2 This slide set was adapted from the ACC/AHA Guidelines for Management of Patients With ST-...

2

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)

3

IntroductionIntroduction

ACC/AHA Guidelines for the Management of Patients with

ST-Elevation Myocardial Infarction

4

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

Elliott M. Antman, MD, FACC, FAHA, Chair

ACC/AHA Guidelines for the Management ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial of Patients With ST-Elevation Myocardial

InfarctionInfarction

Writing Committee MembersWriting Committee Members

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

5

Class I Benefit >>> Risk

Procedure/ Treatment SHOULD be performed/ administered

Class IIa Benefit >> RiskAdditional studies with focused objectives needed

IT IS REASONABLE to perform procedure/administer treatment

Class IIb Benefit ≥ RiskAdditional studies with broad objectives needed; Additional registry data would be helpful

Procedure/Treatment MAY BE CONSIDERED

Class III Risk ≥ BenefitNo additional studies needed

Procedure/Treatment should NOT be performed/administered SINCE IT IS NOT HELPFUL AND MAY BE HARMFUL

shouldis recommendedis indicatedis useful/effective/

beneficial

is reasonablecan be useful/effective/

beneficialis probably recommended or

indicated

may/might be consideredmay/might be reasonableusefulness/effectiveness is

unknown /unclear/uncertain or not well established

is not recommendedis not indicatedshould notis not

useful/effective/beneficialmay be harmful

Applying Classification of Applying Classification of Recommendations and Level of Evidence Recommendations and Level of Evidence

6

Level A

Multiple (3-5) population risk strata evaluated

General consistency of direction and magnitude of effect

Class I

• Recommen-dation that procedure or treatment is useful/ effective

• Sufficient evidence from multiple randomized trials or meta-analyses

Class IIa

• Recommen-dation in favor of treatment or procedure being useful/ effective

• Some conflicting evidence from multiple randomized trials or meta-analyses

Class IIb

• Recommen-dation’s usefulness/ efficacy less well established

• Greater conflicting evidence from multiple randomized trials or meta-analyses

Class III

• Recommen-dation that procedure or treatment not useful/effective and may be harmful

• Sufficient evidence from multiple randomized trials or meta-analyses

Applying Classification of Recommendations and Level of Evidence

7

Level B

Limited (2-3) population risk strata evaluated

Class I

• Recommen-dation that procedure or treatment is useful/effective

• Limited evidence from single randomized trial or non-randomized studies

Class IIa

• Recommen-dation in favor of treatment or procedure being useful/ effective

• Some conflicting evidence from single randomized trial or non-randomized studies

Class IIb


• Greater conflicting evidence from single randomized trial or non-randomized studies

Class III

• Recommen-dation that procedure or treatment not useful/effective and may be harmful

• Limited evidence from single randomized trial or non-randomized studies


8


Level C Very limited (1-2) population risk strata evaluated

Class I

• Recommen-dation that procedure or treatment is useful/ effective

• Only expert opinion, case studies, or standard-of-care

Class IIa

• Recommen-dation in favor of treatment or procedure being useful/effective

• Only diverging expert opinion, case studies, or standard-of-care

Class IIb


• Only diverging expert opinion, case studies, or standard-of-care

Class III

• Recommend-ation that procedure or treatment not useful/effective and may be harmful

• Only expert opinion, case studies, or standard-of-care

9



PathologyPathology

10

Chronology of the interface between the patient and the clinician through the progression of plaque formation and the onset of complications of STEMI.

Management Before STEMI

41 2 3 4 5 6

Onset of STEMI- Prehospital issues- Initial recognition and management in the Emergency Department (ED)- Reperfusion

Hospital Management- Medications- Arrhythmias- Complications- Preparation for discharge

Secondary Prevention/Long-Term Management

Presentation

Working Dx

ECG

Cardiac Biomarker

Final Dx

UA

NQMI QwMI

No ST Elevation

NSTEMI

Ischemic DiscomfortAcute Coronary Syndrome

UnstableAngina

Myocardial Infarction

ST Elevation

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

11

Prevention of Coronary Heart Disease (CHD)Prevention of Coronary Heart Disease (CHD)Campaigns and StatementsCampaigns 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

12

Management Before STEMIManagement Before STEMI



13

Identification of Patients at Risk of STEMIIdentification 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.

III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII


14

Identification of Patients at Risk of STEMIIdentification 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.


