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Acs aha 2015

Updates of AHA 2015 recommendations for ACS

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ACS AHA 2015
Andey Rahman
Kelantan Resuscitation Updates 2015
Content
• Diagnostic Interventions in ACS
• Therapeutic Interventions in ACS
• Reperfusion Decisions in STEMI
• Hospital Reperfusion Decisions After ROSC
Kelantan Resuscitation Updates 2015
Diagnostic Interventions in ACS
• Criteria for diagnosis of AMI include:
– Detection of increase and/or decrease of cardiac biomarkers
(preferably troponin) with at least 1 value above the 99th
percentile of the upper reference limit
– Evidence of myocardial ischemia with at least 1 of the
following: symptoms, ECG changes, or supportive imaging
Kelantan Resuscitation Updates 2015
ECG
• Prehospital ECG
– Recommendation: We recommend prehospital 12-lead ECG acquisition with
hospital notification for adult patients with suspected STEMI (Class I, LOE B-NR)
– Why:
• Early recognition of STEMI
• Ensure identification of dynamic ECG changes
• Coupled with hospital notification reduces the time to reperfusion in-hospital
• Bottom line:
– Prehospital ECG acquisition and hospital notification reduces mortality by:
• 32% - PPCI
• 24% - ED fibrinolysis
Kelantan Resuscitation Updates 2015
ECG
• Computer-Assisted ECG STEMI Interpretation
– Recommendation:
• 1. Because of high false-negative rates, we recommend that computer-
assisted ECG interpretation not be used as a sole means to diagnose
STEMI (Class III, LOE B-NR)
• 2. We recommend that computer-assisted ECG interpretation may be
used in conjunction with physician or trained provider interpretation to
recognize STEMI (Class Iib, LOE C-LD)
Kelantan Resuscitation Updates 2015
ECG
• Nonphysician STEMI ECG Interpretation
– Recommendation: it may be reasonable for trained
nonphysician ECG interpretation to be used as the basis for
decision-making, including activation of the catheterization
laboratory, administration of fibrinolysis, and selection of
destination hospital (Class IIa, LOE B-NR)
– Study shows high agreement between physician and paramedic
rates of distinguishing STEMI from No STEMI
– Keyword: Trained nonphysician
Kelantan Resuscitation Updates 2015

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Acs aha 2015

  • 1. ACS AHA 2015 Andey Rahman Kelantan Resuscitation Updates 2015
  • 2. Content • Diagnostic Interventions in ACS • Therapeutic Interventions in ACS • Reperfusion Decisions in STEMI • Hospital Reperfusion Decisions After ROSC Kelantan Resuscitation Updates 2015
  • 3. Diagnostic Interventions in ACS • Criteria for diagnosis of AMI include: – Detection of increase and/or decrease of cardiac biomarkers (preferably troponin) with at least 1 value above the 99th percentile of the upper reference limit – Evidence of myocardial ischemia with at least 1 of the following: symptoms, ECG changes, or supportive imaging Kelantan Resuscitation Updates 2015
  • 4. ECG • Prehospital ECG – Recommendation: We recommend prehospital 12-lead ECG acquisition with hospital notification for adult patients with suspected STEMI (Class I, LOE B-NR) – Why: • Early recognition of STEMI • Ensure identification of dynamic ECG changes • Coupled with hospital notification reduces the time to reperfusion in-hospital • Bottom line: – Prehospital ECG acquisition and hospital notification reduces mortality by: • 32% - PPCI • 24% - ED fibrinolysis Kelantan Resuscitation Updates 2015
  • 5. ECG • Computer-Assisted ECG STEMI Interpretation – Recommendation: • 1. Because of high false-negative rates, we recommend that computer- assisted ECG interpretation not be used as a sole means to diagnose STEMI (Class III, LOE B-NR) • 2. We recommend that computer-assisted ECG interpretation may be used in conjunction with physician or trained provider interpretation to recognize STEMI (Class Iib, LOE C-LD) Kelantan Resuscitation Updates 2015
