Stemi: Guides

7/27/2019 Stemi: Guides

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ACC/AHA 2009 STEMI Guideline

Focused Update and

Whats New in 2012 Guideline

David Zhao, MD, FACC, FSCAI

Professor of Medicine and Cardiac Surgery

Harry and Shelley Page Professor in Interventional Cardiology

Director, Cardiac Catheterization Laboratories

& Interventional Cardiology

Vanderbilt University Medical Center

Nashville TN, USA


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1990 1992 1994 1996 1998 2000 20021990

ACC/AHAAMI

R. Gunnar1994

AHCPR/NHLBIUA

E. Braunwald 1996 1999Rev UpdACC/AHA AMIT. Ryan

2004 2007Rev UpdACC/AHA STEMI

E. Antman

2000 2002 2007Rev Upd RevACC/AHA UA/NSTEMIE. Braunwald; J. Anderson

2004 2007

Evolution of Guidelines for ACS

2009

2009Upd

ACC/AHA STEMI/PCIF. Kushner


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Hospitalizations in the U.S. Due to Acute

Coronary Syndromes (ACS)

Acute Coronary

Syndromes*

1.57 Million Hospital Admissions - ACS

UA/NSTEMI STEMI

1.24 millionAdmissions per year

.33 millionAdmissions per year

Heart Disease and Stroke Statistics 2007 Update. Circulation 2007; 115:69-171.

*Primary and secondary diagnoses. About 0.57 million NSTEMI and 0.67 million UA.


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Class I

Benefit >>> Risk

Procedure/ Treatment

SHOULD be

performed/

administered

Class IIa

Benefit >> Risk

Additional studies with

focused objectives

neededIT IS REASONABLE

to perform

procedure/administer

treatment

Class IIb

Benefit Risk


broad objectives

needed; Additional

registry data would behelpful

Procedure/Treatment

MAY BE CONSIDERED

Class III

Risk Benefit

No additional studies

neededProcedure/Treatmentshould 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 Recommendations

and Level of Evidence


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Class I

Benefit >>> Risk

Procedure/ Treatment

SHOULD be

performed/

administered

Class IIa

Benefit >> Risk


focused objectives

neededIT IS REASONABLE to

perform

procedure/administer

treatment

Class IIb

Benefit Risk


broad objectives needed;

Additional registry data

would be helpful

Procedure/Treatment

MAY BE CONSIDERED

Class III

Risk Benefit

No additional studies

neededProcedure/Treatment

should NOT be

performed/administered

SINCE IT IS NOT

HELPFUL AND MAY

BE HARMFUL

Applying Classification of Recommendations

and Level of Evidence

Level A: Multiple populations evaluated; Data derived from multiple randomized clinical trials or meta-analyses

Level B: Limited populations evaluated. Data derived from a single randomized trial or non-randomized studies

Level C: Very limited populations evaluated. Only consensus opinion of experts, case studies, or standard-of-care.


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Recommendations for the use ofThienopyridines


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Recommendations for the use of

Thienopyridines

A loading dose of thienopyridine is recommended for

STEMI patients for whom PCI is planned. Regimens shouldbe one of the following:

MODIFIED

Recommendat ion

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

Clopidogrel at least 300 mg to 600mg should

be given as early as possible before or at the

time of primary or non-primary PCI.


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Optimal Plavix Loading Dose:

ISAR CHOICE


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Thienopyridines

Prasugrel 60 mg should be given as soon aspossible for primary PCI.

MODIFIED

Recommendat ion



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0

5

10

15

0 30 60 90 180 270 360 450

Percent(%)

Days From Randomization

9.5%6.5%

HR 0.68(0.54-0.87)

P=0.002

12.4%10.0%

HR 0.79

(0.65-0.97)P=0.02

Clopidogrel

PrasugrelNNT = 42

CV Death / MI / Stroke

TIMI MajorNonCABG Bleeds

ClopidogrelPrasugrel 2.4

2.1

STEMI Cohort

N=3534

Montalescot et al Lancet 2008.Adapted withpermiss ion from Antman EM.

TRITON TIMI-38


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PLATO (The Study of Platelet Inhibition andPatient Outcomes)

Cumulative Incidence of Primary Endpoint* and Major Bleeding

Adapted from: Wallentin L et al.

N Engl J Med. 2009; Available at: http://www.nejm.org.

