ACUTE MYOCARDIAL INFARCTION- GUIDELINE BASED TREATMENT. NCVH/5-28-Thu/FamPractice/1345_Bilal... ·...

Bilal Malik MD,FACP, FACC,FSCAI

Asst. Prof. of Medicine SUNY Downstate Brooklyn, NY

ACUTE MYOCARDIAL INFARCTION-GUIDELINE BASED TREATMENT.

My Disclosure• Speaker Astra Zeneca

• Speaker Medtronic Corporation

• Incidence of MI in US 650,000 new cases/yr. 450,000 recurrent cases/yr.

• CAD most leading cause of death in US.

• Every 29 secs somebody gets an MI & every min somebody dies from it.

Figure 1

Age- and sex-adjusted incidence rates of acute MI, 1999 to 2008. I bars represent 95% confidence intervals. MI indicates myocardial infarction; STEMI,

ST-elevation myocardial infarction.

Community incidence rates for STEMI have declined over the past decade, whereas those for non–ST-elevation ACS have increased (Figure 1). At present, STEMI comprises approximately 25% to 40% of MI presentations (12,13,14,15). In-hospital (approximately 5% to 6%) and 1-year (approximately 7% to 18%) mortality rates from STEMI also have decreased significantly in association with a substantial increase in the frequency of care that includes GDMT and interventions (“defect-free” care)

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T-wave ∆

ST-seg ∆

Path. Q waves

Zone of ischemia

Zone of injury

Zone of necrosis

Lateral AnteriorSeptal

Inferior

T Wave – ST seg. changes

>0.03 seconds

>1/3 the total of QRS

ACC/ AHA Guidelines:Size of Treatment EffectStrength of Recommendation

• Class I: Benefit >>> Risk: ‘Should’

• Class IIa: Benefit>> Risk: ‘is reasonable’

• Class IIb: Benefit>=Risk: ‘may be considered’

• Class III: Risk>=Benefit: ‘Should not..’

Management of STEMI• Pre-hospital and Initial Management

• Hospital Management

• Hemodynamic Disturbances

• Arrhythmias

• Emerging Therapies

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 9-1-1 if symptoms

do not improve or worsen 5 minutes after ONE

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

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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.



Pre hospital Chest pain Evaluation and Treatment

• All ACLS providers perform and evaluate ECGs of suspected STEMI patients

Prehospital Fibrinolysis

• Establishment of prehospital fibrinolysis protocol is reasonable in 1) when physicians are present in ambulance or 2)well organized EMS systems(if transport time more than 60 min)

• 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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INITIAL EVALUATION AND MANAGEMENT IN EMERGENCY ROOM

Initial Evaluation and Management in ER• Initial evaluation in the emergency department focuses on

identification of STEMI, early therapy, and reperfusion strategy.

• Time to reperfusion therapy strongly influences outcomes in STEMI.

Initial patient evaluation

• Targeted history

• Physical examination including focused and limited neurological examination to look for prior stroke or cognitive defects prior to thrombolysis

ECG

• A 12 lead ECG should be performed within 10 min

• If not diagnostic and patient is symptomatic, serial ECGs at 5to10min or continuous ST segment monitoring

• In patients with IWMI, Rt sided ECG leads should be obtained

Laboratory examinations

• Should be performed but should not delay implementation of reperfusion therapy

• Serial biomarker measurements useful to provide supportive noninvasive evidence of reperfusion

• Serial biomarker measurements should not be relied on to diagnose reinfarction in 18 hrs after onset of STEMI

Imaging

• Should have a portable CXR but should not delay reperfusion unless AD is suspected

• Portable CXR,TTE or TEE ,contrast CT or MRI should be used to differentiate STEMI from AD if not clear initially

Echocardiography

Portable echo in ED is reasonable to

• Clarify diagnosis of STEMI

• Risk stratification

• Diagnosis confounded by LBBB or pacing

• Suspicion of PWMI with anterior ST depression

• Mechanical causes of failure or shock

Initial Management in ER

Oxygen

• Supplemental oxygen should be administered to patients with SaO2<90%

• It reasonable in all patients in first 6hrs

Nitroglycerin

• Patients with ongoing pain should receive S/L NTG (.4mg) for a total 3 doses

• IV NTG indicated for

ongoing pain

control of hypertension

pulmonary congestion

Nitroglycerine

Nitrates should not be administered when

SBP<90mmHg

SBP<30mmHg below baseline

Severe bradycardia (<50)