15

Onset of STEMIOnset of STEMI



16

Patient Education for Early Recognition and Patient Education for Early Recognition and Response to STEMIResponse to STEMI

Patients should understand the advisability

of calling 9-1-1 if symptoms are unimproved

or worsening after 5 minutes.

Patients should understand their risk of

STEMI and how to recognize symptoms of

STEMI.



17

If you have any heart attack symptoms,

CALL 9-1-1 immediately.

Don’t wait for more than a few minutes – 5 at most – to call 9-1-1.

ACT in TIMEACT in TIME

http://www.nhlbi.nih.gov/actintime/index.htm. Accessed December 20, 2004.

18

Patient Education for Early Recognition and Patient Education for Early Recognition and Response to STEMIResponse to STEMI

Healthcare providers should instruct patients

previously prescribed nitroglycerin (NTG) on use

for chest discomfort or pain and to call 9-1-1 if

symptoms do not improve or worsen 5 minutes

after ONE sublingual NTG dose*.(* Nitroglycerin Dose: 0.4 mg sublingually)


19

Prehospital Chest Pain Evaluation Prehospital Chest Pain Evaluation and Treatmentand 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.



20

Has the patient been previously prescribed nitroglycerin?


No

Is Chest Discomfort/Pain Unimproved or Worsening5 Minutes After It Starts?

Is Chest Discomfort/Pain Unimproved or Worsening5 Minutes After It Starts?

Yes No

CALL 9-1-1IMMEDIATELY.


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.]

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.]

Notify Physician.Notify Physician.

Instructions for Nitroglycerin Instructions for Nitroglycerin Use and EMS ContactUse and EMS Contact

Patient experiences chest pain/discomfort

21

Take ONE Nitroglycerin Dose Sublingually.

Take ONE Nitroglycerin Dose Sublingually.

Is Chest Discomfort/Pain Unimproved or Worsening5 Minutes After Taking ONE Nitroglycerin Dose*

Sublingually?

Is Chest Discomfort/Pain Unimproved or Worsening5 Minutes After Taking ONE Nitroglycerin Dose*

Sublingually?

Yes

YesNo

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

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



Instructions for Nitroglycerin Instructions for Nitroglycerin Use and EMS ContactUse and EMS Contact



Patient experiences chest pain/discomfort

* Nitroglycerin Dose: 0.4 mg sublingually

22

Prehospital IssuesPrehospital Issues



23

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




24

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




25


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


26


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


27

Options for Transport of Patients With Options for Transport of Patients With STEMI and Initial Reperfusion TreatmentSTEMI and Initial Reperfusion Treatment

EMS Transport

Onset of symptoms of

STEMI

9-1-1EMS

Dispatch

EMS on-scene• Encourage 12-lead ECGs.• Consider prehospital fibrinolytic if

capable and EMS-to-needle within 30 min.

GOALS

PCIcapable

Not PCIcapable

Hospital fibrinolysis:

Door-to-Needle

within 30 min.

EMS Triage Plan

Inter-HospitalTransfer

Golden Hour = first 60 min. Total ischemic time: within 120 min.

Patient EMS Prehospital fibrinolysisEMS-to-needlewithin 30 min.

EMS transportEMS-to-balloon within 90 min.

Patient self-transport Hospital door-to-balloon

within 90 min.Dispatch

1 min.

5 min.

8 min.

28

• 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.

Fibrinolysis

Primary PCI

Noninvasive Risk Stratification

LateHospital Care

and SecondaryPrevention

PCI or CABG

NotPCI Capable

PCI Capable

Rescue Ischemiadriven

Options for Transport of Patients With STEMI and Options for Transport of Patients With STEMI and Initial Reperfusion TreatmentInitial Reperfusion Treatment

29

Initial Recognition and Initial Recognition and Management in the Management in the

Emergency DepartmentEmergency Department



30

ED Evaluation of ED Evaluation of Patients With STEMIPatients With STEMI

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)

Brief Physical Examination in the ED

31


Aortic dissection

Pulmonary embolus

Perforating ulcer

Tension pneumothorax

Boerhaave syndrome

(esophageal rupture with

mediastinitis)

Differential Diagnosis of STEMI: Life-Threatening

32


PericarditisAtypical anginaEarly repolarizationWolff-Parkinson-White

syndromeDeeply inverted T-waves

suggestive of a central nervous system lesion or apical hypertrophic cardiomyopathy

LV hypertrophy with strain

Brugada syndrome

Myocarditis

Hyperkalemia

Bundle-branch blocks

Vasospastic angina

Hypertrophic cardiomyopathy

Differential Diagnosis of STEMI: Other Cardiovascular and Nonischemic

33

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


Differential Diagnosis of STEMI: Other Noncardiac

34

ElectrocardiogramElectrocardiogram

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.


