St Elevation Mi

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  • Cardiac biomarkers in ST-elevation myocardial infarction (STEMI).Typical cardiac biomarkers that are used to evaluate patients with
    STEMI include the MB isoenzyme of CK (CK-MB) and cardiac specific troponins. The horizontal line depicts the upper reference limit (URL)
    for the cardiac biomarker in the clinical chemistry laboratory. The URL is that value representing the 99th percentile of a reference control group without STEMI. The kinetics of release of CK-MB and cardiac troponin in patients who do not undergo reperfusion are shown in the solid green and red curves as multiples of the URL. Note that when patients with STEMI undergo reperfusion, as depicted in the dashed green and red curves, the cardiac biomarkers are detected sooner, rise to a higher peak value, but decline more rapidly, resulting in a smaller area under the curve and limitation of infarct size. Modified with permission from Alpert et al. J Am Coll Cardiol 2000;36:959 and Wu et al. Clin Chem 1999;45:1104.
  • Figure 27. Summary of data from meta-analysis of trials of beta-blocker therapy from the pre-fibrinolytic era in patients with MI.
    RR, relative risk; CI, confidence interval; MI, myocardial infarction
    Reproduced with permission from: Antman E, Braunwald E. Acute Myocardial Infarction. In: Braunwald E, Zipes DP, Libby P, eds. Heart Disease: A textbook of Cardiovascular Medicine, 6th ed., Philadelphia, PA: W.B. Sanders, 2001, 1168 (718).
  • Evidence exists that expeditious restoration of flow in the obstructed infarct artery after the onset of symptoms in patients with STEMI is the key determinent of short- and long-term outcomes regardless of whether reperfusion is accomplished by fibrinolysis or PCI. Efforts should be made to shorten the time from recognition of symptoms by the patient to contact with the medical system.
  • Short term (4 to 6 weeks) outcomes for various endpoints shown are plotted for patients randomized to PCI or fibrinolysis for reperfusion in 23 trials (N = 7739). The magnitude of the treatment differences for death, nonfatal reinfarction and stroke vary depending on whether PCI is compared with streptokinase or a fibrin-specific lytic. For example, when primary PCI is compared with alteplase and the SHOCK trial is excluded, the mortality rate is 5.5% versus 6.7% (OR 0.81, 95% CI 0.64-1.03, P=0.081) (Melandri. Circulation 2003;108:e162.)
  • A decision must be made when a STEMI patient presents to a center without interventional cardiology facilities. Fibrinolytic therapy can generally be provided sooner than primary PCI. As the time delay for performing PCI increases, the mortality benefit associated with expeditiously performed primary PCI over fibrinolysis decreases. Compared with a fibrin-specific lytic agent, a PCI strategy may not reduce mortality when a delay greater than 60 minutes is anticipated versus immediate administration of a lytic, as shown in this figure.
  • After adjustment for baseline characteristics, time from symptom onset to balloon inflation is significantly correlated with 1-year mortality in patients undergoing primary PCI for STEMI (RR equals 1.08 for each 30-minute delay from symptom onset to balloon inflation, p equals 0.04).
    TIME TO REPERFUSION IS AS IMPORTANT FOR PCI AS IT IS FOR FIBRONOLYSIS
  • Georg Ertl
  • Mary Ann Sellers and Sue Edwards.
  • The emergency management of patients with cardiogenic shock (CS), acute pulmonary edema (PE) or both is outlined.
  • This 12-lead ECG was obtained from a middle-aged man admitted with an extensive anterior acute myocardial infarction. (Note pathological Q-waves in the percordial leads and marked repolarization abnormalities in the anterior and lateral leads.) A 5-beat salvo of non-sustained VT is seen extending over the transition between leads III and aVF.
  • This table is designed to summarize the atrioventricular(column headings) and intraventricular (row headings) conduction disturbances that may occur during acute nonanterior STEMI, the possible treatment options, and the indications for each possible therapeutic option.
    Action
    There are 4 possible actions, or therapeutic options, listed and classified for each bradyarrhythmia or conduction problem:
    1. Observe: continued electrocardiographic monitoring, no further action planned.
    2. A, and A*: atropine administered at 0.6 to 1.0 mg intravenously every 5 minutes to up to 0.04 mg/kg. In general, because the increase in sinus rate with atropine is unpredictable, this is to be avoided unless there is symptomatic bradycardia that will likely respond to a vagolytic agent – such as sinus bradycardia or Mobitz I, as denoted by the asterisk, above.
    3. TC: application of transcutaneous pads and standby transcutaneous pacing with no further progression to transvenous pacing imminently planned.
    4. TV: temporary transvenous pacing. It is assumed, but not specified in the table, at the discretion of the clinician, trancutaneous pads will be applied and standby transcutaneous pacing will be in effect as the patient is transferred to the fluoroscopy unit for temporary transvenous pacing.
    How to use the table
    Example: 54 year old man is admitted with an anterior STEMI and a narrow QRS on admission. On day 1 he develops a right bundle branch block (RBBB), with a PR interval of 0.28 seconds.
    RBBB is an intra-ventricular conduction disturbance, so look at row “New BBB”.
    Find the column for “First Degree AV Block”.
    Find the “Action” and “Class” cells at the convergence.
    Note that Observe and Atropine are Class III, not indicated; transcutaneous pacing (TC) is Class I. Temporary transvenous pacing (TV) is Class IIa.
  • Only 16% of the overall MUSTT population was randomized within 1 month of MI.
    Randomized MADIT patients had inducible VT, not suppressed by a procainamide infusion during EPS.
    Randomized MUSTT patients had inducible VT, and were randomized to antiarrhythmic drug therapy. Based on clinical indications, some patients received ICDs during the course of follow-up.
    The hazard ratio on the MUSTT row compares MUSTT patients in the antiarrhythmic arm that received ICDs with those that received only EP-guided antiarrhythmic therapy.
  • Algorithm to aid in selection of implantable cardioverter/defibrillator (ICD) in patients with STEMI and diminished ejection fraction (EF). The appropriate management path is selected based upon left ventricular ejection fraction (LVEF) measured at least one month after STEMI. These criteria, that are based on the published data, form the basis for the full-text guidelines in section 7.7.1.5. All patients, whether an ICD is implanted or not, should receive medical therapy as outlined in the full-text guidelines.
  • This algorithm shows the treatment paths for patients who initially undergo a primary invasive strategy, receive fibrinolytic therapy, or do not undergo reperfusion therapy for STEMI. Patients who have not undergone a primary invasive strategy and have no high risk features should undergo functional evaluation using one of the noninvasive tests shown. When clinically significant ischemia is detected, patients should undergo catheterization and revascularization as indicated; if no clinically significant ischemia is detected, medical therapy is prescribed post-STEMI.
  • Long-term antithrombotic therapy at hospital discharge after STEMI for patients who have not had a stent implanted.
  • Long-term antithrombotic therapy at hospital discharge after STEMI for patients who have had a stent implanted.
