IV access with two large bore peripheral IVs

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

acs risk stratification
ACS Risk Stratification

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

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

Assess cardiac risk factors

assessment of risk
Assessment of Risk

Identify chest pain into 4 groups

Non-cardiac Pain

Stable Angina

Possible Acute Coronary Syndrome

Definite Acute Coronary Syndrome

evidence based strategies for acute myocardial infarction care8
Evidence Based Strategies for Acute Myocardial Infarction Care

Pre-hospital Care/Diagnosing Acute Coronary Syndromes

Acute Myocardial Infarction in the rural hospital setting

STEMI Treatment/Transfer Thrombolytics/Anticoagulants/Beta Blockers

American College of Cardiology Website

ACC/AHA STEMI and non-STEMI guidelines

thrombolytic therapy indications
Thrombolytic Therapy Indications

Presentation consistent with signs and symptoms of AMI

Time of symptom onset 12 hours or less

ST elevation > 1mm in 2 or more contiguous leads

New Left Bundle Branch Block

True Posterior Wall MI

contraindications to thrombolytics
Contraindications to Thrombolytics

Known prior hemorrhagic CVA

IC trauma

Active internal bleeding

Suspected aortic dissection

cautions to thrombolytics
Cautions to Thrombolytics

Persistent BP ≥ 180/110mmHG

Prior cerebrovascular accident/intracerebral pathology

Current use of anticoagulants in therapeutic doses

Trauma or surgery within 2 weeks

cautions to thrombolytics cont
Noncompressible vascular punctures

Recent (within 2-4 weeks) internal bleeding

Pregnancy

Active peptic ulcer disease

History of chronic severe hypertension

Cautions to Thrombolytics cont.
thrombolytic agents
Thrombolytic Agents

Alteplase

15mg bolus

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

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

Maximum dose 100mg

This agent requires concurrent administration of heparin or alternative agent

thrombolytic agents15
Thrombolytic Agents

Reteplase

First bolus 10U over 2 minutes

30 minutes later, second bolus 10U over 2 minutes

Heparin (or alternative agent) and aspirin required adjuncts

thrombolytic agents16
Thrombolytic Agents

Tenecteplase

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

Heparin (or alternative agent) and aspirin are required adjuncts

stemi unfractionated heparin adjunctive therapy
STEMI Unfractionated Heparin Adjunctive Therapy

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

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

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

stemi low molecular weight heparin adjunctive therapy
STEMI Low Molecular Weight Heparin Adjunctive Therapy

Enoxaparin

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

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

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

Monitor Hemoglobin, Hematocrit and Platelets

stemi fondaparinux adjunctive therapy
STEMI Fondaparinux Adjunctive Therapy

Initial Dose 2.5mg/kg IV

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

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

Do not use as monotherapy in patients undergoing PCI

stemi beta blocker use
STEMI Beta Blocker Use
  • Class Ib
    • Oral beta blocker (ie metoprolol 25 mg po) unless contraindicated by the following
      • Acute heart failure
      • Low cardiac output state
      • Increased risk of cardiogenic shock
      • PR interval >0.24 seconds, second degree or third degree heart block
  • Class II
    • IV beta blocker for hypertensive patients that do not have the above exclusion criteria
additional therapeutics
Additional Therapeutics
  • Aspirin 162-325mg, if not already given
  • Nitrates, preferably IV
  • Antiarrhythmics, if indicated
  • Transport with defibrillator patches attached, if possible
  • Clopidogrel can be given with high level of evidence to support use; however, if surgical disease is present, surgery will be delayed
transfer considerations
Transfer Considerations
  • Establish contact with accepting hospital
    • Accepting Physician
    • Administrative Acceptance
  • Establish safest method of transfer
  • Arrange for copies of transfer documents
  • Copies of all pertinent clinical material
summary evidence based strategies for acute myocardial infarction care
Summary:Evidence Based Strategies for Acute Myocardial Infarction Care

Pre-hospital Care/Diagnosing Acute Coronary Syndromes

Acute Myocardial Infarction in the rural hospital setting

STEMI Treatment/Transfer Thrombolytics/Anticoagulants/Beta Blockers

American College of Cardiology Website

ACC/AHA STEMI and non-STEMI guidelines