35

ElectrocardiogramElectrocardiogram

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.



36

Laboratory ExaminationsLaboratory 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


37

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.

Biomarkers of Cardiac DamageBiomarkers of Cardiac Damage



38

00 11 22 33 44 55 66 7788

Cardiac troponin-no reperfusion Cardiac troponin-no reperfusion

Days After Onset of STEMIDays After Onset of STEMI

Mu

ltip

les

of

the

UR

LM

ult

iple

s o

f th

e U

RL

Upper reference limitUpper reference limit11

22

55

1010

2020

5050

URL = 99th %tile of URL = 99th %tile of Reference Control GroupReference Control Group

100100

Cardiac troponin-Cardiac troponin-reperfusion reperfusion

CKMB-no reperfusion CKMB-no reperfusion

CKMB-CKMB-reperfusion reperfusion

Cardiac Biomarkers in STEMICardiac Biomarkers in STEMI

Alpert et al. J Am Coll Cardiol 2000;36:959.Wu et al. Clin Chem 1999;45:1104.

39

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.

ImagingImaging



40

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.

OxygenOxygen



41

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.

NitroglycerinNitroglycerin



42

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.

NitroglycerinNitroglycerin



43

AnalgesiaAnalgesia

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.


44

AspirinAspirin


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.


45

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.

Beta-BlockersBeta-Blockers



46

Phase of Treatment

Acute treatment

Secondaryprevention

Overall

Total No.Patients

28,970

24,298

53,268

0.5 1 2

Relative risk (RR) of death

Beta blockerbetter

RR (95% CI)

Placebobetter

0.87 (0.77-0.98)

0.77 (0.70-0.84)

0.81 (0.75-0.87)

Summary of Trials of Beta-Blocker TherapySummary of Trials of Beta-Blocker Therapy

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.

47

ReperfusionReperfusion

• 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

48


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.

49

Media campaignPatient education

Methods of Speeding Time to

Reperfusion

Greater use of 9-1-1

Prehospital Rx

MI protocolCritical pathwayQuality

improvement program

Bolus lytics Dedicated

PCI team

5 min < 30 minD-B ≤ 90 min

D-N ≤ 30 min

Goals

Prehospital ECG

Patient Transport Inhospital Reperfusion


50

Symptom Recognition

Call to Medical System

ED Cath LabPreHospital

Delay in Initiation of Reperfusion Therapy

Increasing Loss of Myocytes

Treatment Delayed is Treatment DeniedTreatment Delayed is Treatment Denied

51

PCI vs Fibrinolysis for STEMI:PCI vs Fibrinolysis for STEMI:Short Term Clinical OutcomesShort Term Clinical Outcomes

74.5

2.2

6

1 0

7 897 7

21

2 1

5

13

0

5

10

15

20

25

30

35

PCI

Fre

qu

en

cy (

%)

P=0.0002

P=0.0003 P < 0.0001

P < 0.0001

P < 0.0001P=0.0004

P=0.032

P < 0.0001

Death Death, no

SHOCKdata

Recurr.MI

Recurr.Ischemia

Total Stroke

Hemorrh.Stroke

Major Bleed

DeathMI

CVA

Fibrinolysis

N = 7739

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

52

Overview of PCI vs Lysis: Overview of PCI vs Lysis: Issues to ConsiderIssues 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 MIUFH used in lytic arms--? Better antithrombinsDependent on use of PCI post-lysis

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

53

Contraindications and CautionsContraindications and Cautionsfor Fibrinolysis in STEMIfor Fibrinolysis in STEMI

Absolute Contraindications

• 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

NOTE: Age restriction for fibrinolysis has been removed compared with prior guidelines.

54


Absolute Contraindications

• Suspected aortic dissection

• Active bleeding or bleeding diathesis (excluding menses)

• Significant closed-head or facial trauma within 3 months

55


• 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)

RelativeContraindications

56


RelativeContraindications

• 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

57

PCI versus Fibrinolysis with Fibrin-Specific PCI versus Fibrinolysis with Fibrin-Specific Agents: Is Timing (Almost) Everything?Agents: Is Timing (Almost) Everything?