  • St Elevation Mi

    1. 1. 2 This slide set was adapted from the ACC/AHA Guidelines for Management of Patients With ST- Elevation Myocardial Infarction (Journal of the American College of Cardiology 2004;44:671- 719, e1-e211 and Circulation 2004;44:671-619, e82-e292) The full-text guidelines and executive summary are also available on the Web sites: ACC (www.acc.org) and, AHA (www.americanheart.org)
    2. 2. 3 IntroductionIntroduction ACC/AHA Guidelines for the Management of Patients with ST-Elevation Myocardial Infarction
    3. 3. 4 Daniel T. Anbe, MD, FACC, FAHA Paul Wayne Armstrong, MD, FACC, FAHA Eric R. Bates, MD, FACC, FAHA Lee A. Green, MD, MPH Mary Hand, MSPH, RN, FAHA Judith S. Hochman, MD, FACC, FAHA Harlan M. Krumholz, MD, FACC, FAHA Elliott M. Antman, MD, FACC, FAHA, Chair ACC/AHA Guidelines for the ManagementACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardialof Patients With ST-Elevation Myocardial InfarctionInfarction Writing Committee MembersWriting Committee Members Frederick G. Kushner, MD, FACC, FAHA Gervasio A. Lamas, MD, FACC Charles J. Mullany, MB, MS, FACC Joseph P. Ornato, MD, FACC, FAHA David L. Pearle, MD, FACC, FAHA Michael A. Sloan, MD, FACC Sidney C. Smith, Jr., MD, FACC, FAHA
    4. 4. 5 Class I Benefit >>> Risk Procedure/ Treatment SHOULD be performed/ administered Class IIa Benefit >> Risk Additional studies with focused objectives needed IT IS REASONABLE to perform procedure/administer treatment Class IIb Benefit ≥ Risk Additional studies with broad objectives needed; Additional registry data would be helpful Procedure/Treatment MAY BE CONSIDERED Class III Risk ≥ Benefit No additional studies needed Procedure/Treatment should NOT be performed/administered SINCE IT IS NOT HELPFUL AND MAY BE HARMFUL should is recommended is indicated is useful/effective/ beneficial is reasonable can be useful/effective/ beneficial is probably recommended or indicated may/might be considered may/might be reasonable usefulness/effectiveness is unknown /unclear/uncertain or not well established is not recommended is not indicated should not is not useful/effective/beneficial may be harmful Applying Classification ofApplying Classification of Recommendations and Level of EvidenceRecommendations and Level of Evidence
    5. 5. 6 Level A Multiple (3-5) population risk strata evaluated General consistency of direction and magnitude of effect Class I • Recommen- dation that procedure or treatment is useful/ effective • Sufficient evidence from multiple randomized trials or meta- analyses Class IIa • Recommen- dation in favor of treatment or procedure being useful/ effective • Some conflicting evidence from multiple randomized trials or meta- analyses Class IIb • Recommen- dation’s usefulness/ efficacy less well established • Greater conflicting evidence from multiple randomized trials or meta- analyses Class III • Recommen- dation that procedure or treatment not useful/effective and may be harmful • Sufficient evidence from multiple randomized trials or meta- analyses Applying Classification of Recommendations and Level of Evidence
    6. 6. 7 Level B Limited (2-3) population risk strata evaluated Class I • Recommen- dation that procedure or treatment is useful/effective • Limited evidence from single randomized trial or non- randomized studies Class IIa • Recommen- dation in favor of treatment or procedure being useful/ effective • Some conflicting evidence from single randomized trial or non- randomized studies Class IIb • Recommen- dation’s usefulness/ efficacy less well established • Greater conflicting evidence from single randomized trial or non- randomized studies Class III • Recommen- dation that procedure or treatment not useful/effective and may be harmful • Limited evidence from single randomized trial or non- randomized studies Applying Classification ofApplying Classification of Recommendations and Level of EvidenceRecommendations and Level of Evidence
    7. 7. 8 Applying Classification ofApplying Classification of Recommendations and Level of EvidenceRecommendations and Level of Evidence Level C Very limited (1- 2) population risk strata evaluated Class I • Recommen- dation that procedure or treatment is useful/ effective • Only expert opinion, case studies, or standard-of- care Class IIa • Recommen- dation in favor of treatment or procedure being useful/effective • Only diverging expert opinion, case studies, or standard-of- care Class IIb • Recommen- dation’s usefulness/ efficacy less well established • Only diverging expert opinion, case studies, or standard-of- care Class III • Recommend- ation that procedure or treatment not useful/effective and may be harmful • Only expert opinion, case studies, or standard-of- care
    8. 8. 9 ACC/AHA Guidelines for the Management of Patients with ST-Elevation Myocardial Infarction PathologyPathology
    9. 9. 10 Chronology of the interface between the patient and the clinician through the progression of plaque formation and the onset of complications of STEMI. Management Before STEMI 4 1 2 3 4 5 6 Onset of STEMI - Prehospital issues - Initial recognition and management in the Emergency Department (ED) - Reperfusion Hospital Management - Medications - Arrhythmias - Complications - Preparation for discharge Secondary Prevention/ Long-Term Management Presentation Working Dx ECG Cardiac Biomarker Final Dx UA NQMI QwMI No ST Elevation NSTEMI Ischemic Discomfort Acute Coronary Syndrome Unstable Angina Myocardial Infarction ST Elevation Modified from Libby. Circulation 2001;104:365, Hamm et al. The Lancet 2001;358:1533 and Davies. Heart 2000;83:361.
    10. 10. 11 Prevention of Coronary Heart Disease (CHD)Prevention of Coronary Heart Disease (CHD) Campaigns and StatementsCampaigns and Statements • National Cholesterol Education Program (NCEP) Adult Treatment Panel (ATP) III • LDL goals, CHD risk equivalent, metabolic syndrome • Joint National Committee (JNC)-7 • Hypertension management • World Heart Federation (WHF), World Health Organization (WHO) • Cigarette smoking • National Heart, Lung, and Blood Institute (NHLBI), Food and Drug Administration (FDA), Centers for Disease Control (CDC) • Obesity • AHA/NHLBI Go Red for Women, AHA Guidelines on Prevention of Cardiovascular Disease (CVD) in Women • Women and CVD
    11. 11. 12 Management Before STEMIManagement Before STEMI ACC/AHA Guidelines for the Management of Patients with ST-Elevation Myocardial Infarction
    12. 12. 13 Identification of Patients at Risk of STEMIIdentification of Patients at Risk of STEMI The presence and status of control of major risk factors for CHD should be evaluated approximately every 3 to 5 years. 10-year risk of developing symptomatic CHD should be calculated for all patients with ≥ 2 major risk factors to assess the need for primary prevention strategies. III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
    13. 13. 14 Identification of Patients at Risk of STEMIIdentification of Patients at Risk of STEMI Patients with established CHD or a CHD risk equivalent (diabetes mellitus, chronic kidney disease, > 20% 10-year Framingham risk) should be identified for secondary prevention. III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
    14. 14. 15 Onset of STEMIOnset of STEMI ACC/AHA Guidelines for the Management of Patients with ST-Elevation Myocardial Infarction
    15. 15. 16 Patient Education for Early Recognition andPatient Education for Early Recognition and Response to STEMIResponse to STEMI Patients should understand the advisability of calling 9-1-1 if symptoms are unimproved or worsening after 5 minutes. Patients should understand their risk of STEMI and how to recognize symptoms of STEMI. III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
    16. 16. 17 If you have any heart attack symptoms, CALL 9-1-1 immediately. Don’t wait for more than a few minutes – 5 at most – to call 9-1-1. ACT in TIMEACT in TIME http://www.nhlbi.nih.gov/actintime/index.htm. Accessed December 20, 2004.