Ticagrelor

Clopidogrel

HR=0.84 (0.77 0.92)

P


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Thienopyridines

For STEMI patients undergoing non-pr imaryPCI, the

following regimens are recommended:

III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII a. and has been given clopidogrel, it should be

continued as the thienopyridine of choice.b. without a thienopyridine, a loading dose of 300-600

mg of clopidogrel should be given as the

thienopyridine of choice.

If the patient did not receive fibrinolytic therapyc. either a loading dose of 300-600 mg of clopidogrel

should be given or, once the coronary anatomy is

known and PCI is planned, a loading dose of 60 mg of

prasugrel should be given promptly and no later than 1

hour after the PCI.


If the patient has received fibrinolytic therapy

MODIFIED

Rec


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Thienopyridines

The duration of thienopyridine therapyshould be as follows:MODIFIED

Recommendat ion


III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII a. In patients receiving a stent (BMS or DES)

during PCI for ACS, clopidogrel 75 mg daily

or prasugrel 10 mg daily should be given

for at least 12 months;

b. If the risk of morbidity from bleeding

outweighs the anticipated benefit affordedby thienopyridine therapy, earlier

discontinuation should be considered.


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Thienopyridines


In patients taking a thienopyridine in whom coronary

artery bypass surgery (CABG) is planned and can be

delayed, it is recommended that the drug be discontinued

to allow for dissipation of the antiplatelet effect.

The period of withdrawal should be at least 5 days in

patients receiving clopidogrel

and at least 7 days in patients receiving prasugrel,

unless the need for revascularization and/or the net

benefit of the thienopyridine outweighs the potential risks

of excess bleeding.

MODIFIED

Recommendat ion (prasugrel added)





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Thienopyridines

NEW

Recommendat ion

In STEMI patients with a prior

history of stroke and transientischemic attack for whom primary

PCI is planned, prasugrel is not

recommended as part of a dual

antiplatelet therapy regimen



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TRITON TIMI-38 Net Clinical BenefitBleeding Risk Subgroups

Overall

60 kg


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Recommendations for the Use of

Glycoprotein IIb/IIIa Receptor

Antagonists in STEMI


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It is reasonable to start treatment with glycoprotein

IIb/IIIa receptor antagonists at the time of primaryPCI (with or without stenting) in selected patients

with STEMI:

abciximab

tirofiban and eptifibatide

Use of Glycoprotein IIb/IIIa Receptor




Modif ied

Recommendat ion


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Use of Glycoprotein IIb/IIIa Receptor


III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIIIThe usefulness of glycoprotein IIb/IIIa receptorantagonists (as part of a preparatory

pharmacologic strategy for patients with STEMI

prior to arrival in the cardiac catheterizationlaboratory for angiography and PCI) is uncertain.

Modif ied

Recommendat ion


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BRAVE 3: Effects of Abciximab

Mehilli et al. Circ. 2009;119:1933-1940

No significant difference in infarct

size or major bleeding

Patient received Plavix 600mg

loading

P= 0.47

P= 0.40


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Recommendations for

Use of Parenteral

Anticoagulants in Patients

with STEMI


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Use of Parenteral Anticoagulants

in STEMI(cont.)

Modif ied

Recommendat ion

b. Bivalirudin is useful as support for primary PCI with orwithout prior treatment with heparin.

For patients proceeding to primary

PCI, who have been treated with

ASA and a thienopyridine,

recommended supportive

anticoagulant regimens include:



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Bilvalirudin added as an acceptable anticoagulant for

primary PCI

Unfractionated heparin (UFH) administration guided

by: Therapeutic activated clotting time (ACT) levels

Prior administration of GP IIb/IIIa receptor

antagonists

Enoxaparin and fondaparinux unchanged from 2007STEMI Focused Update

Use of Parenteral Anticoagulants in STEMI

Patients Proceeding to Primary PCI:

Modified Class I Recommendations


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HORIZONS-AMI: Time-to-Event Curves

through 30 days: Net Adverse Clinical Events

Treatment with bivalirudin alone compared with UFH + GP IIb/IIIa

Inhibitors resulted in reduced 30-day rates of net adverse

clinical events

[HR=0.75, (0.62-0.92); p=0.006]Stone et al. N Eng J Med. 2008;358:2218-30.