Favors PCI

Favors fibrinolysis with a fibrin-specific agent

13 RCTsN = 5494 P = 0.04

Ab

solu

te R

isk

Dif

fere

nce

in D

eath

(%

)

30 40 50 60 70 80PCI-Related Time Delay (minutes)

10 −

5 −

0 −

-5 − ┬ ┬ ┬ ┬ ┬ ┬

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

58

Symptoms Symptoms to to balloon inflation (minutes)balloon inflation (minutes)

On

e-ye

ar m

ort

alit

y, %

On

e-ye

ar m

ort

alit

y, %

6 RCTs of Primary PCI by Zwolle Group 1994 6 RCTs of Primary PCI by Zwolle Group 1994 – – 20012001N = 1791N = 1791

RR = 1.08 [1.01 RR = 1.08 [1.01 – – 1.16] for each 30 min delay1.16] for each 30 min delay((PP = 0.04) = 0.04)

PP < 0.0001 < 0.00011212

1010

88

66

44

22

0000 6060 120120 180180 240240 300300

360360

Symptom Onset to Balloon Time and Symptom Onset to Balloon Time and Mortality in Primary PCI for STEMIMortality in Primary PCI for STEMI

DeLuca et al. Circulation 2004;109:1223.

59

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

Time Since Symptom

Onset

Time Required for Transport to

a Skilled PCI Lab

Risk of STEMI Risk of Fibrinolysis

60

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

Reperfusion Options for STEMI PatientsReperfusion Options for STEMI Patients Step 2:Step 2: Select Reperfusion Treatment. Select Reperfusion Treatment.

If presentation is < 3 hours and there is no delay to an invasive strategy, there is no preference for either strategy.

61

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

Reperfusion Options for STEMI PatientsReperfusion Options for STEMI Patients Step 2:Step 2: Select Reperfusion Treatment. Select Reperfusion Treatment.

If presentation is < 3 hours and there is no delay to an invasive strategy, there is no preference for either strategy.

62

PCI vs Lysis: PCI vs Lysis: Additional DataAdditional 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 delayRR = 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 timesPCI mortality higher than prehospital lysis in pts

treated early (2h)

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

63

FibrinolysisFibrinolysis

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).

III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII


64


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.



65


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.



66

Evolution of PCI for STEMIEvolution of PCI for STEMI

Antman. Circulation 2001;103:2310.

Balloon Antiplatelet Rx

Stent DES

GP IIb/IIIa inhibitor

ASAClopidogrel

AngioJet

Thrombus Removal and

Distal Embolization

Protection Devices

Embolization Protection Device

Platelet

67

Primary PCI for STEMI:Primary PCI for STEMI:General ConsiderationsGeneral 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


68

Primary PCI for STEMI:Primary PCI for STEMI:Specific ConsiderationsSpecific 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.




69


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.


70


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.


71

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.



72

Rescue PCIRescue 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.



73


Rescue PCIRescue 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.


74

PCI for Cardiogenic ShockPCI 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.



75

Cardiogenic Shock

Early Shock, Diagnosed on Hospital Presentation

Fibrinolytic therapy if all of the following are present:

1. Greater than 90 minutes to PCI2. Less than 3 hours post STEMI

onset3. No contraindications

Arrange prompt transfer to invasive procedure-capable center


IABP

76

Cardiogenic Shock


Delayed Onset Shock Echocardiogram to Rule Out

Mechanical Defects

IABP





Arrange rapid transfer to invasive procedure-capable center


77

Cardiogenic Shock

1-2 vessel CAD Moderate 3-vessel CAD Severe 3-vessel CAD Left main CAD

PCI IRA PCI IRA Immediate CABG

Staged Multivessel PCI

Staged CABGCannot be performed


Delayed Onset Shock Echocardiogram to Rule Out

Mechanical Defects

Cardiac Catheterization and Coronary Angiography

IABP





Arrange rapid transfer to invasive procedure-capable center


78

PCI After FibrinolysisPCI After Fibrinolysis

In patients whose anatomy is suitable, PCI should beperformed for the following:

Objective evidence of recurrent MI

Moderate or severe spontaneous/provocable myocardial ischemia during recovery from STEMI

Cardiogenic shock or hemodynamic instability.




79

PCI After FibrinolysisPCI After Fibrinolysis

It is reasonable to perform routine PCI in patients with left ventricular ejection fraction (LVEF) ≤ 0.40, CHF, or serious ventricular arrhythmias.

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

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).