Tachycardia(>100)

Suspected RV infarction

Those received PDE inhibitor in 24 hrs (48hrs

for tadalafil)

Analgesia

• Morphine sulfate(2-4mg IV with increments 2-8mg IV 5 to 15 min intervals) is the choice

• Patients taking NSAIDS should be discontinued due to increased risk of mortality ,reinfarction , HTN,HF and myocardial rupture

• (ExTRACT TIMI25)

Aspirin

• Aspirin should be chewed by patients who have not taken ,initial dose 162 or 325

• maintenance dose of 75 to 162 mg should be given indefinitely after STEMI to all patients without a true aspirin allergy

Beta blocker

• Oral beta blocker therapy should be initiated in 24hrs to those who not have

Signs of HF

E/O low out put state

Increased risk for cardiogenic shock

>70yrs,SBP< 120,HR>110 or< 60 or

Increased time since onset of symptoms

•Other relative CI

PR>.24sec

2nd or 3rd degree HB

Active asthma

Reactive airway diseases

Beta blockers

• It is reasonable to administer IV BB at the time of presentation to patients who are hypertensive without any above contraindications

• Continue indefinitely

• (COMMIT/CCS 2)

Assessment of Reperfusion Options for STEMI Patients

• Step 1: Assess time and risk.

• Time since onset of symptoms

• Risk of STEMI

• Risk of fibrinolysis

• Time required for transport to a skilled PCI laboratory

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 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.

Fibrinolytic Therapy When There Is an Anticipated Delay to Performing Primary PCI Within 120 Minutes of FMC

In the absence of contraindications, fibrinolytic therapy should be given to patients with STEMI and onset of ischemic symptoms within the previous 12 hours when it is anticipated that primary PCI cannot be performed within 120 minutes of FMC.

In the absence of contraindications and when PCI is not available, fibrinolytic therapy is reasonable for patients with STEMI if there is clinical and/or ECG evidence of ongoing ischemia within 12 to 24 hours of symptom onset and a large area of myocardium at risk or hemodynamic instability.

Fibrinolytic therapy should not be administered to patients with ST depression except when a true posterior (inferobasal) MI is suspected or when associated with ST elevation in lead aVR.

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Thrombolytic Agents

• t-PA: 5-mg intravenous bolus followed by an infusion of 0.75 mg/kg (maximum 50 mg) over 30 minutes, followed by an infusion of 0.5 mg/kg (maximum 35 mg) over 60 minutes.

• Reteplase: therapeutically similar to t-PA and the double-bolus method of administration of reteplase an advantage over t-PA.

• Tenecteplase: comparable to t-PA; with the exception of patients treated after 4 hours from the onset of symptoms, among whom the mortality rate was 7.0% with tenecteplase and 9.2% with t-PA (P = 0.018).

• Other agents: Urokinase, Streptokinase, Anistreplase, Staphylokinase

Absolute Contraindications to Thrombolytic Therapy

• History of any intracranial hemorrhage

• History of ischemic stroke within the preceding three months except for acute ischemic stroke within three hours which may be treated thrombolytic therapy

• Presence of cerebral vascular malformation or metastatic intracranial malignancy

• Symptoms and signs suggestive of acute aortic dissection

• A bleeding diathesis or active bleeding with the exception of menses;

• Significant closed head or facial trauma within the preceding three months

Relative Contraindications to Thrombolytic Therapy• History of chronic, sever, poorly controlled hypertension or uncontrolled

hypertension at presentation (SBP >180 mmHg and/or DBP >110 mmHg)

• History of ischemic stroke more than 3 months previously

• Dementia

• Any know intra-cranial disease that is not an absolute contraindication

• Traumatic or prolonged (>10 mins) CPR

• Major surgery within the preceding three weeks

• Internal bleeding within the preceding two to four weeks or active peptic ulcer

• Noncompressible vascular punctures

• Pregnancy

• Current warfarin therapy: the risks of bleeding increases as INR increases

• For streptokinase or anistreplase: a prior exposure (more than 5 days previously) or allergic reactions to these drugs


Assessment 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.