  • 6. ECG • Nonphysician STEMI ECG Interpretation – Recommendation: it may be reasonable for trained nonphysician ECG interpretation to be used as the basis for decision-making, including activation of the catheterization laboratory, administration of fibrinolysis, and selection of destination hospital (Class IIa, LOE B-NR) – Study shows high agreement between physician and paramedic rates of distinguishing STEMI from No STEMI – Keyword: Trained nonphysician Kelantan Resuscitation Updates 2015
  • 7. Biomakers in ACS • The detection of an elevated troponin (Tn) above the 99th percentile upper reference limit is highly sensitive and specific for myocardial necrosis, and is required in the universal definition of myocardial infarction (MI) • hs – “high sensitivity” = if they are able to detect measurable troponin levels even in healthy individuals • Focus on low risk ACS – to rule out Kelantan Resuscitation Updates 2015
  • 8. Biomakers in ACS • Recommendation: – 1. We recommend against using hs-cTnT and cTnI alone measured at 0 and 2 hours (without performing clinical risk stratification) to identify patients at low risk for ACS (Class III:Harm, LOE B-NR) • Why: – Without formal risk assessment tools ACS would have been missed in 2.5% to 7.8% of patients – False negative Kelantan Resuscitation Updates 2015
  • 9. Biomakers in ACS • Recommendation: – 2. We recommend that hs-cTnI measurements that are less than the 99th percentile, measured at 0 and 2 hours, may be used together with low-risk stratification (TIMI score of 0 or 1 or low risk per Vancouver rule) to predict a less than 1% chance of 30-day MACE (Class IIa, LOE B-NR) – 3. We recommend that negative cTnI or cTnT measurements at 0 and between 3 and 6 hours may be used together with very low-risk stratification (TIMI score of 0, low-risk score per Vancouver rule, North American Chest Pain score of 0 and age less than 50 years, or low-risk HEART score) to predict a less than 1% chance of 30-day MACE (Class Iia, LOE B-NR) Kelantan Resuscitation Updates 2015
  • 10. Therapeutic Interventions in ACS • ADP inhibitors (Clopidogrel, prasugrel, Ticagrelor) – Recommendation: • In patients with suspected STEMI intending to undergo PPCI, initiation of ADP inhibition may be reasonable in either the prehospital or in- hospital setting (Class Iib, LOE C-LD) – No additional benefit to the outcome of 30-day mortality and no additional benefit or harm with respect to major bleeding with prehospital administration compared with in-hospital administration of an ADP-receptor antagonist Kelantan Resuscitation Updates 2015
  • 11. Therapeutic Interventions in ACS • Prehospital Anticoagulants Versus None in STEMI – Recommendation: • We recommend that EMS systems that do not currently administer heparin to suspected STEMI patients do not add this treatment, whereas those that do administer it may continue their current practice (Class Iib, LOE B-NR) – Practice what you are doing now! Kelantan Resuscitation Updates 2015
  • 12. Routine Supplementary Oxygen Therapy in Patients Suspected of ACS • The 2 treatment approaches (either providing or withholding oxygen) were compared with respect to outcomes: rate of death, infarction size, resolution of chest pain, and ECG abnormality resolution • The new recommendation in this 2015 Guidelines Update applies only to the use of oxygen for patients suspected of ACS who have normal oxygen saturations Kelantan Resuscitation Updates 2015
  • 13. Routine Supplementary Oxygen Therapy in Patients Suspected of ACS • Recommendation: – The provision of supplementary oxygen to patients with suspected ACS who are normoxic has not been shown to reduce mortality or hasten the resolution of chest pain – Withholding supplementary oxygen in these patients has been shown to minimally reduce infarct size – In the prehospital, ED, and hospital settings, the withholding of supplementary oxygen therapy in normoxic patients with suspected or confirmed acute coronary syndrome may be considered (Class Iib, LOE C-LD) Kelantan Resuscitation Updates 2015
  • 14. Reperfusion Decisions in STEMI Patients • Prehospital Fibrinolysis, Hospital Fibrinolysis, and Prehospital Triage to PCI Center – Prehospital fibrinolysis will achieve earlier treatment as compared with ED fibrinolysis – requires a sophisticated system of provider expertise, well- established protocols, comprehensive training programs etc – Is it worthwhile to do? Kelantan Resuscitation Updates 2015
