Emergency Medical System Network for STEMI Management

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dr. Dyah Siswanti E, SpJP, FIHA. 3rd Pekanbaru Cardiology Update, August 24th 2013. Pangeran Hotel, Pekanbaru. Learn more at PerkiPekanbaru.com

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Emergency Medical System Network for STEMI Management

  1. 1. Emergency Medical System Network for STEMI management Dyah Siswanti 3rd PCU August 24th 2013,Pekanbaru
  2. 2. CURRICULUM VITAE Nama : dr. Dyah Siswanti Estiningsih, SpJP, FIHA Tempat tanggal lahir : Yogyakarta, 5 Nopember 1964 Pendidikan : FK UKI lulus 1989 FK UI bagian kardiologi lulus 1999 Alamat : Jln. Diponegoro no. 22 Pekanbaru • Rumah Sakit Tebet Jakarta 1989 - 1992 • Puskesmas Weluli, kab Belu, Nusa Tenggara Timur 1992 – 1995 • Kepala SMF Kardiologi dan Kedokteran Vaskuler RSUD Arifin Ahmad Pekanbaru / FK Unri • Direktur Medik dan Keperawatan di RSUD Arifin Ahmad Pekanbaru
  3. 3. Patofisiologi STEMI Copyright ©2007 American College of Cardiology Foundation. Restrictions may apply. Anderson, J. L. et al. J Am Coll Cardiol 2007;50:e1-e157
  4. 4. Chest painAdmission Working diagnosis ECG Bio- chemistry Risk stratification Treatment Secondary prevention Suspicion of Acute Coronary Syndrome Persistent ST-elevation No Persistent ST-elevation Normal or Undetermined Troponin (CKMB) Troponin ECG Troponin Twice negative (+) High Risk (-) Low Risk Probably not ACS Acute coronary syndromes : initial assessment ESC ACS Guideline 2002
  5. 5. A 12-lead ECG must be obtained with a target delay of ≤ 10 min.
  6. 6. ESC Guidelines for STEMI • Management, including diagnosis and treatment, starts at the point of first medical contact. • ECG monitoring must be initiated in all patients with suspected STEMI.
  7. 7. • The pre-hospital management of STEMI patients must be based on regional networks designed to deliver reperfusion therapy expeditiously and effectively, with efforts made to make primary PCI available to as many patients as possible.
  8. 8. Primary PCI-capable centres must deliver 24/7 service, be able to start primary PCI as soon as possible and within 60 min from the initial call.
  9. 9. Target : First medical contact to first ECG ≤10 min; First medical contact to reperfusion therapy; For fibrinolysis ≤30 min; For primary PCI ≤90 min (≤60 min if the patient presents within 120 minutes of symptom onset or directly to a PCI-capable hospital).
  10. 10. • In all patients with symptoms of <12 hours duration and persistent ST-segment elevation or (presumed) new LBBB -- reperfusion therapy • Reperfusion therapy (preferably primary PCI) is indicated if there is evidence of ongoing ischaemia, even if symptoms may have started >12 hours beforehand or if pain and ECG changes have been stuttering.
  11. 11. REPERFUSION STRATEGY
  12. 12. Primary PCI • Primary PCI is the recommended reperfusion therapy over fibrinolysis if performed by an experienced team within 120 minutes of FMC. • Primary PCI is indicated for patients with severe acute heart failure or cardiogenic shock, unless the expected PCI related delay is excessive and the patient presents early after symptom onset. • Stenting is recommended (over balloon angioplasty alone) for primary PCI.
  13. 13. Routine PCI of a totally occluded artery >24 hours after symptom onset in stable patients without signs of ischaemia (regardless of whether fibrinolysis was given or not) is not recommended. If the patient has no contraindications to prolonged DAPT and is likely to be compliant, DES should be preferred over BMS.
  14. 14. • Dual antiplatelet therapy with aspirin and an ADP-receptor blocker is recommended with Prasugrel in clopidogrel-naive patients, if no history of prior stroke/TIA and age <75 Ticagrelor or Clopidogrel, if prasugrel or ticagrelor are not available or contraindicated
  15. 15. An injectable anticoagulant must be used Bivalirudin is preferred over heparin and a GPIIb/IIIa blocker Enoxaparin may be preferred over unfractionated heparin Unfractionated heparin must be used in patients not receiving either bivalirudin or enoxaparin
  16. 16. Fibrinolytic therapy • Fibrinolytic therapy is recommended within 12 hours of symptom onset in patients without contraindications if primary PCI cannot be performed by an experienced team within 120 min of first medical contact. • In patients presenting early (<2 hours after symptom onset) with a large infarct and low bleeding risk, fibrinolysis should be considered if time from first medical contact to balloon inflation is >90 min.
  17. 17. • If possible, fibrinolysis should start in the pre- hospital setting. A fibrin-specific agent (tenecteplase, alteplase, reteplase) is recommended (over non-fibrin specific agents). • Oral or i.v. aspirin must be administered. Clopidogrel is indicated in addition to aspirin.