    17. 17. 18 Patient Education for Early Recognition andPatient Education for Early Recognition and Response to STEMIResponse 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) III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
    18. 18. 19 Prehospital Chest Pain EvaluationPrehospital Chest Pain Evaluation and Treatmentand 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. III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
    19. 19. 20 Has the patient been previously prescribed nitroglycerin? Has the patient been previously prescribed nitroglycerin? No Is Chest Discomfort/Pain Unimproved or Worsening 5 Minutes After It Starts? Is Chest Discomfort/Pain Unimproved or Worsening 5 Minutes After It Starts? Yes No CALL 9-1-1 IMMEDIATELY. CALL 9-1-1 IMMEDIATELY. Follow 9-1-1 instructions. [Patients may receive instructions to chew aspirin (162-325 mg) if not contraindicated or may receive aspirin en route to the hospital.] Follow 9-1-1 instructions. [Patients may receive instructions to chew aspirin (162-325 mg) if not contraindicated or may receive aspirin en route to the hospital.] Notify Physician.Notify Physician. Instructions for NitroglycerinInstructions for Nitroglycerin Use and EMS ContactUse and EMS Contact Patient experiences chest pain/discomfort
    20. 20. 21 Take ONE Nitroglycerin Dose Sublingually. Take ONE Nitroglycerin Dose Sublingually. Is Chest Discomfort/Pain Unimproved or Worsening 5 Minutes After Taking ONE Nitroglycerin Dose* Sublingually? Is Chest Discomfort/Pain Unimproved or Worsening 5 Minutes After Taking ONE Nitroglycerin Dose* Sublingually? Yes YesNo See ACC/AHA Guidelines for the Management of Patients with Chronic Stable Angina. See ACC/AHA Guidelines for the Management of Patients with Chronic Stable Angina. Has the patient been previously prescribed nitroglycerin? Has the patient been previously prescribed nitroglycerin? Instructions for NitroglycerinInstructions for Nitroglycerin Use and EMS ContactUse and EMS Contact CALL 9-1-1 IMMEDIATELY. CALL 9-1-1 IMMEDIATELY. Patient experiences chest pain/discomfort * Nitroglycerin Dose: 0.4 mg sublingually
    21. 21. 22 Prehospital IssuesPrehospital Issues ACC/AHA Guidelines for the Management of Patients with ST-Elevation Myocardial Infarction
    22. 22. 23 All public safety first responders trained and equipped to provide early defibrillation with AEDs. Prehospital aspirin 162 to 325 mg (chewed) administration: By prehospital providers Advice by dispatchers Prehospital IssuesPrehospital Issues III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
    23. 23. 24 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 Prehospital IssuesPrehospital Issues III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
    24. 24. 25 Prehospital IssuesPrehospital 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 III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
    25. 25. 26 Prehospital IssuesPrehospital 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 III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
    26. 26. 27 Options for Transport of Patients WithOptions for Transport of Patients With STEMI and Initial Reperfusion TreatmentSTEMI and Initial Reperfusion Treatment EMS Transport Onset of symptoms of STEMI 9-1-1 EMS Dispatch EMS on-scene • Encourage 12-lead ECGs. • Consider prehospital fibrinolytic if capable and EMS-to-needle within 30 min. GOALS PCI capable Not PCI capable Hospital fibrinolysis: Door-to-Needle within 30 min. EMS Triage Plan Inter- Hospital Transfer Golden Hour = first 60 min. Total ischemic time: within 120 min. 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. 5 min. 8 min.
    27. 27. 28 • 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. Fibrinolysis Primary PCI Noninvasive Risk Stratification Late Hospital Care and Secondary Prevention PCI or CABG Not PCI Capable PCI Capable Rescue Ischemia driven Options for Transport of Patients With STEMI andOptions for Transport of Patients With STEMI and Initial Reperfusion TreatmentInitial Reperfusion Treatment
    28. 28. 29 Initial Recognition andInitial Recognition and Management in theManagement in the Emergency DepartmentEmergency Department ACC/AHA Guidelines for the Management of Patients with ST-Elevation Myocardial Infarction
    29. 29. 30 ED Evaluation ofED Evaluation of Patients With STEMIPatients With STEMI 1. Airway, Breathing, Circulation (ABC) 2. Vital signs, general observation 3. Presence or absence of jugular venous distension 4. Pulmonary auscultation for rales 5. Cardiac auscultation for murmurs and gallops 6. Presence or absence of stroke 7. Presence or absence of pulses 8. Presence or absence of systemic hypoperfusion (cool, clammy, pale, ashen) Brief Physical Examination in the ED
    30. 30. 31 ED Evaluation ofED Evaluation of Patients With STEMIPatients With STEMI Aortic dissection Pulmonary embolus Perforating ulcer Tension pneumothorax Boerhaave syndrome (esophageal rupture with mediastinitis) Differential Diagnosis of STEMI: Life-Threatening
    31. 31. 32 ED Evaluation ofED Evaluation of Patients With STEMIPatients With STEMI Pericarditis Atypical angina Early repolarization Wolff-Parkinson-White syndrome Deeply inverted T-waves suggestive of a central nervous system lesion or apical hypertrophic cardiomyopathy LV hypertrophy with strain Brugada syndrome Myocarditis Hyperkalemia Bundle-branch blocks Vasospastic angina Hypertrophic cardiomyopathy Differential Diagnosis of STEMI: Other Cardiovascular and Nonischemic
    32. 32. 33 Gastroesophageal reflux (GERD) and spasm Chest-wall pain Pleurisy Peptic ulcer disease Panic attack Cervical disc or neuropathic pain Biliary or pancreatic pain Somatization and psychogenic pain disorder ED Evaluation ofED Evaluation of Patients With STEMIPatients With STEMI Differential Diagnosis of STEMI: Other Noncardiac
    33. 33. 34 ElectrocardiogramElectrocardiogram If the initial ECG is not diagnostic of STEMI, serial ECGs or continuous ST-segment monitoring should be performed in the patient who remains symptomatic or if there is high clinical suspicion for STEMI. III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
    34. 34. 35 ElectrocardiogramElectrocardiogram 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. III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
    35. 35. 36 Laboratory ExaminationsLaboratory 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 III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
    36. 36. 37 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. Biomarkers of Cardiac DamageBiomarkers of Cardiac Damage III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
    37. 37. 38 00 11 22 33 44 55 66 77 88 Cardiac troponin-no reperfusionCardiac troponin-no reperfusion Days After Onset of STEMIDays After Onset of STEMI MultiplesoftheURLMultiplesoftheURL Upper reference limitUpper reference limit 11 22 55 1010 2020 5050 URL = 99th %tile ofURL = 99th %tile of Reference Control GroupReference Control Group 100100 Cardiac troponin-Cardiac troponin-reperfusionreperfusion CKMB-no reperfusionCKMB-no reperfusion CKMB-CKMB-reperfusionreperfusion Cardiac Biomarkers in STEMICardiac Biomarkers in STEMI Alpert et al. J Am Coll Cardiol 2000;36:959. Wu et al. Clin Chem 1999;45:1104.
    38. 38. 39 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. ImagingImaging III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
    39. 39. 40 Supplemental oxygen should be administered to patients with arterial oxygen desaturation (SaO2 < 90%). It is reasonable to administer supplemental oxygen to all patients with uncomplicated STEMI during the first 6 hours. OxygenOxygen III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
    40. 40. 41 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. NitroglycerinNitroglycerin III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
    41. 41. 42 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. NitroglycerinNitroglycerin III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
    42. 42. 43 AnalgesiaAnalgesia 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. III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
    43. 43. 44 AspirinAspirin III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII 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. III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
    44. 44. 45 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. Beta-BlockersBeta-Blockers III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
    45. 45. 46 Phase of Treatment Acute treatment Secondary prevention Overall Total No. Patients 28,970 24,298 53,268 0.5 1 2 Relative risk (RR) of death Beta blocker better RR (95% CI) Placebo better 0.87 (0.77-0.98) 0.77 (0.70-0.84) 0.81 (0.75-0.87) Summary of Trials of Beta-Blocker TherapySummary of Trials of Beta-Blocker Therapy Antman E, Braunwald E. Acute Myocardial Infarction. In: Braunwald E, Zipes DP, Libby P, eds. Heart Disease: A textbook of Cardiovascular Medicine, 6th ed., Philadelphia, PA: W.B. Sanders, 2001, 1168.
    46. 46. 47 ReperfusionReperfusion • Given the current literature, it is not possible to say definitively that a particular reperfusion approach is superior for all pts, in all clinical settings, at all times of day • The main point is that some type of reperfusion therapy should be selected for all appropriate pts with suspected STEMI • The appropriate & timely use of some reperfusion therapy is likely more important than the choice of therapy
    47. 47. 48 ReperfusionReperfusion 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.