Adjunctive Antiplatelet Therapy With Fibrinolysis

Aspirin (162- to 325-mg loading dose) and clopidogrel (300-mg loading dose for patients ≤75 years of age, 75-mg dose for patients >75 years of age) should be administered to patients with STEMI who receive fibrinolytic therapy.

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• aspirin should be continued indefinitely and

In patients with STEMI who receive fibrinolytic therapy: I IIa IIb III

• clopidogrel (75 mg daily) for at least 14 days

o and up to 1 year I IIa IIb III

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It is reasonable to use aspirin 81 mg per day in preference to higher maintenance doses after fibrinolytic therapy.

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Adjunctive Anticoagulant Therapy With Fibrinolysis

Patients with STEMI undergoing reperfusion with fibrinolytic therapy should receive anticoagulant therapy for a minimum of 48 hours, and preferably for the duration of the index hospitalization, up to 8 days or until revascularization if performed. Recommended regimens include:

a. UFH administered as a weight-adjusted intravenous bolus and infusion to obtain an activated partial thromboplastin time of 1.5 to 2.0 times control, for 48 hours or until revascularization;

b. Enoxaparin administered according to age, weight, and creatinineclearance, given as an intravenous bolus, followed in 15 minutes by subcutaneous injection for the duration of the index hospitalization, up to 8 days or until revascularization; or

c. Fondaparinux administered with initial intravenous dose, followed in 24 hours by daily subcutaneous injections if the estimated creatinineclearance is greater than 30 mL/min, for the duration of the index hospitalization, up to 8 days or until revascularization.

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Transfer of Patients With STEMI to a PCI-Capable Hospital for Coronary Angiography After Fibrinolytic Therapy

Immediate transfer to a PCI-capable hospital for coronary angiography is recommended for suitable patients with STEMI who develop cardiogenic shock or acute severe HF, irrespective of the time delay from MI onset.

Urgent transfer to a PCI-capable hospital for coronary angiography is reasonable for patients with STEMI who demonstrate evidence of failed reperfusion or reocclusion after fibrinolytic therapy.

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Transfer of Patients With STEMI to a PCI-Capable Hospital for Coronary Angiography After Fibrinolytic Therapy

Transfer to a PCI-capable hospital for coronary angiography is reasonable for patients with STEMI who have received fibrinolytictherapy even when hemodynamically stable* and with clinical evidence of successful reperfusion. Angiography can be performed as soon as logistically feasible at the receiving hospital, and ideally within 24 hours, but should not be performed within the first 2 to 3 hours after administration of fibrinolytic therapy.

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*Although individual circumstances will vary, clinical stability is defined by the absence of low output, hypotension, persistent tachycardia, apparent shock, high-grade ventricular or symptomatic supraventricular tachyarrhythmias, and spontaneous recurrent ischemia.

Primary PCI in STEMI

I IIa IIb IIIPrimary PCI should be performed in patients with STEMI and ischemic symptoms of less than 12 hours’ duration.

Primary PCI should be performed in patients with STEMI and ischemic symptoms of less than 12 hours’ duration who have contraindications to fibrinolytic therapy, irrespective of the time delay from FMC.

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Primary PCI should be performed in patients with STEMI and cardiogenic shock or acute severe HF, irrespective of time delay from MI onset.

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Primary PCI in STEMI

Primary PCI is reasonable in patients with STEMI if there is clinical and/or ECG evidence of ongoing ischemia between 12 and 24 hours after symptom onset.

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PCI should not be performed in a noninfarct artery at the time of primary PCI in patients with STEMI who are hemodynamically stable

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Relationship between D2B time NRMI Registry

McNamara RL, et al. J Am Cardiol 2006; 47:2180-2186

Aspiration Thrombectomy

Manual aspiration thrombectomy is reasonable for patients undergoing primary PCI.

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Use of Stents in Patients With STEMI

Placement of a stent (BMS or DES) is useful in primary PCI for patients with STEMI.