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HORIZONS-AMI: Time-to-Event Curves

through 30 days: Major Bleeding

HR=0.59 (0.45-0.76); p


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Recommendations for triage and

transfer for PercutaneousCoronary Intervention for Patients

with STEMI


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Recommendations for Triage and

Transfer for PCI (for STEMI)


NEW

Recommendat ion

Each community should develop aSTEMI system of care following the

standards developed forMission

Lifeline including:

Ongoing multidisciplinary team

meetings with EMS, non-PCI-

capable hospitals (STEMI Referral

Centers), & PCI-capable hospitals

(STEMI Receiving Centers)


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Transfer for PCI (for STEMI) (cont.)


NEW

Recommendat ion

STEMI system of care standards incommunities should also include:

Process for prehospital

identification & activation

Destination protocols to STEMIReceiving Centers

Transfer protocols for patients

who arrive at STEMI Referral

Centers and are primary PCI

candidates, and/or are fibrinolytic

ineligible and/or in cardiogenic

shock


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2.5

1

0.05

9

6.8

21.1

0

1

2

3

4

5

6

7

8

9

10

Death Re-MI CVA Hemo CVA

%P

atients

PCI Thrombolytics

p=0.0002

P


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Stenestrand, U. et al. JAMA 2006;296:1749-1756.

Age-Adjusted and Propensity Score-Adjusted MortalityAccording to Time to Reperfusion and Type of Therapy


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Transfer for PCI (for STEMI)(cont.)

NEW

Recommendat ion

I IIaIaIa IIbIbIb IIIIIIIIIaIaIa IIbIbIb IIIIIIIIIaIaIa IIbIbIb IIIIIIIIaIaIa IIbIbIb IIIIIII

It is reasonable to transfer high

risk patients who receive fibrinolytic

therapy as primary reperfusiontherapy at a non-PCI capable facility

to a PCI-capable facility as soon as

possible where either PCI can be

performed when needed or as apharmacoinvasive strategy.


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CARESS-IN-AMI:Primary Outcomeprimary outcome (composite of all cause mortality, reinfarction, & refractory MI within 30 days)

occurred significantly less often in the immediate PCI group vs. standard care/rescue PCI group

10.7%

4.4%

HR=0.40 (0.21-0.76)

Di Mario et al. Lancet 2008;371.

TRANSFER AMI Effi


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TRANSFER-AMI: Efficacy

Kaplan Meier Curves for Primary Endpoint

17.2%

11.0%

primary end point: composite of death, reinfarction, recurrent ischemia, new

or worsening CHF, or shock within 30 dayspharmaco-invasive group=11.0% vs. standard treatment group=17.2%

RR= 0.64, 95 CI% (0.47-0.87)

C

umulativeIncidence

Days

p=0.004

Cantor et al. N Engl J Med 2009;360:26


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Transfer for PCI (for STEMI)(cont.)

NEW

Recommendat ion

I IIaIaIa IIbIbIb IIIIIIIIIaIaIa IIbIbIb IIIIIIIIIaIaIa IIbIbIb IIIIIIIIaIaIa IIbIbIb IIIIIII

Consideration should be given

to initiating a preparatory

antithrombotic (anticoagulant

plus antiplatelet) regimen prior

to and during patient transfer

to the catheterizationlaboratory.


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Triage and Transfer for PCI (in STEMI)

2009 STEMI Focused Update. Appendix 5

Each community and each facility in thatcommunity should have an agreed-upon planfor how STEMI patients are to be treated,including:

which hospitals should receive STEMI patientsfrom EMS units capable of obtaining diagnosticECGs

management at the initial receiving hospital, and

written criteria & agreements for expeditioustransfer of patients from non-PCI-capable to PCI-capable facilities


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Need for the development of regionalsystems of STEMI care through stakeholderefforts to evaluate ACS care using: standardized performance & quality improvement

measures, (e.g., endorsed by the ACC, AHA, JointCommission, Centers for Medicare and MedicaidServices)

standardized quality-of-care data registriesdesigned to track and measure outcomes,complications and adherence to evidence-based

processes of care NCDR ACTION Registry

American Heart Association Get With the Guidelines


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American Heart Associations Mission

Lifel ineis an initiative to encourage

closer cooperation and trust amongst

prehospital care providers, and cardiaccare professionals.


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Whats New in 2012

STEMI Guideline


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Whats New in 2012

STEMI Guideline

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Whats New in 2012

STEMI Guideline

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STEMI Guideline

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STEMI Guideline

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STEMI Guideline

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Whats New in 2012

STEMI Guideline

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