    48. 48. 49 Media campaign Patient education Methods of Speeding Time to Reperfusion Greater use of 9-1-1 Prehospital Rx MI protocol Critical pathway Quality improvement program Bolus lytics Dedicated PCI team 5 min < 30 min D-B ≤ 90 min D-N ≤ 30 min Goals Prehospital ECG Patient Transport Inhospital Reperfusion ReperfusionReperfusion
    49. 49. 50 Symptom Recognition Call to Medical System ED Cath LabPreHospital Delay in Initiation of Reperfusion Therapy Increasing Loss of Myocytes Treatment Delayed is Treatment DeniedTreatment Delayed is Treatment Denied
    50. 50. 51 PCI vs Fibrinolysis for STEMI:PCI vs Fibrinolysis for STEMI: Short Term Clinical OutcomesShort Term Clinical Outcomes 7 4.5 2.2 6 1 0 7 89 7 7 21 2 1 5 13 0 5 10 15 20 25 30 35 PCI Frequency(%) P=0.0002 P=0.0003 P < 0.0001 P < 0.0001 P < 0.0001 P=0.0004 P=0.032 P < 0.0001 Death Death, no SHOCK data Recurr. MI Recurr. Ischemia Total Stroke Hemorrh. Stroke Major Bleed Death MI CVA Fibrinolysis N = 7739 Keeley et al. The Lancet 2003;361:13.
    51. 51. 52 Overview of PCI vs Lysis:Overview of PCI vs Lysis: Issues to ConsiderIssues to Consider • Sample Size = 7739 • Data span 10–15 years • Selection bias of pts enrolled • 2% mortality benefit with PCI depends on lytic – (not significant vs tPA if SHOCK is excluded) • Composite endpoint is driven by reMI – potential biases against lytic arms: Hard to diagnose peri-PCI MI UFH used in lytic arms--? Better antithrombins Dependent on use of PCI post-lysis JACC 2004;44: 671. Circulation 2004;110: 588.
    52. 52. 53 Contraindications and CautionsContraindications and Cautions for Fibrinolysis in STEMIfor Fibrinolysis in STEMI Absolute Contraindications • 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 NOTE: Age restriction for fibrinolysis has been removed compared with prior guidelines.
    53. 53. 54 Contraindications and CautionsContraindications and Cautions for Fibrinolysis in STEMIfor Fibrinolysis in STEMI Absolute Contraindications • Suspected aortic dissection • Active bleeding or bleeding diathesis (excluding menses) • Significant closed-head or facial trauma within 3 months
    54. 54. 55 Contraindications and CautionsContraindications and Cautions for Fibrinolysis in STEMIfor Fibrinolysis in STEMI • 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) Relative Contraindications
    55. 55. 56 Contraindications and CautionsContraindications and Cautions for Fibrinolysis in STEMIfor 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
    56. 56. 57 PCI versus Fibrinolysis with Fibrin-SpecificPCI versus Fibrinolysis with Fibrin-Specific Agents: Is Timing (Almost) Everything?Agents: Is Timing (Almost) Everything? Favors PCI Favors fibrinolysis with a fibrin-specific agent 13 RCTs N = 5494 P = 0.04 AbsoluteRiskDifferenceinDeath(%) 30 40 50 60 70 80 PCI-Related Time Delay (minutes) 10 − 5 − 0 − -5 − ┬ ┬ ┬ ┬ ┬ ┬ Nallamothu and Bates. Am J Cardiol 2003;92:824.
    57. 57. 58 SymptomsSymptoms toto balloon inflation (minutes)balloon inflation (minutes) One-yearmortality,%One-yearmortality,% 6 RCTs of Primary PCI by Zwolle Group 19946 RCTs of Primary PCI by Zwolle Group 1994 –– 20012001 N = 1791N = 1791 RR = 1.08 [1.01RR = 1.08 [1.01 –– 1.16] for each 30 min delay1.16] for each 30 min delay ((PP = 0.04)= 0.04) PP < 0.0001< 0.0001 1212 1010 88 66 44 22 00 00 6060 120120 180180 240240 300300 360360 Symptom Onset to Balloon Time andSymptom Onset to Balloon Time and Mortality in Primary PCI for STEMIMortality in Primary PCI for STEMI DeLuca et al. Circulation 2004;109:1223.
    58. 58. 59 Reperfusion Options for STEMI PatientsReperfusion Options for STEMI Patients Step OneStep One: Assess Time and Risk.: Assess Time and Risk. Time Since Symptom Onset Time Required for Transport to a Skilled PCI Lab Risk of STEMI Risk of Fibrinolysis
    59. 59. 60 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 PatientsReperfusion Options for STEMI Patients Step 2:Step 2: Select Reperfusion Treatment.Select Reperfusion Treatment. If presentation is < 3 hours and there is no delay to an invasive strategy, there is no preference for either strategy.
    60. 60. 61 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 Reperfusion Options for STEMI PatientsReperfusion Options for STEMI Patients Step 2:Step 2: Select Reperfusion Treatment.Select Reperfusion Treatment. If presentation is < 3 hours and there is no delay to an invasive strategy, there is no preference for either strategy.
    61. 61. 62 PCI vs Lysis:PCI vs Lysis: Additional DataAdditional Data • Mortality advantage of PCI diminishes: As risk with lytic decreases: PCI = Lysis at 3% With increasing delay: PCI = Fibrin spec lytic with 60 min delay RR = 1.08 for every 30 min from onset of sx The earlier patient is seen: PCI = Lysis in < 3 h from sx • Outcomes with PCI are influenced by time of day and operator/institution volume and experience • Trials of transfer for PCI: Had very short transport and D-B times PCI mortality higher than prehospital lysis in pts treated early (2h) JACC 2004;44: 671 Circ 2004;110: 588
    62. 62. 63 FibrinolysisFibrinolysis 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). III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
    63. 63. 64 FibrinolysisFibrinolysis 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. III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
    64. 64. 65 FibrinolysisFibrinolysis 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. III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
    65. 65. 66 Evolution of PCI for STEMIEvolution of PCI for STEMI Antman. Circulation 2001;103:2310. Balloon Antiplatelet Rx Stent DES GP IIb/IIIa inhibitor ASA Clopidogrel AngioJet Thrombus Removal and Distal Embolization Protection Devices Embolization Protection Device Platelet
    66. 66. 67 Primary PCI for STEMI:Primary PCI for STEMI: General ConsiderationsGeneral 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 III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
    67. 67. 68 Primary PCI for STEMI:Primary PCI for STEMI: Specific ConsiderationsSpecific 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. III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
    68. 68. 69 Primary PCI for STEMI:Primary PCI for STEMI: Specific ConsiderationsSpecific 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. III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
    69. 69. 70 Primary PCI for STEMI:Primary PCI for STEMI: Specific ConsiderationsSpecific 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. III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
    70. 70. 71 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. Primary PCI for STEMI:Primary PCI for STEMI: Specific ConsiderationsSpecific Considerations III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
    71. 71. 72 Rescue PCIRescue PCI Rescue 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. Rescue PCI should be performed in patients with severe CHF and/or pulmonary edema (Killip class 3) and onset of symptoms within 12 hours. III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
    72. 72. 73 III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII Rescue PCIRescue PCI Rescue PCI is reasonable for selected patients 75 years or older with ST elevation or LBBB or who develop shock within 36 hours of MI and are suitable for revascularization that can be performed within 18 hours of shock. It is reasonable to perform rescue PCI for patients with one or more of the following: a. Hemodynamic or electrical instability b. Persistent ischemic symptoms. III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
    73. 73. 74 PCI for Cardiogenic ShockPCI for Cardiogenic Shock Primary PCI is recommended for patients less than 75 years with ST elevation or LBBB or who develop shock within 36 hours of MI and are suitable for revascularization that can be performed within 18 hours of shock. Primary PCI is reasonable for selected patients 75 years or older with ST elevation or LBBB or who develop shock within 36 hours of MI and are suitable for revascularization that can be performed within 18 hours of shock. III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
    74. 74. 75 Cardiogenic Shock Early Shock, Diagnosed on Hospital Presentation Fibrinolytic therapy if all of the following are present: 1. Greater than 90 minutes to PCI 2. Less than 3 hours post STEMI onset 3. No contraindications Arrange prompt transfer to invasive procedure-capable center PCI for Cardiogenic ShockPCI for Cardiogenic Shock IABP