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BMS* should be used in patients with high bleeding risk, inability to comply with 1 year of DAPT, or anticipated invasive or surgical procedures in the next year.

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DES should not be used in primary PCI for patients with STEMI who are unable to tolerate or comply with a prolonged course of DAPT because of the increased risk of stent thrombosis with premature discontinuation of one or both agents.

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*Balloon angioplasty without stent placement may be used in selected patients.

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Antiplatelet Therapy to Support Primary PCI for STEMI

Aspirin 162 to 325 mg should be given before primary PCI.

After PCI, aspirin should be continued indefinitely.

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A loading dose of a P2Y12 receptor inhibitor should be given as early as possible or at time of primary PCI to patients with STEMI. Options include:

• Clopidogrel 600 mg; or

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• Prasugrel 60 mg; or

• Ticagrelor 180 mg


P2Y12 inhibitor therapy should be given for 1 year to patients with STEMI who receive a stent (BMS or DES) during primary PCI using the following maintenance doses:

• Clopidogrel 75 mg daily; or

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• Prasugrel 10 mg daily; or

• Ticagrelor 90 mg twice a day*

*The recommended maintenance dose of aspirin to be used with ticagrelor is 81 mg daily.


It is reasonable to use 81 mg of aspirin per day in preference to higher maintenance doses after primary PCI.

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It is reasonable to start treatment with an intravenous GP IIb/IIIa receptor antagonist at the time of primary PCI (with or without stenting or clopidogrel pretreatment) in selected patients with STEMI who are receiving UFH.

• Double-bolus eptifibatide: 180 mcg/kg IV bolus, then 2 mcg/kg/min; a 2nd 180-mcg/kg bolus is administered 10 min after the 1st bolus.

• Abciximab: 0.25 mg/kg IV bolus, then 0.125 mcg/kg/min (maximum 10 mcg/min); or

• High-bolus-dose tirofiban: 25 mcg/kg IV bolus, then 0.15 mcg/kg/min; or

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It may be reasonable to administer intravenous GP IIb/IIIa receptor antagonist in the precatheterization laboratory setting (e.g., ambulance, ED) to patients with STEMI for whom primary PCI is intended.

It may be reasonable to administer intracoronary abciximab to patients with STEMI undergoing primary PCI.

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Continuation of a P2Y12 inhibitor beyond 1 year may be considered in patients undergoing DES placement.

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Prasugrel should not be administered to patients with a history of prior stroke or transient ischemic attack.

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Anticoagulant Therapy to Support Primary PCI

For patients with STEMI undergoing primary PCI, the following supportive anticoagulant regimens are recommended:

• UFH, with additional boluses administered as needed to maintain therapeutic activated clotting time levels, taking into account whether a GP IIb/IIIa receptor antagonist has been administered; or

• Bivalirudin with or without prior treatment with UFH.

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Anticoagulant Therapy to Support Primary PCI

In patients with STEMI undergoing PCI who are at high risk of bleeding, it is reasonable to use bivalirudin monotherapy in preference to the combination of UFH and a GP IIb/IIIa receptor antagonist.

Fondaparinux should not be used as the sole anticoagulant to support primary PCI because of the risk of catheter thrombosis.

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PCI of a Noninfarct Artery Before Hospital Discharge

PCI is indicated in a noninfarct artery at a time separate from primary PCI in patients who have spontaneous symptoms of myocardial ischemia.

PCI is reasonable in a noninfarct artery at a time separate from primary PCI in patients with intermediate- or high-risk findings on noninvasive testing.

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Antiplatelet Therapy to Support PCI After Fibrinolytic Therapy

After PCI, aspirin should be continued indefinitely.

b. A 600-mg loading dose should be given before or at the time of PCI to patients who did not receive a previous loading dose and who are undergoing PCI more than 24 hours after receiving fibrinolytic therapy; and

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Clopidogrel should be provided as follows:

a. A 300-mg loading dose should be given before or at the time

of PCI to patients who did not receive a previous loading

dose and who are undergoing PCI within 24 hours of

receiving fibrinolytic therapy;

c. A dose of 75 mg daily should be given after PCI.


After PCI, it is reasonable to use 81 mg of aspirin per day in preference to higher maintenance doses.

