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

ACC/AHA Guidelines for the Management of Patients with ST-Elevation Myocardial Infarction. Applying Classification of Recommendations and Level of Evidence . Patient Education for Early Recognition and Response to STEMI.

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

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  1. ACC/AHA Guidelines for the Management of Patients with ST-Elevation Myocardial Infarction

  2. Applying Classification of Recommendations and Level of Evidence

  3. 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 9-1-1if symptoms do not improve or worsen 5 minutes after ONE sublingual NTG dose*. (* Nitroglycerin Dose: 0.4 mg sublingually)

  4. 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.

  5. 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 IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I B IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I C Prehospital Issues

  6. IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I A Prehospital Issues 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

  7. IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I B Prehospital Issues 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

  8. Options for Transport of Patients With STEMI and Initial Reperfusion Treatment Hospital fibrinolysis: Door-to-Needle within 30 min. Not PCI capable Call 9-1-1 Call fast • EMS on-scene • Encourage 12-lead ECGs. • Consider prehospital fibrinolytic if capable and EMS-to-needle within 30 min. Inter-Hospital Transfer Onset of symptoms of STEMI 9-1-1 EMS Dispatch EMS Triage Plan PCI capable GOALS 5 min. 8 min. EMS Transport Patient EMS Prehospital fibrinolysis EMS-to-needle within 30 min. EMS transport EMS-to-balloon within 90 min. Patient self-transport Hospital door-to-balloon within 90 min. Dispatch 1 min. Golden Hour = first 60 min. Total ischemic time: within 120 min.

  9. Options for Transport of Patients With STEMI and Initial Reperfusion Treatment Fibrinolysis Noninvasive Risk Stratification Late Hospital Care and Secondary Prevention Not PCI Capable Ischemia driven Rescue PCI Capable PCI or CABG Primary PCI • 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.

  10. Electrocardiogram 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.

  11. Laboratory 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

  12. Biomarkers of Cardiac Damage 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.

  13. IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I Imaging 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.

  14. Nitroglycerin 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.

  15. Nitroglycerin 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.

  16. Analgesia 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.

  17. Aspirin 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.

  18. Beta-Blockers 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.

  19. Reperfusion 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.

  20. Symptom Onset to Balloon Time and Mortality in Primary PCI for STEMI 6 RCTs of Primary PCI by Zwolle Group 1994 – 2001N = 1791 12 10 8 6 4 2 0 P < 0.0001 One-year mortality, % RR = 1.08 [1.01 – 1.16] for each 30 min delay(P = 0.04) 0 60 120 180 240 300 360 Symptoms to balloon inflation (minutes) DeLuca et al. Circulation 2004;109:1223.

  21. PCI vs Fibrinolysis for STEMI: Short Term Clinical Outcomes PCI P < 0.0001 Fibrinolysis P < 0.0001 Frequency (%) P=0.0002 P < 0.0001 P=0.0003 P=0.032 P=0.0004 P < 0.0001 Hemorrh.Stroke Death Death, no SHOCKdata Recurr. MI Recurr.Ischemia Total Stroke Major Bleed DeathMICVA N = 7739 Keeley et al. The Lancet 2003;361:13.

  22. Contraindications and Cautions for Fibrinolysis in STEMI • 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 Absolute Contraindications NOTE: Age restriction for fibrinolysis has been removed compared with prior guidelines.

  23. Contraindications and Cautions for Fibrinolysis in STEMI Absolute Contraindications • Suspected aortic dissection • Active bleeding or bleeding diathesis (excluding menses) • Significant closed-head or facial trauma within 3 months

  24. Contraindications and Cautions for Fibrinolysis in STEMI Relative Contraindications • 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)

  25. Contraindications and Cautions for Fibrinolysis in STEMI Relative Contraindications • 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

  26. 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. • 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

  27. 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. • 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

  28. Fibrinolysis 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).

  29. Fibrinolysis 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.

  30. Fibrinolysis 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.

  31. Primary PCI for STEMI: General 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

  32. Primary PCI for STEMI: Specific 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.

  33. Primary PCI for STEMI: Specific Considerations 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.

  34. Primary PCI for STEMI: Specific Considerations 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.

  35. Primary PCI for STEMI: Specific Considerations 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.

  36. PCI After Fibrinolysis In patients whose anatomy is suitable, PCI should be performed for the following: Objective evidence of recurrent MI Moderate or severe spontaneous/provocable myocardial ischemia during recovery from STEMI Cardiogenic shock or hemodynamic instability.

  37. PCI After Fibrinolysis It is reasonable to perform routine PCI in patients with left ventricular ejection fraction (LVEF) ≤ 0.40, CHF, or serious ventricular arrhythmias. 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). Routine PCI might be considered as part of an invasive strategy after fibrinolytic therapy.

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

  39. Aspirin 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.

  40. Thienopyridines 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.

  41. Thienopyridines 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.

  42. Glycoprotein 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.

  43. ACE/ARB: Within 24 Hours • An ACE inhibitor should be administered orally • within the first 24 hours of STEMI to the following • patients without hypotension or known class of • contraindications: • 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.

  44. ACE/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).

  45. Summary of Pharmacologic Rx: Ischemia JACC 2004;44: 671Circulation 2004;110: 588

  46. Summary of Pharmacologic Rx: LVD, Sec. Prev., JACC 2004;44:671Circ 2004;110:588

  47. RUSH HOUR OR CARDIOGENIC SHOCK 6 – 10 AM & 4 – 7 PM Drip and ship – Give Lytics and Airlift to EMORY HOSPITAL NON RUSH HOUR : e.g. 2 AM Drip and ship – Give lytics and ship by ambulance to EMORY HOSPITAL What to do at EJCH ?

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