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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

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

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
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
slide16
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
slide17
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
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.
slide33
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

slide34
(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
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
slide40
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