Prasugrel, in a 60-mg loading dose, is reasonable once the coronary anatomy is known in patients who did not receive a previous loading dose of clopidogrel at the time of administration of a fibrinolytic agent, but prasugrel should not be given sooner than 24 hours after administration of a fibrin-specific agent or 48 hours after administration of a non–fibrin-specific agent.

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Prasugrel, in a 10-mg daily maintenance dose, is reasonable after PCI.

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Prasugrel should not be administered to patients with a history of prior stroke or transient ischemic attack.

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Anticoagulant Therapy to Support PCI After Fibrinolytic Therapy

For patients with STEMI undergoing PCI after receiving fibrinolytic therapy with intravenous UFH, additional boluses of intravenous UFH should be administered as needed to support the procedure, taking into account whether GP IIb/IIIa receptor antagonists have been administered.

For patients with STEMI undergoing PCI after receiving fibrinolytic therapy with enoxaparin, if the last subcutaneous dose was administered within the prior 8 hours, no additional enoxaparin should be given; if the last subcutaneous dose was administered between 8 and 12 hours earlier, enoxaparin 0.3 mg/kg IV should be given.

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Anticoagulant Therapy to Support PCI After Fibrinolytic Therapy

Fondaparinux should not be used as the sole anticoagulant to support PCI. An additional anticoagulant with anti-IIa activity should be administered because of the risk of catheter thrombosis.

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CABG in Patients With STEMI

Urgent CABG is indicated in patients with STEMI and coronary anatomy not amenable to PCI who have ongoing or recurrent ischemia, cardiogenic shock, severe HF, or other high-risk features.

CABG is recommended in patients with STEMI at time of operative repair of mechanical defects.

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CABG in Patients With STEMI

The use of mechanical circulatory support is reasonable in patients with STEMI who are hemodynamically unstable and require urgent CABG.

Emergency CABG within 6 hours of symptom onset may be considered in patients with STEMI who do not have cardiogenic shock and are not candidates for PCI or fibrinolytic therapy.

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Timing of Urgent CABG in Patients With STEMI in Relation to Use of Antiplatelet Agents

Aspirin should not be withheld before urgent CABG.

Short-acting intravenous GP IIb/IIIa receptor antagonists (eptifibatide, tirofiban) should be discontinued at least 2 to 4 hours before urgent CABG.

Clopidogrel or ticagrelor should be discontinued at least 24 hours before urgent on-pump CABG, if possible.

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Timing of Urgent CABG in Patients With STEMI in Relation to Use of Antiplatelet Agents

Abciximab should be discontinued at least 12 hours before urgent CABG.

Urgent off-pump CABG within 24 hours of clopidogrel or ticagrelor administration might be considered, especially if the benefits of prompt revascularization outweigh the risks of bleeding.

Urgent CABG within 5 days of clopidogrel or ticagrelor administration or within 7 days of prasugrel administration might be considered, especially if the benefits of prompt revascularization outweigh the risks of bleeding.

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Hospital Management• Focus on monitoring for and treating secondary complications of

STEMI

• Admitted to a coronary care unit (CCU) or step-down unit (for low-risk patients)

• Beta-adrenergic blocking agents: if received within the first 24 hours continue; if not received within first 24 hours and not contraindicated start; if contraindicated within first 24 hours reassess

• Nitroglycerin: Intravenous nitroglycerin is indicated in the first 48 hours after STEMI for the treatment of persistent ischemia, congestive heart failure (CHF), or hypertension. Intravenous, oral, or topical nitrates are useful beyond the first 48 hours after STEMI for treatment of recurrent angina or persistent CHF if their use does not preclude therapy with beta blockers or ACE inhibitors

Routine Medical Therapies

Guideline for STEMI

Beta Blockers

Oral beta blockers should be initiated in the first 24 hours in patients with STEMI who do not have any of the following: signs of HF, evidence of a low output state, increased risk for cardiogenic shock,* or other contraindications to use of oral beta blockers (PR interval >0.24 seconds, second- or third-degree heart block, active asthma, or reactive airways disease).

Beta blockers should be continued during and after hospitalization for all patients with STEMI and with no contraindications to their use.