80

Assessment of ReperfusionAssessment of Reperfusion

It is reasonable to monitor the pattern of ST elevation, cardiac rhythm and clinical symptoms over the 60 to 180minutes 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.


81

Ancillary Therapy to ReperfusionAncillary 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.


82

Ancillary Therapy to ReperfusionAncillary Therapy to Reperfusion

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.

Platelet counts should be monitored daily in patients taking UFH.



83

AspirinAspirin

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.


84

ThienopyridinesThienopyridines

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.


85


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.


86


Clopidogrel is probably indicated in patients

receiving fibrinolytic therapy who are unable

to take aspirin because of hypersensitivity or

gastrointestinal intolerance.


87

Glycoprotein IIb/IIIa InhibitorsGlycoprotein 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.



88

Other Pharmacological MeasuresOther 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

89

All-Cause Mortality

Years

Pro

bab

ilit

y o

f Even

t

0

0.05

0.1

0.15

0.2

0.25

0.3

0 1 2 3

0.35

0.4

4

ACE-I

Placebo

ACE-I 2995 2250 1617 892 223

Placebo 2971 2184 1521 853 138

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

OR: 0.74 (0.66–0.83)OR: 0.74 (0.66–0.83)

ACE-I: 702/2995 (23.4%)ACE-I: 702/2995 (23.4%)

Placebo: 866/2971 (29.1%)Placebo: 866/2971 (29.1%)

TRACEEchocardiographicEF 35%

AIREClinical and/or radiographic signs of HF

SAVERadionuclideEF 40%

90

Captopril

0

0.05

0.1

0.15

0.2

0.25

0.3

0 6 12 18 24 30 36

Pro

bab

ilit

y o

f Even

tMortality by Treatment

Pfeffer, McMurray, Velazquez, et al. N Engl J Med 2003;349

Valsartan 4909 4464 4272 4007 2648 1437 357

Months

Valsartan vs. Captopril: HR = 1.00; P = 0.982

Valsartan + Captopril vs. Captopril: HR = 0.98; P = 0.726

Captopril 4909 4428 4241 4018 2635 1432 364

Valsartan + Cap 4885 4414 4265 3994 2648 1435 382

Valsartan

Valsartan + Captopril

91

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

EPHESUS: All-Cause Mortality

Eplerenone 3319 3044 2463 1260 336 0 0

Placebo 3313 2983 2418 1213 323 2 0

Month 6 12 18 24 30 360

5

10

15

20

25

Cu

mu

lati

ve I

nci

den

ce (

%)

0

Eplerenone

Placebo

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

92

ACE/ARB: Within 24 HoursACE/ARB: Within 24 Hours

An ACE inhibitor should be administered orallywithin the first 24 hours of STEMI to the followingpatients without hypotension or known class ofcontraindications:

• 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.



93

ACE/ARB: Within 24 HoursACE/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).



94

Strict Glucose Control During STEMIStrict 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.



95

Hospital ManagementHospital Management



96

Sample Admitting Orders for the Sample Admitting Orders for the Patient With STEMIPatient 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

97

Sample Admitting Orders for the Sample Admitting Orders for the Patient With STEMIPatient 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

98

Emergency Management of Complicated STEMIEmergency Management of Complicated STEMI

Administer• Fluids• Blood transfusions• Cause-specific interventionsConsider vasopressors

Arrhythmia

Bradycardia Tachycardia

Systolic BPGreater than 100 mm Hg

Systolic BP 70 to 100 mm Hg

NO signs/symptomsof shock

Systolic BP70 to 100 mm HgSigns/symptoms

of shock

Systolic BP less than 70 mm Hg

Signs/symptoms of shock

Dobutamine2 to 20

mcg/kg per minute IV

Low Output -Cardiogenic Shock

Nitroglycerin10 to 20 mcg/min IV

Dopamine5 to 15

mcg/kg per minute IV

Norepinephrine0.5 to 30 mcg/min IV

Hypovolemia

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

Firs

t lin

e o

f a

ctio

nS

eco

nd

lin

e o

f a

ctio

nT

hird

lin

e o

f a

ctio

n

See Section 7.7in the ACC/AHA Guidelines for

Patients With ST-Elevation Myocardial Infarction

Check Blood Pressure

Clinical signs: Shock, hypoperfusion, congestive heart failure, acute pulmonary edemaMost likely major underlying disturbance?

