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Classes of Recommendations

Guidelines for the Management of Patients With ST- Elevation Myocardial Infarction Adapted from Focused Updates: ACC/AHA 2009. Classes of Recommendations. I=Should (Recommended) IIa = Is Reasonable IIb = May be considered III = Is not recommended. Levels of Evidences (LOE).

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Classes of Recommendations

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  1. Guidelines for the Management of Patients With ST- Elevation Myocardial Infarction Adapted from Focused Updates: ACC/AHA 2009

  2. Classes of Recommendations • I=Should (Recommended) • IIa = Is Reasonable • IIb = May be considered • III = Is not recommended

  3. Levels of Evidences (LOE) • A = Multiple RCTs or meta-analyses • B = One RCT or observational study • C = Experts’ opinions

  4. Updated Recommendations • Glycoprotein (GP) IIb/IIIa receptor antagonists • Thienopyridines • Parenteral anticoagulants • Transfer for PCI

  5. Updated Recommendation CLASS I STEMI management should include ASA+ thienopyridine + anticoagulant.

  6. GP IIb/IIIa Receptor Antagonist Class IIa • In selected patients at the time of primary PCI (with or without stenting) Class IIb • GP IIb/IIIa receptor antagonists (before arrival in the catheterization laboratory (uncertain benefit). LOE=Level Of Evidence

  7. Thienopyridine Primary PCI Loading of At least Clopidogrel 300 to 600 mg OR Prasugrel 60 mg

  8. Thienopyridine Non-Primary PCI If patient has received non fibrin-specific FL, • <48 hr, 300 mg Clopidogrel • > 48 hr, 300-600 mg Clopidogrel If patient has received fibrin-specific FL, • <24 hr 300 mg Clopidogrel • >24 hr 300-600 mg Clopidogrel

  9. Thienopyridine Non-Primary PCI If patient did not receive FL, Clopidogrel 300 to 600 mg or Prasugrel 60 mg (once the coronary anatomy is known and PCI is planned)

  10. Duration of Thienopyridine BMS Stent 12-month Clopidogrel 75 mg or Prasugrel 10 mg DES Stent Thienopyridines may be considered >15 months

  11. Prasugrel - Precautions • NO data after FL. In these pts, use Clopidogrel • Contra-indicated for patients less than 60 kg • Contra-indicated in pts with prior TIA/CVA • Not recommended in ≥75 yrs old • To be given at the time of PCI only

  12. Before CABG Stop Clopidogrel x 5 days Stop Prasugrel x 7 days

  13. Parenteral Anticoagulants Class I Recommendation for PCI • Unfractionated heparin (UFH) (LOE:C) • Enoxaparin(LOE:B) last SC dose >8 hrs, 0.3 mg/kg of iv Last SC dose <8 hours, no additional enoxaparin • Fondaparinux, additional anti-II anticoagulants in the cath lab(LOE:C) • Bivalirudin is useful with or without UFH. (LOE:B)

  14. Parenteral Anticoagulants Class IIa (new recommendation) • In patients at high risk of bleeding, bivalirudin anticoagulation is reasonable. (LOE:B)

  15. Recommendations for Triage and Transfer for PCI Class I(new recommendation) STEMI system of care • Multidisciplinary team meetings (EMS, referral and PCI hospitals) • Prehospital identification and activation; • Destination protocols for PCI hospitals; • Transfer protocols for primary PCI candidates, FL-ineligible and cardiogenic shock.

  16. Adapted by: Kamelia Emamian M.D. and Thao Huynh, MD, MSC.

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