    75. 75. 76 Cardiogenic Shock Early Shock, Diagnosed on Hospital Presentation Delayed Onset Shock Echocardiogram to Rule Out Mechanical Defects IABP Fibrinolytic therapy if all of the following are present: 1. Greater than 90 minutes to PCI 2. Less than 3 hours post STEMI onset 3. No contraindications Arrange prompt transfer to invasive procedure-capable center Arrange rapid transfer to invasive procedure-capable center PCI for Cardiogenic ShockPCI for Cardiogenic Shock
    76. 76. 77 Cardiogenic Shock 1-2 vessel CAD Moderate 3-vessel CAD Severe 3-vessel CAD Left main CAD PCI IRA PCI IRA Immediate CABG Staged Multivessel PCI Staged CABG Cannot be performed Early Shock, Diagnosed on Hospital Presentation Delayed Onset Shock Echocardiogram to Rule Out Mechanical Defects Cardiac Catheterization and Coronary Angiography IABP Fibrinolytic therapy if all of the following are present: 1. Greater than 90 minutes to PCI 2. Less than 3 hours post STEMI onset 3. No contraindications Arrange prompt transfer to invasive procedure-capable center Arrange rapid transfer to invasive procedure-capable center PCI for Cardiogenic ShockPCI for Cardiogenic Shock
    77. 77. 78 PCI After FibrinolysisPCI 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. III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
    78. 78. 79 PCI After FibrinolysisPCI After Fibrinolysis It is reasonable to perform routine PCI in patients with left ventricular ejection fraction (LVEF) ≤ 0.40, CHF, or serious ventricular arrhythmias. Routine PCI might be considered as part of an invasive strategy after fibrinolytic therapy. 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). III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
    79. 79. 80 Assessment of ReperfusionAssessment 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. III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
    80. 80. 81 Ancillary Therapy to ReperfusionAncillary Therapy to Reperfusion Unfractionated heparin (UFH) should be given intravenously in:  Patients undergoing PCI or surgical revascularization  After alteplase, reteplase, tenecteplase  After streptokinase, anistreplase, urokinase in patients at high risk for systemic emboli. III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
    81. 81. 82 Ancillary Therapy to ReperfusionAncillary Therapy to Reperfusion Low molecular-weight heparin (LMWH) might be considered an acceptable alternative to UFH in patients less than 75 years who are receiving fibrinolytic therapy in the absence of significant renal dysfunction. Enoxaparin used with tenecteplase is the most comprehensively studied. Platelet counts should be monitored daily in patients taking UFH. III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
    82. 82. 83 AspirinAspirin 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. III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
    83. 83. 84 ThienopyridinesThienopyridines 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. III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
    84. 84. 85 ThienopyridinesThienopyridines 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. III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
    85. 85. 86 ThienopyridinesThienopyridines Clopidogrel is probably indicated in patients receiving fibrinolytic therapy who are unable to take aspirin because of hypersensitivity or gastrointestinal intolerance. III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
    86. 86. 87 Glycoprotein IIb/IIIa InhibitorsGlycoprotein 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. III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
    87. 87. 88 Other Pharmacological MeasuresOther Pharmacological Measures Angiotensin converting enzyme (ACE) inhibitors Angiotensin receptor blockers (ARB) Aldosterone blockers Glucose control Magnesium Calcium channel blockers Inhibition of the renin -angiotensin -aldosterone system
    88. 88. 89 All-Cause Mortality Years ProbabilityofEvent 0 0.05 0. 1 0.15 0.2 0.25 0.3 0 1 2 3 0.35 0.4 4 ACE-I Placebo ACE-I 2995 2250 1617 892 223 Placebo 2971 2184 1521 853 138 Flather MD, et al. Lancet. 2000;355:1575–1581 OR: 0.74 (0.66–0.83) ACE-I: 702/2995 (23.4%) Placebo: 866/2971 (29.1%) TRACE Echocardiographic EF ≤ 35% AIRE Clinical and/or radiographic signs of HF SAVE Radionuclide EF ≤ 40%
    89. 89. 90 Captopril 0 0.05 0.1 0.15 0.2 0.25 0.3 0 6 12 18 24 30 36 ProbabilityofEvent Mortality by Treatment Pfeffer, McMurray, Velazquez, et al. N Engl J Med 2003;349 Valsartan 4909 4464 4272 4007 2648 1437 357 Months Valsartan vs. Captopril: HR = 1.00; P = 0.982 Valsartan + Captopril vs. Captopril: HR = 0.98; P = 0.726 Captopril 4909 4428 4241 4018 2635 1432 364 Valsartan + Cap 4885 4414 4265 3994 2648 1435 382 Valsartan Valsartan + Captopril
    90. 90. 91 P = 0.008 RR = 0.85 (95% CI, 0.75–0.96) EPHESUS: All-Cause Mortality Eplerenone 3319 3044 2463 1260 336 0 0 Placebo 3313 2983 2418 1213 323 2 0 Month 6 12 18 24 30 36 0 5 10 15 20 25 CumulativeIncidence(%) 0 Eplerenone Placebo Pitt et al. N Engl J Med 2003;348:1309-1321
    91. 91. 92 ACE/ARB: Within 24 HoursACE/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. III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
    92. 92. 93 ACE/ARB: Within 24 HoursACE/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). III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
    93. 93. 94 Strict Glucose Control During STEMIStrict Glucose Control During STEMI An insulin infusion to normalize blood glucose is recommended for patients and complicated courses. It is reasonable to administer an insulin infusion to normalize blood glucose even in patients with an uncomplicated course. III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
    94. 94. 95 Hospital ManagementHospital Management ACC/AHA Guidelines for the Management of Patients with ST-Elevation Myocardial Infarction
    95. 95. 96 Sample Admitting Orders for theSample Admitting Orders for the Patient With STEMIPatient With STEMI 1. Condition: Serious 2. Normal Saline or D5W intravenous to keep vein open 3. Vital signs: Heart rate, blood pressure, respiratory rate 4. Monitor: Continuous ECG monitoring for arrhythmia/ST- segment deviation 5. Diet: NCEP ATP III Therapeutic Lifestyle Changes, low sodium diet
    96. 96. 97 Sample Admitting Orders for theSample Admitting Orders for the Patient With STEMIPatient With STEMI 6. Activity: Bed rest with bedside commode, light activity when stable 7. Oxygen: 2 L/min when stable for 6 hrs, reassess need (i.e., O2 sat < 90%). Consider discontinuing if O2 saturation is > 90%. 8. Medications: NTG, ASA, beta-blocker, ACE, ARB, pain meds, anxiolytics, daily stool softener 9. Laboratory tests: cardiac biomarkers, CBC w/platelets, INR, aPTT, electrolytes, Mg2+ , BUN, creatinine, glucose, serum lipids
    97. 97. 98 Emergency Management of Complicated STEMIEmergency Management of Complicated STEMI Administer • Fluids • Blood transfusions • Cause-specific interventions Consider vasopressors Arrhythmia Bradycardia Tachycardia Systolic BP Greater than 100 mm Hg Systolic BP 70 to 100 mm Hg NO signs/symptoms of shock Systolic BP 70 to 100 mm Hg Signs/symptoms of shock Systolic BP less than 70 mm Hg Signs/symptoms of shock Dobutamine 2 to 20 mcg/kg per minute IV Low Output - Cardiogenic Shock Nitroglycerin 10 to 20 mcg/min IV Dopamine 5 to 15 mcg/kg per minute IV Norepinephrine 0.5 to 30 mcg/min IV Hypovolemia Administer • Furosemide IV 0.5 to 1.0 mg/kg • Morphine IV 2 to 4 mg • Oxygen/intubation as needed • Nitroglycerin SL, then 10 to 20 mcg/min IV if SBP greater than 100 mm Hg • Dopamine 5 to 15 mcg/kg per minute IV if SBP 70 to 100 mm Hg and signs/symptoms of shock present • Dobutamine 2 to 20 mcg/kg per minute IV if SBP 70 to 100 mm Hg and no signs/symptoms of shock FirstlineofactionSecondlineofactionThirdlineofaction See Section 7.7 in the ACC/AHA Guidelines for Patients With ST-Elevation Myocardial Infarction Check Blood Pressure Clinical signs: Shock, hypoperfusion, congestive heart failure, acute pulmonary edema Most likely major underlying disturbance? Further diagnostic/therapeutic considerations (should be considered in nonhypovolemic shock) Diagnostic Therapeutic ♥ Pulmonary artery catheter ♥ Intra-aortic balloon pump ♥ Echocardiography ♥ Reperfusion/revascularization ♥ Angiography for MI/ischemia ♥ Additional diagnostic studies Acute Pulmonary Edema Check Blood Pressure Systolic BP Greater than 100 mm Hg and not less than 30 mm Hg below baseline ACE Inhibitors Short-acting agent such as captopril (1 to 6.25 mg) Circulation 2000;102(suppl I):I-172-I-216.