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

Acute Pulmonary Edema

Check Blood Pressure

Systolic BP Greater than 100 mm Hg

and not less than 30 mm Hg below baseline

ACE InhibitorsShort-acting agent such as

captopril (1 to 6.25 mg)

Circulation 2000;102(suppl I):I-172-I-216.

99

Right Ventricular InfarctionRight 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.

100

Ventricular Ventricular Septal RuptureSeptal Rupture

Mitral RegurgitationMitral Regurgitation(Pap. M. dysfunction)(Pap. M. dysfunction)

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.

Free WallFree WallRuptureRupture

101

““Warning Arrhythmias”Warning Arrhythmias”

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

102

Arrhythmias During Acute Phase of STEMI:Arrhythmias During Acute Phase of STEMI: Electrical Instability Electrical Instability

VPBs K+ , Mg++, beta blocker

VT Antiarrhythmics, DC shock

AIVR Observe unless hemodynamiccompromise

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

Arrhythmia Treatment

103

Sinus Tach Treat cause; beta blocker

Afib / Flutter Treat cause; slow ventricular rate; DC shock

PSVT Vagal maneuvers; beta blocker, verapamil / diltiazem; DC shock

Arrhythmias During Acute Phase of STEMI:Arrhythmias During Acute Phase of STEMI: Pump Failure / Excess Sympathetic Tone Pump Failure / Excess Sympathetic Tone


104

Sinus Brady Treat if hemodynamic compromise;atropine / pacing

Junctional Treat if hemodynamic compromise; atropine / pacing

Arrhythmias During Acute Phase of STEMI:Arrhythmias During Acute Phase of STEMI: Bradyarrhythmias Bradyarrhythmias


105

Arrhythmias During Acute Phase of STEMI: Arrhythmias During Acute Phase of STEMI: AV Conduction Disturbances AV Conduction Disturbances

Escape Rhythm His Bundle Distal< 120 ms > 120 ms45 - 60 Often < 30

Duration of AVB 2 - 3 days Transient

Mortality Low High (CHF, VT)

Rx Observe PM (ICD)

Proximal Distal

106

Recommendations for Treatment of Atrioventricular and Intraventricular Conduction

Disturbances During STEMIINTRAVENTRICULAR CONDUCTION Normal

ACTION CLASS ACTION CLASS ACTION CLASS ACTION CLASS ACTION CLASS ACTION CLASS ACTION CLASS

Observe I Observe I Observe I Observe IIb Observe IIa Observe III Observe IIIA III A III A III A* III A III A III A IIITC III TC IIb TC IIb TC I TC I TC I TC ITV III TV III TV III TV III TV III TV IIa TV IIa

Old or New Observe I Observe IIb Observe IIb Observe IIb Observe IIb Observe III Observe IIIFascicular block A III A III A III A* III A III A III A III(LAFB or LPFB) TC IIb TC I TC IIa TC I TC I TC I TC I

TV III TV III TV III TV III TV III TV IIa TV IIbObserve I Observe III Observe III Observe III Observe III Observe III Observe IIIA III A III A III A* III A III A III A IIITC IIb TC I TC I TC I TC I TC I TC ITV III TV IIb TV IIb TV IIb TV IIb TV IIa TV IIaObserve III Observe III Observe III Observe III Observe III Observe III Observe IIIA III A III A III A* III A III A III A IIITC I TC I TC I TC I TC I TC IIb TC IIbTV IIb TV IIa TV IIa TV IIa TV IIa TV I TV I

Fascicular Observe III Observe III Observe III Observe III Observe III Observe III Observe IIIblock + RBBB A III A III A III A* III A III A III A III

TC I TC I TC I TC I TC I TC IIb TC IIbTV IIb TV IIa TV IIa TV IIa TV IIa TV I TV I

Alternating Observe III Observe III Observe III Observe III Observe III Observe III Observe IIIleft and right A III A III A III A* III A III A III A IIIbundle branch TC IIb TC IIb TC IIb TC IIb TC IIb TC IIb TC IIbblock TV I TV I TV I TV I TV I TV I TV I

Normal

Old bundle branch block

New bundle branch block

Mobitz II second degree AV blockMobitz I second degree AV blockFirst degree AV block

ANTERIOR MI NON-ANTERIOR ANTERIOR MI NON-ANTERIOR ANTERIOR MI NON-ANTERIOR

Atrioventricular Conduction

107

ICD Trials in Post-MI Patients

NEJM 1996;335:1933-40.NEJM 1999;341;1882-90.NEJM 2002;346:877-93.