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*Risk factors for cardiogenic shock (the greater the number of risk factors present, the higher the risk of developing cardiogenic shock) are age >70 years, systolic BP <120 mm Hg, sinus tachycardia >110 bpm or heart rate <60 bpm, and increased time since onset of symptoms of STEMI.

Beta Blockers

Patients with initial contraindications to the use of beta blockers in the first 24 hours after STEMI should be reevaluated to determine their subsequent eligibility.

It is reasonable to administer intravenous beta blockers at the time of presentation to patients with STEMI and no contraindications to their use who are hypertensive or have ongoing ischemia.

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Renin-Angiotensin-Aldosterone System Inhibitors

An ACE inhibitor should be administered within the first 24 hours to all patients with STEMI with anterior location, HF, or EF less than or equal to 0.40, unless contraindicated.

An ARB should be given to patients with STEMI who have indications for but are intolerant of ACE inhibitors.

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Renin-Angiotensin-Aldosterone System Inhibitors

An aldosterone antagonist should be given to patients with STEMI and no contraindications who are already receiving an ACE inhibitor and beta blocker and who have an EF less than or equal to 0.40 and either symptomatic HF or diabetes mellitus.

ACE inhibitors are reasonable for all patients with STEMI and no contraindications to their use.

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Lipid Management

High-intensity statin therapy should be initiated or continued in all patients with STEMI and no contraindications to its use.

It is reasonable to obtain a fasting lipid profile in patients with STEMI, preferably within 24 hours of presentation.

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Blood sugar control

• It is reasonable to use an insulin based regimen

to achieve and maintain glucose levels less than

180 mg/dl while avoiding hypoglycemia for

patients with STEMI with either a complicated or

uncomplicated course

• NICE SUGAR

Use of Noninvasive Testing for

Ischemia Before Discharge

Risk Assessment After STEMI

Use of Noninvasive Testing for Ischemia Before Discharge

Noninvasive testing for ischemia should be performed before discharge to assess the presence and extent of inducible ischemia in patients with STEMI who have not had coronary angiography and do not have high-risk clinical features for which coronary angiography would be warranted.

Noninvasive testing for ischemia might be considered before discharge to guide the postdischarge exercise prescription.

Noninvasive testing for ischemia might be considered before discharge to evaluate the functional significance of a noninfarct artery stenosis previously identified at angiography.

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Assessment of LV Function

LVEF should be measured in all patients with STEMI. I IIa IIb III

Assessment of Risk for SCD

Patients with an initially reduced LVEF who are possible candidates for ICD therapy should undergo reevaluation of LVEF 40 or more days after discharge.

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Posthospitalization Plan of Care

Posthospital systems of care designed to prevent hospital readmissions should be used to facilitate the transition to effective, coordinated outpatient care for all patients with STEMI.

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Exercise-based cardiac rehabilitation/secondary prevention programs are recommended for patients with STEMI.

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Secondary Prevention and Long Term Management

• Recommendations for secondary prevention after STEMI include the following:

▪ Complete smoking cessation

▪ Blood pressure at goal < 140/90 mm Hg unless diabetes or chronic kidney disease is

present (blood pressure < 130/90 mm Hg)

▪ Physical activity 30 minutes, 3 to 4 days/week, optimally daily

▪ Hemoglobin A1c (HbA1c) < 7%

▪ Body mass index (BMI), 18.5 to 24.9

ICD & CRT

• ICD: more than 40 days post MI and more than 3 mths post PCI or CABG 1) LVEF < 30%, 2) LVEF < 35% with NYHA II or III, 3) LVEF < 40% need holter monitor NSVT EP study positive ICD

• CRT: LVEF < 35%, LV dyssynchrony (QES >120 msec) and NYHA class III or IV HF despite optimal medical therapy

Thank You!

Bilal Malik MD,FACP, FACC,FSCAI

Asst. Prof. of Medicine SUNY Downstate Brooklyn, NY

ACUTE MYOCARDIAL INFARCTION-GUIDELINE BASED TREATMENT.

ACUTE MYOCARDIAL INFARCTION- GUIDELINE BASED TREATMENT. NCVH/5-28-Thu/FamPractice/1345_Bilal... ·...

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