    98. 98. 99 Right Ventricular InfarctionRight Ventricular Infarction Clinical findings: Shock with clear lungs, elevated JVP Kussmaul sign Hemodynamics: Increased RA pressure (y descent) Square root sign in RV tracing ECG: ST elevation in R sided leads Echo: Depressed RV function Rx: Maintain RV preload Lower RV afterload (PA---PCW) Inotropic support ReperfusionV4R Modified from Wellens. N Engl J Med 1999;340:381.
    99. 99. 100 VentricularVentricular Septal RuptureSeptal Rupture Mitral RegurgitationMitral Regurgitation (Pap. M. dysfunction)(Pap. M. dysfunction) Incidence 1-2% 1-6% 1-2% Timing 3-5 d p MI 3-6 d p MI 3-5 d p MI Phy Exam murmur 90% JVD, EMD murmur 50% Thrill Common No Rare Echo Shunt Peric. Effusion Regurg. Jet PA cath O2 step up Diast Press Equal. c-v wave in PCW Images:Courtesy of W D Edwards (Mayo Foundation) Data: Lavocitz. CV Rev Rpt 1984;5:948; Birnbaum. NEJM 2002;347:1426. Free WallFree Wall RuptureRupture
    100. 100. 101 ““Warning Arrhythmias”Warning Arrhythmias” Antman and Rutherford. Coronary Care Medicine. Boston, MA: Martinus Nijhoff Publishing;1986:81.
    101. 101. 102 Arrhythmias During Acute Phase of STEMI:Arrhythmias During Acute Phase of STEMI: Electrical InstabilityElectrical Instability VPBs K+ , Mg++ , beta blocker VT Antiarrhythmics, DC shock AIVR Observe unless hemodynamic compromise NPJT Search for cause (e.g., dig toxicity) Arrhythmia Treatment
    102. 102. 103 Sinus Tach Treat cause; beta blocker Afib / Flutter Treat cause; slow ventricular rate; DC shock PSVT Vagal maneuvers; beta blocker, verapamil / diltiazem; DC shock Arrhythmias During Acute Phase of STEMI:Arrhythmias During Acute Phase of STEMI: Pump Failure / Excess Sympathetic TonePump Failure / Excess Sympathetic Tone Arrhythmia Treatment
    103. 103. 104 Sinus Brady Treat if hemodynamic compromise; atropine / pacing Junctional Treat if hemodynamic compromise; atropine / pacing Arrhythmias During Acute Phase of STEMI:Arrhythmias During Acute Phase of STEMI: BradyarrhythmiasBradyarrhythmias Arrhythmia Treatment
    104. 104. 105 Arrhythmias During Acute Phase of STEMI:Arrhythmias During Acute Phase of STEMI: AV Conduction DisturbancesAV Conduction Disturbances Escape Rhythm His Bundle Distal < 120 ms > 120 ms 45 - 60 Often < 30 Duration of AVB 2 - 3 days Transient Mortality Low High (CHF, VT) Rx Observe PM (ICD) Proximal Distal
    105. 105. 106 Recommendations for Treatment of Atrioventricular and Intraventricular Conduction Disturbances During STEMI INTRAVENTRICULAR CONDUCTION Normal ACTION CLASS ACTION CLASS ACTION CLASS ACTION CLASS ACTION CLASS ACTION CLASS ACTION CLASS Observe I Observe I Observe I Observe IIb Observe IIa Observe III Observe III A III A III A III A* III A III A III A III TC III TC IIb TC IIb TC I TC I TC I TC I TV III TV III TV III TV III TV III TV IIa TV IIa Old or New Observe I Observe IIb Observe IIb Observe IIb Observe IIb Observe III Observe III Fascicular block A III A III A III A* III A III A III A III (LAFB or LPFB) TC IIb TC I TC IIa TC I TC I TC I TC I TV III TV III TV III TV III TV III TV IIa TV IIb Observe I Observe III Observe III Observe III Observe III Observe III Observe III A III A III A III A* III A III A III A III TC IIb TC I TC I TC I TC I TC I TC I TV III TV IIb TV IIb TV IIb TV IIb TV IIa TV IIa Observe III Observe III Observe III Observe III Observe III Observe III Observe III A III A III A III A* III A III A III A III TC I TC I TC I TC I TC I TC IIb TC IIb TV IIb TV IIa TV IIa TV IIa TV IIa TV I TV I Fascicular Observe III Observe III Observe III Observe III Observe III Observe III Observe III block + RBBB A III A III A III A* III A III A III A III TC I TC I TC I TC I TC I TC IIb TC IIb TV IIb TV IIa TV IIa TV IIa TV IIa TV I TV I Alternating Observe III Observe III Observe III Observe III Observe III Observe III Observe III left and right A III A III A III A* III A III A III A III bundle branch TC IIb TC IIb TC IIb TC IIb TC IIb TC IIb TC IIb block TV I TV I TV I TV I TV I TV I TV I Normal Old bundle branch block New bundle branch block Mobitz II second degree AV blockMobitz I second degree AV blockFirst degree AV block ANTERIOR MI NON-ANTERIOR ANTERIOR MI NON-ANTERIOR ANTERIOR MI NON-ANTERIOR Atrioventricular Conduction
    106. 106. 107 ICD Trials in Post-MI Patients NEJM 1996;335:1933-40. NEJM 1999;341;1882-90. NEJM 2002;346:877-93. EF Upper limit, mean 3-30 VPBs rate greater than 120 Greater than 2 VPS rate greater than 100 MADIT 2 2002 1232 Greater than 29 None necessary 30%, 23% No 0.69 (0.51-0.93) 35%, 26% Yes 0.46 (0.26-0.82) MUSTT 1999 704 Greater than 3 40%, 30% Yes 0.42 (0.28-0.62) MADIT 1996 196 Greater than 20 Qualifying arrhythmia EPS Mortality hazard ICD versus no ICD (95%CI) Study Name Year Number of patients Days post-MI
    107. 107. 108 ICD Implantation After STEMI One Month After STEMI; No Spontaneous VT or VF 48 hours post-STEMI EF < 0.30 EPS Yes + NEJM 349: 1836,2003 EF 0.31 - 0.40 No No ICD. Medical Rx EF > 0.40 - Additional Marker of Electrical Instability?