EFUpper limit,

mean

3-30 VPBsrate greater

than 120

Greater than 2 VPS

rate greater than 100

MADIT 2 2002 1232 Greater than 29

None necessary

30%, 23% No 0.69 (0.51-0.93)

35%, 26% Yes 0.46 (0.26-0.82)

MUSTT 1999 704 Greater than 3

40%, 30% Yes 0.42 (0.28-0.62)

MADIT 1996 196 Greater than 20

Qualifying arrhythmia

EPS Mortality hazard ICD versus no ICD (95%CI)

Study Name

Year Number of

patients

Days post-MI

108

ICD Implantation After STEMIOne Month After STEMI;

No Spontaneous VT or VF 48 hours post-STEMI

EF < 0.30

EPS

Yes

+

NEJM 349: 1836,2003

EF 0.31 - 0.40

No

No ICD.Medical Rx

EF > 0.40

-

Additional Marker of Electrical Instability?

109

Algorithm for Management of Recurrent Ischemia/Infarction After STEMI

Obtain 12-lead ECG

ST-segment elevation?

• Escalation of medical therapy (nitrates, beta-blockers)

• Anticoagulation if not already given• Consider IABP for hemodynamic instability,

poor LV function, or a large area of myocardium at risk

• Correct secondary causes of ischemia

Recurrent ischemic-type discomfort at rest after STEMI

Obtain 12-lead ECG

ST-segment elevation?ST-segment elevation?






110


Obtain 12-lead ECG

YES NO

Consider (re) administration of

YES

Is patient a candidate for

revascularization?







YES

Coronary angiography

Revascularization with PCI and/or CABG as dictated by

anatomy

NO

Can catheterization

be performed promptly?*

Obtain 12-lead ECG

YES NO

Consider (re) administration of fibrinolytic therapy

YES


revascularization?


revascularization?







YES



anatomy

NO

Can catheterization


Can catheterization

be performed promptly?

Modified from Braunwald. Heart Disease: A Textbook of Cardiovascular Medicine. 6th ed. Philadelphia, PA: WB Saunders Co. Ltd. 2001:1195.


111


Obtain 12-lead ECG

YES NO

Consider (re) administration of

YES NO


revascularization?







YES NO

Refer for nonurgent

catheterization

Refer for urgent catheterization (consider

IABP)

Is ischemia controlled by escalation

of medical therapy?

YES



anatomy

NO

Can catheterization


Obtain 12-lead ECG

YES NO


YES NO


revascularization?


revascularization?







YES NO

Refer for nonurgent

catheterization


IABP)

YES NO

Refer for nonurgent

catheterization


IABP)


of medical therapy?


of medical therapy?

YES



anatomy

NO

Can catheterization


Can catheterization

be performed promptly?

Modified from Braunwald. Heart Disease: A Textbook of Cardiovascular Medicine. 6th ed. Philadelphia, PA: WB Saunders Co. Ltd. 2001:1195.


112

Evidence-Based Approach to Need for Catheterization and Revascularization After STEMI