  • 15. Prehospital Fibrinolysis, Hospital Fibrinolysis, and Prehospital Triage to PCI Center • Recommendation – 1. Where prehospital fibrinolysis is available as part of a STEMI system of care, and in-hospital fibrinolysis is the alternative treatment strategy, it is reasonable to administer prehospital fibrinolysis when transport times are more than 30 minutes (Class IIa, LOE B-R) – 2. Where prehospital fibrinolysis is available as part of the STEMI system of care and direct transport to a PCI center is available, prehospital triage and transport directly to a PCI center may be preferred because of the small relative decrease in the incidence of intracranial hemorrhage without evidence of mortality benefit to either therapy (Class Iib, LOE B-R) Kelantan Resuscitation Updates 2015
  • 16. ED Fibrinolysis and Immediate PCI Versus Immediate PCI Alone • Delays in PPCI are common • This make administration of fibrinolytic with the downstream certainty of mechanical reperfusion with facilitated PCI an attractive concept • Counterbalanced by the concern for a heightened risk of bleeding complications • Studies shows: – 1. No benefit to mortality, non fatal MI or target vessel revascularization – 2. Harm in increase risk of ICH & major bleeding • Recommendation: – Not recommended (Class III:Harm, LOE B-R) Kelantan Resuscitation Updates 2015
  • 17. Delayed PCI Versus Fibrinolysis • Recommendation: – Regardless of whether time of symptom onset is known, the interval between first medical contact and reperfusion should not exceed 120 minutes (Class I, LOE C-EO) – In STEMI patients presenting within 2 hours of symptom onset, immediate fibrinolysis rather than PPCI may be considered when the expected delay to PPCI is more than 60 minutes (Class IIb, LOE C-LD) – In STEMI patients presenting within 2 to 3 hours after symptom onset, either immediate fibrinolysis or PPCI involving a possible delay of 60 to 120 minutes might be reasonable (Class IIb, LOE C-LD) – In STEMI patients presenting within 3 to 12 hours after symptom onset, performance of PPCI involving a possible delay of up to 120 minutes may be considered rather than initial fibrinolysis (Class IIb, LOE C-LD) – If PCI > 120 minutes, fibrinolytics + early PCI is the strategy (Class Iib, LOE B-R Kelantan Resuscitation Updates 2015
  • 18. Reperfusion therapy for STEMI in Non- PCI Capable Hospital • What we are doing now? – Thrombolytic/ fibrinolytic then send • Evidence: – Fibrinolysis and transfer vs immediate transfer for PPCI • No benefit to 30-day mortality, stroke or reinfarction and • no different in rate of ICH or major bleeding Kelantan Resuscitation Updates 2015
  • 19. Reperfusion therapy for STEMI in Non- PCI Capable Hospital • Fibrinolysis & routine transfer vs no transfer – 30-day mortality • No benefit – ICH or major bleeding • No difference in rates – Reinfarction • Decrease in reinfarction rate Kelantan Resuscitation Updates 2015
  • 20. Reperfusion therapy for STEMI in Non- PCI Capable Hospital • Recommendation: – 1. Immediate transfer without fibrinolysis to PCI center (Class I, LOE B-R) – 2. When STEMI patient cannot be transferred in timely manner – fibrinolytics then transfer is an acceptable alternative ( Class Iib, LOE C-LD) – When fibrinolytics is administered, it may be reasonable to transfer to PCI center for early angiography in the first 24 hours (Class IIB, LOE B-R) Kelantan Resuscitation Updates 2015
  • 21. Hospital Reperfusion Decisions After ROSC • Recommendation – 1. OHCA + STEMI – emergent PCI post ROSC should be performed (Class I, LOE B-NR) – 2. OHCA + No STEMI – emergency PCI post ROSC reasonable for selected pt • Unstable • Comatose (Class Iia, LOE B-NR) Kelantan Resuscitation Updates 2015
  • 22. Summary • Except ECG + Prehospital notification, other pre-hospital intervention – doesn’t change the outcome much • Troponins is good – rule in, rule out+ risk stratification • O2 in normoxia - NO • Facilitated PCI – NO • Time is myocardium Kelantan Resuscitation Updates 2015