  18. 18. Brief Review of Thrombolytic Trials GISSI-1: Streptokinase 18% reduction in mortality at 21 d GUSTO-1: tPA. 15% reduction in 30-day mortality compared to Streptokinase GUSTO-3: Reteplase had no benefit over tPA but is easier to use (double bolus) ASSENT: TNKase is similar to tPA but with less non-cerebral bleeding and better mortality with symptoms>4 hrs: Single bolus, fibrin selective, resistance to PAI-1 *Overall risk of ICH is 0.7%; Strokes occurred in 1.4%
  19. 19. Contraindications and Cautions for 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.
  20. 20. Contraindications and Cautions for Fibrinolysis in STEMI Absolute Contraindications • Suspected aortic dissection • Active bleeding or bleeding diathesis (excluding menses) • Significant closed-head or facial trauma within 3 months
  21. 21. Contraindications and Cautions for 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
  22. 22. Contraindications and Cautions for Fibrinolysis in STEMI Relative Contraindications • Recent (< 2 to 4 weeks) internal bleeding • Noncompressible vascular punctures • For streptokinase/anistreplase: prior exposure (> 5 days ago) or prior allergic reaction to these agents • Pregnancy • Active peptic ulcer • Current use of anticoagulants: the higher the INR, the higher the risk of bleeding
  23. 23. • Anticoagulation is recommended in STEMI patients treated with lytics until revascularization (if performed) or for the duration of hospital stay up to 8 days. The anticoagulant can be:  Enoxaparin i.v followed by s.c. (preferred over unfractionated heparin),  Unfractionated heparin given as a weight adjusted IV bolus and infusion,  In patients treated with streptokinase, Fondaparinux i.v. bolus followed by s.c. dose 24 hours later. • Transfer to a PCI-capable centre following fibrinolysis is indicated in all patients after fibrinolysis.
  24. 24. • Rescue PCI is indicated immediately when fibrinolysis has failed (<50% ST-segment resolution at 60 min). • Emergency PCI is indicated in the case of recurrent ischaemia or evidence of re-occlusion after initial successful fibrinolysis. • Emergency angiography with a view to revascularization is indicated in heart failure/shock patients after initial fibrinolysis.
  25. 25. Logistics • All hospitals participating in the care of STEMI patients should have a coronary care unit equipped to provide all aspects of care, including treatment of ischaemia, severe heart failure, arrhythmias and common comorbidities. • Patients undergoing uncomplicated successful reperfusion therapy should be kept in the coronary care unit for a minimum of 24 hours, after which they may be moved to a step-down monitored bed for another 24–48 hours.
  26. 26. Risk assessment and imaging • In the acute phase, when diagnosis is uncertain, emergency echocardiography may be useful. However, if inconclusive or unavailable and persistent doubt, emergency angiography should be considered. • After the acute phase, all patients should have an echocardiography for assessment of infarct size and resting LV function, If echocardiography is not feasible, MRI may be used as an alternative. • For patients with multivessel disease, or in whom revascularization of other vessels is considered, stress testing or imaging for ischaemia and viability is indicated.
  27. 27. Long term therapies • Risk factor control, particularly smoking, must be stringent. • Antiplatelet therapy is indicated indefinitely. • Dual antiplatelet therapy is indicated up to 12 months. • Oral treatment with beta-blockers is indicated in patients with heart failure or left ventricular dysfunction.
  28. 28. A fasting lipid profile must be obtained in all patients. • A high-dose statin should be initiated or continued early after admission in all patients without contraindication or history of intolerance. • ACE inhibitors are indicated in patients with heart failure, LV systolic dysfunction diabetes or an anterior infarct. • An ARB is an alternative to ACE inhibitors. • Aldosterone antagonists are indicated if EF ≤40% or heart failure or diabetes, provided there is no renal failure or hyperkalaemia.
  29. 29. Emergency Medical System Network Diagnosis :as soon and as accurate as possible Management : prehospital setting,ambulatory,hospital non PCI,hospital PCI
  30. 30. Emergency medical system network for STEMI Community in populationCommunity in population primary care physician 2º 3º 4º
  31. 31. Emergency medical system network for STEMI
  32. 32. Thank youThank youThank youThank you

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