STEMI

Primary Invasive Strategy Fibrinolytic Therapy No Reperfusion Therapy

Cath Performed

No Cath Performed

EF greater than 0.40

EF less than 0.40

EF less than 0.40


High-RiskFeatures †

No High -RiskFeatures †

No High -RiskFeatures †

High-RiskFeatures †

Functional Evaluation

ECG Interpretable ECG Uninterpretable

Able to Exercise Unable to Exercise

SubmaximalExercise Test

Before Discharge

Symptom-LimitedExercise Test

Before or After Discharge

Pharmacological Stress

Nuclear Scan

DobutamineEcho

Clinically SignificantIschemia*

No Clinically SignificantIschemia*

MedicalTherapy

Revascularization as Indicated

Catheterization and Revascularization as

Indicated


Indicated

Able to Exercise

Exercise Echo

Exercise Nuclear

STEMI

Primary Invasive Strategy Fibrinolytic Therapy No Reperfusion Therapy

Cath Performed

No Cath Performed


EF less than 0.40

EF less than 0.40


High-RiskFeatures

No High -RiskFeatures

No High -RiskFeatures

High-RiskFeatures

Functional Evaluation

ECG Interpretable ECG Uninterpretable

Able to Exercise Unable to Exercise

SubmaximalExercise Test

Before Discharge

Symptom-LimitedExercise Test

Before or After Discharge

Pharmacological Stress

Adenosineor Dipyridamole Dobutamine

Echo

Clinically SignificantIschemia

No Clinically SignificantIschemia

MedicalTherapy

Revascularization as Indicated


Indicated


Indicated

Able to Exercise

Exercise Echo

Exercise Nuclear

113

Long-Term Antithrombotic Therapy at Hospital Discharge After STEMI

No Stent Implanted

No ASA allergy ASA Allergy

Preferred:ASA 75 to 162 mg

Class I; LOE: A

Preferred:Clopidogrel 75 mg

Class I; LOE: C

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

Indicationsfor Anticoagulation

No Indicationsfor Anticoagulation

No Indicationsfor Anticoagulation


ASA 75 to 162 mgWarfarin

(INR 2.0 to 3.0)Class I; LOE B

OR

Warfarin(INR 2.5 to 3.5)Class I; LOE: B

WarfarinINR (2.5 to 3.5)Class I; LOE: B

STEMI Patient at Discharge

114

Long-Term Antithrombotic Therapy at Hospital Discharge After STEMI

Stent Implanted

No ASA Allergy ASA Allergy

ASA 75 to 162 mgClopidogrel 75 mgClass: I; LOE: B

ASA 75 to 162 mgClopidogrel 75 mg

Warfarin (INR 2.0 to 3.0)

Class: IIb; LOE: C

Clopidogrel 75 mgClass I; LOE: B

Clopidogrel 75 mgWarfarin

(INR 2.0 to 3.0)Class I; LOE: C

STEMI Patient at Discharge

No Indicationsfor

Anticoagulation


Indicationsfor

Anticoagulation

No Indicationsfor

Anticoagulation

115

Long-Term ManagementLong-Term Management



116

Secondary Prevention and Long Term Management

• 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

Goals Recommendations

117


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


118


• 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


119


• 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 ontreatment):

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

120


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


121



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.

Weight management:Goal:BMI 18.5 to 24.9 kg/m2

Waist circumference:Women: < 35 in.Men: < 40 in.

122



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).

Diabetes management: Goal: HbA1c < 7%

123



• 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.

Antiplatelet agents/ anticoagulants

124



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.

Renin-Angiotensin-Aldosterone System Blockers

125



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

Beta- Blockers

126

1st 1st 24 h24 h

During During HospHosp

Hosp DC + Hosp DC + Long TermLong Term

Aspirin 162-325 mgchewed

75-162 mg/d p.o.

75-162 mg/d p.o.

Fibrinolytic tPA,TNK,rPA, SK

UFH60U/kg (4000)

12 U/kg/h (1000)aPTT 1.5 - 2 x C

aPTT1.5 - 2 x C

Beta-blocker Oral daily Oral daily Oral daily

Summary of Pharmacologic Rx:Summary of Pharmacologic Rx: Ischemia Ischemia

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

127

1st 1st 24 h24 h

During HospDuring Hosp Hosp DC + Hosp DC + Long TermLong Term

ACEI Anterior MI,Pulm Cong., EF < 40 Oral

Daily

Oral

Daily

IndefinitelyARB ACEI intol.,HF, EF < 40

Aldo Blocker

No renal dysf, K+ < 5.0 mEq/L

On ACEI, HF or DM

Same as during Hosp.

Statin Start w/o lipid profile

Indefinitely,

LDL << 100

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

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

128

Hormone TherapyHormone Therapy

Hormone therapy with estrogen plus progestin

should not be given de novo to postmenopausal

women after STEMI for secondary prevention of

coronary events.


129

Hormone TherapyHormone 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.


130

AntioxidantsAntioxidants

Antioxidant vitamins such as vitamin E and/or

vitamin C supplements should not be prescribed to

patients recovering from STEMI to prevent

cardiovascular disease.


131

Psychosocial Impact of STEMIPsychosocial 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.



132

Cardiac RehabilitationCardiac 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.


133

• Review and continue predischarge risk assessment.

• Delineate cardiovascular symptoms and functional class.

• Evaluate current medications and titrate if needed.

• Review secondary prevention principles.

• Check psychosocial status.

• Discuss resumption of daily activities.

• Address plan for recognizing and responding to potential cardiac event.

• Refer to a cardiac rehabilitation program.

Follow-Up Visit With Medical ProviderFollow-Up Visit With Medical Provider


2 This slide set was adapted from the ACC/AHA Guidelines for Management of Patients With ST-...

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Transcript of 2 This slide set was adapted from the ACC/AHA Guidelines for Management of Patients With ST-...