    108. 108. 109 Algorithm for Management of Recurrent Ischemia/Infarction After STEMI Obtain 12-lead ECG ST-segment elevation? • Escalation of medical therapy (nitrates, beta- blockers) • Anticoagulation if not already given • Consider IABP for hemodynamic instability, poor LV function, or a large area of myocardium at risk • Correct secondary causes of ischemia Recurrent ischemic-type discomfort at rest after STEMI Obtain 12-lead ECG ST-segment elevation?ST-segment elevation? • Escalation of medical therapy (nitrates, beta- blockers) • Anticoagulation if not already given • Consider IABP for hemodynamic instability, poor LV function, or a large area of myocardium at risk • Correct secondary causes of ischemia Recurrent ischemic-type discomfort at rest after STEMI
    109. 109. 110 Algorithm for Management of Recurrent Ischemia/Infarction After STEMI Obtain 12-lead ECG YES NO Consider (re) administration of YES Is patient a candidate for revascularization? ST-segment elevation? • Escalation of medical therapy (nitrates, beta- blockers) • Anticoagulation if not already given • Consider IABP for hemodynamic instability, poor LV function, or a large area of myocardium at risk • Correct secondary causes of ischemia Recurrent ischemic-type discomfort at rest after STEMI YES Coronary angiography Revascularization with PCI and/or CABG as dictated by anatomy NO Can catheterization be performed promptly?* Obtain 12-lead ECG YES NO Consider (re) administration of fibrinolytic therapy YES Is patient a candidate for revascularization? Is patient a candidate for revascularization? ST-segment elevation?ST-segment elevation? • Escalation of medical therapy (nitrates, beta- blockers) • Anticoagulation if not already given • Consider IABP for hemodynamic instability, poor LV function, or a large area of myocardium at risk • Correct secondary causes of ischemia Recurrent ischemic-type discomfort at rest after STEMI YES Coronary angiography Revascularization with PCI and/or CABG as dictated by anatomy NO Can catheterization be performed promptly?* Can catheterization be performed promptly? Modified from Braunwald. Heart Disease: A Textbook of Cardiovascular Medicine. 6th ed. Philadelphia, PA: WB Saunders Co. Ltd. 2001:1195. Consider (re) administration of fibrinolytic therapy
    110. 110. 111 Algorithm for Management of Recurrent Ischemia/Infarction After STEMI Obtain 12-lead ECG YES NO Consider (re) administration of YES NO Is patient a candidate for revascularization? ST-segment elevation? • Escalation of medical therapy (nitrates, beta- blockers) • Anticoagulation if not already given • Consider IABP for hemodynamic instability, poor LV function, or a large area of myocardium at risk • Correct secondary causes of ischemia Recurrent ischemic-type discomfort at rest after STEMI YES NO Refer for nonurgent catheterization Refer for urgent catheterization (consider IABP) Is ischemia controlled by escalation of medical therapy? YES Coronary angiography Revascularization with PCI and/or CABG as dictated by anatomy NO Can catheterization be performed promptly?* Obtain 12-lead ECG YES NO Consider (re) administration of fibrinolytic therapy YES NO Is patient a candidate for revascularization? Is patient a candidate for revascularization? ST-segment elevation?ST-segment elevation? • Escalation of medical therapy (nitrates, beta- blockers) • Anticoagulation if not already given • Consider IABP for hemodynamic instability, poor LV function, or a large area of myocardium at risk • Correct secondary causes of ischemia Recurrent ischemic-type discomfort at rest after STEMI YES NO Refer for nonurgent catheterization Refer for urgent catheterization (consider IABP) YES NO Refer for nonurgent catheterization Refer for urgent catheterization (consider IABP) Is ischemia controlled by escalation of medical therapy? Is ischemia controlled by escalation of medical therapy? YES Coronary angiography Revascularization with PCI and/or CABG as dictated by anatomy NO Can catheterization be performed promptly?* Can catheterization be performed promptly? Modified from Braunwald. Heart Disease: A Textbook of Cardiovascular Medicine. 6th ed. Philadelphia, PA: WB Saunders Co. Ltd. 2001:1195. Consider (re) administration of fibrinolytic therapy
    111. 111. 112 Evidence-Based Approach to Need for Catheterization and Revascularization After STEMI STEMI Primary Invasive Strategy Fibrinolytic Therapy No Reperfusion Therapy Cath Performed No Cath Performed EF greater than 0.40 EF less than 0.40 EF less than 0.40 EF greater than 0.40 High-Risk Features † No High-Risk Features † No High-Risk Features † High-Risk Features † Functional Evaluation ECG Interpretable ECG Uninterpretable Able to Exercise Unable to Exercise Submaximal Exercise Test Before Discharge Symptom-Limited Exercise Test Before or After Discharge Pharmacological Stress Nuclear Scan Dobutamine Echo Clinically Significant Ischemia* No Clinically Significant Ischemia* Medical Therapy Revascularization as Indicated Catheterization and Revascularization as Indicated Catheterization and Revascularization as Indicated Able to Exercise Exercise Echo Exercise Nuclear STEMI Primary Invasive Strategy Fibrinolytic Therapy No Reperfusion Therapy Cath Performed No Cath Performed EF greater than 0.40 EF less than 0.40 EF less than 0.40 EF greater than 0.40 High-Risk Features No High-Risk Features No High-Risk Features High-Risk Features Functional Evaluation ECG Interpretable ECG Uninterpretable Able to Exercise Unable to Exercise Submaximal Exercise Test Before Discharge Symptom-Limited Exercise Test Before or After Discharge Pharmacological Stress Adenosine or Dipyridamole Dobutamine Echo Clinically Significant Ischemia No Clinically Significant Ischemia Medical Therapy Revascularization as Indicated Catheterization and Revascularization as Indicated Catheterization and Revascularization as Indicated Able to Exercise Exercise Echo Exercise Nuclear
    112. 112. 113 Long-Term Antithrombotic Therapy at Hospital Discharge After STEMI No Stent Implanted No ASA allergy ASA Allergy Preferred: ASA 75 to 162 mg Class I; LOE: A Preferred: Clopidogrel 75 mg Class I; LOE: C Alternative: Warfarin INR (2.5 to 3.5) Class I; LOE: B Alternative: ASA 75 to 162 mg Warfarin (INR 2.0 to 3.0) Class: IIa; LOE: B OR Warfarin (INR 2.5 to 3.5) Class IIa; LOE: B Indications for Anticoagulation No Indications for Anticoagulation No Indications for Anticoagulation Indications for Anticoagulation ASA 75 to 162 mg Warfarin (INR 2.0 to 3.0) Class I; LOE B OR Warfarin (INR 2.5 to 3.5) Class I; LOE: B Warfarin INR (2.5 to 3.5) Class I; LOE: B STEMI Patient at Discharge
    113. 113. 114 Long-Term Antithrombotic Therapy at Hospital Discharge After STEMI Stent Implanted No ASA Allergy ASA Allergy ASA 75 to 162 mg Clopidogrel 75 mg Class: I; LOE: B ASA 75 to 162 mg Clopidogrel 75 mg Warfarin (INR 2.0 to 3.0) Class: IIb; LOE: C Clopidogrel 75 mg Class I; LOE: B Clopidogrel 75 mg Warfarin (INR 2.0 to 3.0) Class I; LOE: C STEMI Patient at Discharge No Indications for Anticoagulation Indications for Anticoagulation Indications for Anticoagulation No Indications for Anticoagulation
    114. 114. 115 Long-Term ManagementLong-Term Management ACC/AHA Guidelines for the Management of Patients with ST-Elevation Myocardial Infarction
    115. 115. 116 Secondary Prevention and Long Term Management • Assess tobacco use. • Strongly encourage patient and family to stop smoking and to avoid secondhand smoke. • Provide counseling, pharmacological therapy (including nicotine replacement and bupropion), and formal smoking cessation programs as appropriate. Smoking Goal: Complete Cessation Goals Recommendations
    116. 116. 117 Secondary Prevention and Long Term Management If blood pressure is 120/80 mm Hg or greater: • Initiate lifestyle modification (weight control, physical activity, alcohol moderation, moderate sodium restriction, and emphasis on fruits, vegetables, and low-fat dairy products) in all patients. If blood pressure is 140/90 mm Hg or greater or 130/80 mm Hg or greater for individuals with chronic kidney disease or diabetes: • Add blood pressure-reducing medications, emphasizing the use of beta-blockers and inhibitors of the renin-angiotensin- aldosterone system. Blood pressure control: Goal: < 140/90 mm Hg or <130/80 mm Hg if chronic kidney disease or diabetes Goals Recommendations
    117. 117. 118 Secondary Prevention and Long Term Management • Assess risk, preferably with exercise test, to guide prescription. • Encourage minimum of 30 to 60 minutes of activity, preferably daily but at least 3 or 4 times weekly (walking, jogging, cycling, or other aerobic activity) supplemented by an increase in daily lifestyle activities (e.g., walking breaks at work, gardening, household work). • Cardiac rehabilitation programs are recommended for patients with STEMI. Physical activity: Minimum goal: 30 minutes 3 to 4 days per week; Optimal daily Goals Recommendations
    118. 118. 119 Secondary Prevention and Long Term Management • Start dietary therapy in all patients (< 7% of total calories as saturated fat and < 200 mg/d cholesterol). Promote physical activity and weight management. Encourage increased consumption of omega-3 fatty acids. • Assess fasting lipid profile in all patients, preferably within 24 hours of STEMI. Add drug therapy according to the following guide: Lipid management: (TG less than 200 mg/dL) Primary goal: LDL-C << than 100 mg/dL Goals Recommendations LDL-C < 100 mg/dL (baseline or on treatment): Statins should be used to lower LDL-C. LDL-C ≥ 100 mg/dL (baseline or on treatment): Intensify LDL-C–lowering therapy with drug treatment, giving preference to statins.
