Evidence Based Strategies for Acute Myocardial Infarction Care: STEMI

1. Evidence Based Strategies for Acute Myocardial Infarction Care:STEMI Scott A. Sample DO, FACC Cardiovascular Interventionist April 2010

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

3. Evidence Based Strategies for Acute Myocardial Infarction Care Pre-hospital Care/Diagnosing Acute Coronary Syndromes Acute Myocardial Infarction in the rural hospital setting STEMI Treatment/Transfer Thrombolytics/Anticoagulants/Beta Blockers American College of Cardiology Website ACC/AHA STEMI and non-STEMI guidelines

4. Pre-Hospital Care Patients with chest pain suspicious for acute coronary syndromes should undergo the following: Activation of EMS LOE* B Aspirin 162-325mg chewed and swallowed (Unless already self administered by patient) LOE A 12 Lead EKG, if available in the field LOE B Rapid stabilization and transfer to Emergency Department (Unless care pathways for Acute MI PCI direct to the catheterization laboratory are in place) LOE A * LOE = Level of Evidence

5. ACS Recognition Upon arrival to the Emergency Department, 12 lead EKG (10 minutes) LOE B Initiate continuous EKG monitoring, oximetry, and frequent vital sign monitoring LOE B Establish IV access with two large bore peripheral IVs Once ACS is suspected/established, initiate aspirin, oxygen, nitrates and morphine

6. ACS Risk Stratification Obtain Baseline laboratory markers including a CBC, Metabolic Panel and Cardiac Markers If the initial EKG is nondiagnostic, repeat every 15-30 minutes Assess cardiac risk factors

7. Assessment of Risk Identify chest pain into 4 groups Non-cardiac Pain Stable Angina Possible Acute Coronary Syndrome Definite Acute Coronary Syndrome

8. Evidence Based Strategies for Acute Myocardial Infarction Care Pre-hospital Care/Diagnosing Acute Coronary Syndromes Acute Myocardial Infarction in the rural hospital setting STEMI Treatment/Transfer Thrombolytics/Anticoagulants/Beta Blockers American College of Cardiology Website ACC/AHA STEMI and non-STEMI guidelines

9. Approach For Acute Coronary Syndrome for Critical Access Hospitals: STEMI

10. Thrombolytic Therapy Indications Presentation consistent with signs and symptoms of AMI Time of symptom onset 12 hours or less ST elevation > 1mm in 2 or more contiguous leads New Left Bundle Branch Block True Posterior Wall MI

11. Contraindications to Thrombolytics Known prior hemorrhagic CVA IC trauma Active internal bleeding Suspected aortic dissection

12. Cautions to Thrombolytics Persistent BP ≥ 180/110mmHG Prior cerebrovascular accident/intracerebral pathology Current use of anticoagulants in therapeutic doses Trauma or surgery within 2 weeks

13. Noncompressible vascular punctures Recent (within 2-4 weeks) internal bleeding Pregnancy Active peptic ulcer disease History of chronic severe hypertension Cautions to Thrombolytics cont.

14. Thrombolytic Agents Alteplase 15mg bolus Then 0.75mg/kg IV drip over 30 minutes (not to exceed 50mg) Then 0.5mg/kg over next 60 minutes (not to exceed 35mg) Maximum dose 100mg This agent requires concurrent administration of heparin or alternative agent

15. Thrombolytic Agents Reteplase First bolus 10U over 2 minutes 30 minutes later, second bolus 10U over 2 minutes Heparin (or alternative agent) and aspirin required adjuncts

16. Thrombolytic Agents Tenecteplase 30-50mg weight adjusted IV bolus; see package insert for dosing scale Heparin (or alternative agent) and aspirin are required adjuncts

17. STEMI Unfractionated Heparin Adjunctive Therapy Initial bolus 60 IU/kg, Maximum 4,000 IU 12 IU/kg/hr drip, Maximum 1,000 IU/hr Monitor PTT, Hemoglobin, Hematocrit and Platelet count per institutional protocol

18. STEMI Low Molecular Weight Heparin Adjunctive Therapy Enoxaparin Age <75 with normal creatinine clearance: bolus 30mg IV; 15 minutes later, 1mg/kg SQ every 12 hours Age >75 no IV bolus; 0.75mg/kg SQ every 12 hours Creatinine Clearance <30mL/min, regardless of age, 1mg/kg SQ every 24 hours Monitor Hemoglobin, Hematocrit and Platelets

19. STEMI Fondaparinux Adjunctive Therapy Initial Dose 2.5mg/kg IV Subsequent dose 2.5mg/kg SQ every 24 hours for up to 8 days Do not use in patients with creatinine clearance of less than 30mL/min Do not use as monotherapy in patients undergoing PCI

20. STEMI Beta Blocker Use • Class Ib • Oral beta blocker (ie metoprolol 25 mg po) unless contraindicated by the following • Acute heart failure • Low cardiac output state • Increased risk of cardiogenic shock • PR interval >0.24 seconds, second degree or third degree heart block • Class II • IV beta blocker for hypertensive patients that do not have the above exclusion criteria

21. Additional Therapeutics • Aspirin 162-325mg, if not already given • Nitrates, preferably IV • Antiarrhythmics, if indicated • Transport with defibrillator patches attached, if possible • Clopidogrel can be given with high level of evidence to support use; however, if surgical disease is present, surgery will be delayed

22. Transfer Considerations • Establish contact with accepting hospital • Accepting Physician • Administrative Acceptance • Establish safest method of transfer • Arrange for copies of transfer documents • Copies of all pertinent clinical material

23. Summary:Evidence Based Strategies for Acute Myocardial Infarction Care Pre-hospital Care/Diagnosing Acute Coronary Syndromes Acute Myocardial Infarction in the rural hospital setting STEMI Treatment/Transfer Thrombolytics/Anticoagulants/Beta Blockers American College of Cardiology Website ACC/AHA STEMI and non-STEMI guidelines