    119. 119. 120 Secondary Prevention and Long Term Management If TGs are ≥ 150 mg/dL or HDL-C is < 40 mg/dL: Emphasize weight management and physical activity. Advise smoking cessation. If TG is 200 to 499 mg/dL: After LDL-C–lowering therapy, consider adding fibrate or niacin. If TG is ≥ 500 mg/dL: Consider fibrate or niacin before LDL-C–lowering therapy. Consider omega-3 fatty acids as adjunct for high TG. Lipid management: (TG 200 mg/dL or greater) Primary goal: Non–HDL-C << 130 mg/dL Goals Recommendations
    120. 120. 121 Secondary Prevention and Long Term Management Goals Recommendations Calculate BMI and measure waist circumference as part of evaluation. Monitor response of BMI and waist circumference to therapy. Start weight management and physical activity as appropriate. Desirable BMI range is 18.5 to 24.9 kg/m2 . If waist circumference is ≥ 35 inches in women or ≥ 40 inches in men, initiate lifestyle changes and treatment strategies for metabolic syndrome. Weight management: Goal: BMI 18.5 to 24.9 kg/m2 Waist circumference: Women: < 35 in. Men: < 40 in.
    121. 121. 122 Secondary Prevention and Long Term Management Goals Recommendations Appropriate hypoglycemic therapy to achieve near-normal fasting plasma glucose, as indicated by HbA1c. Treatment of other risk factors (e.g., physical activity, weight management, blood pressure, and cholesterol management). Diabetes management: Goal: HbA1c < 7%
    122. 122. 123 Secondary Prevention and Long Term Management Goals Recommendations • In the absence of contraindications, start aspirin 75 to 162 mg/d and continue indefinitely. • If aspirin is contraindicated, consider clopidogrel 75 mg/day or warfarin. • Manage warfarin to INR 2.5 to 3.5 in post- STEMI patients when clinically indicated or for those not able to take aspirin or clopidogrel. Antiplatelet agents/ anticoagulants
    123. 123. 124 Secondary Prevention and Long Term Management Goals Recommendations ACE inhibitors in all patients indefinitely; start early in stable, high-risk patients (ant. MI, previous MI, Killip class ≥ 2 [S3 gallop, rales, radiographic CHF], LVEF < 0.40). Angiotensin receptor blockers in patients who are intolerant of ACE inhibitors and with either clinical or radiological signs of heart failure or LVEF < 0.40. Aldosterone blockade in patients without significant renal dysfunction or hyperkalemia who are already receiving therapeutic doses of an ACE inhibitor, have LVEF ≤ 0.40, and have either diabetes or heart failure. Renin- Angiotensin- Aldosterone System Blockers
    124. 124. 125 Secondary Prevention and Long Term Management Goals Recommendations Start in all patients. Continue indefinitely. Observe usual contraindications. Beta- Blockers
    125. 125. 126 1st1st 24 h24 h DuringDuring HospHosp Hosp DC +Hosp DC + Long TermLong Term Aspirin 162-325 mg chewed 75-162 mg/d p.o. 75-162 mg/d p.o. Fibrinolytic tPA,TNK, rPA, SK UFH 60U/kg (4000) 12 U/kg/h (1000) aPTT 1.5 - 2 x C aPTT 1.5 - 2 x C Beta-blocker Oral daily Oral daily Oral daily Summary of Pharmacologic Rx:Summary of Pharmacologic Rx: IschemiaIschemia JACC 2004;44: 671 Circulation 2004;110: 588
    126. 126. 127 1st1st 24 h24 h During HospDuring Hosp Hosp DC +Hosp DC + Long TermLong Term ACEI Anterior MI, Pulm Cong., EF < 40 Oral Daily Oral Daily IndefinitelyARB ACEI intol., HF, EF < 40 Aldo Blocker No renal dysf, K+ < 5.0 mEq/L On ACEI, HF or DM Same as during Hosp. Statin Start w/o lipid profile Indefinitely, LDL << 100 Summary of Pharmacologic Rx:Summary of Pharmacologic Rx: LVD, Sec. Prev.,LVD, Sec. Prev., JACC 2004;44:671JACC 2004;44:671 Circ 2004;110:588Circ 2004;110:588
    127. 127. 128 Hormone TherapyHormone Therapy Hormone therapy with estrogen plus progestin should not be given de novo to postmenopausal women after STEMI for secondary prevention of coronary events. III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
    128. 128. 129 Hormone TherapyHormone Therapy Postmenopausal women who are already taking estrogen plus progestin at the time of STEMI should not continue hormone therapy. However, women who are beyond 1 to 2 years after initiation of hormone therapy who wish to continue such therapy for another compelling indication should weigh the risks and benefits. III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
    129. 129. 130 AntioxidantsAntioxidants Antioxidant vitamins such as vitamin E and/or vitamin C supplements should not be prescribed to patients recovering from STEMI to prevent cardiovascular disease. III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
    130. 130. 131 Psychosocial Impact of STEMIPsychosocial Impact of STEMI The psychosocial status of the patient should be evaluated, including inquiries regarding symptoms of depression, anxiety, or sleep disorders and the social support environment. Treatment with cognitive-behavioral therapy and selective serotonin reuptake inhibitors can be useful for STEMI patients with depression that occurs in the year after hospital discharge. III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
    131. 131. 132 Cardiac RehabilitationCardiac Rehabilitation Cardiac rehabilitation/secondary prevention programs, when available, are recommended for patients with STEMI, particularly those with multiple modifiable risk factors and/or those moderate- to high-risk patients in whom supervised exercise training is warranted. III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
    132. 132. 133 • Review and continue predischarge risk assessment. • Delineate cardiovascular symptoms and functional class. • Evaluate current medications and titrate if needed. • Review secondary prevention principles. • Check psychosocial status. • Discuss resumption of daily activities. • Address plan for recognizing and responding to potential cardiac event. • Refer to a cardiac rehabilitation program. Follow-Up Visit With Medical ProviderFollow-Up Visit With Medical Provider III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII

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