Download Transfer of Patients With STEMI to a PCI

A.SOLEIMANI MD
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A history of ischemic-type discomfort and the
initial 12-lead ECG are the primary tools for
screening patients with possible STEMI
Because the 12-lead ECG is at the center of the
decision pathway it should be obtained promptly
(≤10 minutes after hospital arrival) in patients with
ischemic discomfort.
Prehospital 12-lead ECGs: early triage of patients
with STEMI.
Because lethal arrhythmias can occur suddenly in
patients with STEMI, all patients should have
bedside monitoring of the ECG and intravenous
access.
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If the initial ECG reveals ST-segment elevation
of 0.1 mV or greater in at least two contiguous
leads or a new or presumably new left bundle
branch block, the patient should be evaluated
immediately for a reperfusion strategy.
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In patients with a clinical history suggestive of
STEMI and an initial nondiagnostic ECG (i.e.,
no ST-segment deviation or T wave inversion),
serial tracings should be obtained during
evaluation in the emergency department.
Emergency department staff can seek the
sudden development of ST-segment elevation
by periodic visual inspection of the bedside
electrocardiographic monitor
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Aspirin
Analgesics
Nitrate
Beta blocker
Oxygen
Reperfusion therapy:
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Thrombolytic
Primary PCI
Aspirin is effective across the entire ACS spectrum
and is part of the initial management strategy for
patients with suspected STEMI.
 Because low doses take several days to achieve
a full antiplatelet effect, 162 to 325 mg should
be administered at the first opportunity after
initial medical contact.
 To achieve therapeutic blood levels rapidly,
the patient should chew the tablet to promote
buccal absorption rather than absorption
through the gastric mucosa
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Initial management of patients with STEMI
should target relief of pain and its associated
heightened sympathetic activity.
Control of cardiac pain is achieved with a
combination of analgesics (e.g.,morphine) and
interventions to favorably improve the balance
of myocardial oxygen supply and demand,
including oxygen, nitrates, and in
appropriately selected patients, beta blockers.
a wide variety of analgesic agents—including meperidine,
pentazocine, and morphine—have been used to treat the pain
associated with STEMI, morphine remains the drug of choice,
except in patients with well-documented morphine
hypersensitivity.
 Doses of 4 to 8 mg administered intravenously and doses of
2 to 8 mg repeated at intervals of 5 to 15 minutes have been
recommended until the pain is relieved or side effects
emerge—hypotension, depression of respiration, or severe
vomiting.
 Appropriate dosing of morphine sulfate will vary,
depending on the patient’s age, body size, blood pressure,
and heart rate.
 Reduction of anxiety with successful analgesia diminishes
the patient’s restlessness and the activity of the autonomic
nervous system, with a consequent reduction in the heart’s
metabolic demands.
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Morphine has beneficial effects in patients with
pulmonary edema caused by peripheral arterial and
venous dilation (particularly in those with excessive
sympathoadrenal activity); it reduces the work of
breathing and slows the heart rate secondary to
combined withdrawal of sympathetic tone and
augmentation of vagal tone.
Maintaining the patient in a supine position and
elevating the lower extremities if blood pressure falls
can minimize hypotension following the
administration of nitroglycerin and morphine. Such
positioning is undesirable in patients with pulmonary
edema, but morphine rarely produces hypotension in
these circumstances. Administration of atropine
intravenously may be helpful in treating the excessive
vagomimetic effects of morphine
Enhance coronary blood flow by coronary
vasodilation and decrease ventricular preload by
increasing venous capacitance, sublingual nitrates
are indicated for most patients with an ACS
At present, the only groups of patients with
STEMI in whom sublingual nitroglycerin should
not be given are those with suspected right
ventricular infarction or marked hypotension (e.g.,
systolic pressure <90 mm Hg), especially if
accompanied by bradycardia.
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Once hypotension is excluded, a sublingual TNG
should be administered and the patient observed for
improvement in symptoms or change in
hemodynamics. If an initial dose is well tolerated,
further nitrates should be administered while
monitoring vital signs. Even small doses can produce
sudden hypotension and bradycardia, a reaction that
can usually be reversed with intravenous atropine.
Long-acting oral nitrate preparations should be
avoided in the early course of STEMI because of the
frequently changing hemodynamic status of the
patient.
In patients with a prolonged period of waxing and
waning chest pain, intravenous nitroglycerin may help
control the symptoms and correct the ischemia, but
frequent monitoring of blood pressure is required.
These drugs aid in the relief of ischemic pain,
reduce the need for analgesics in many patients,
and reduce infarct size and life-threatening
arrhythmias.
 Avoiding early intravenous blockade in
patients with Killip class II or greater is
important, because of the risk of precipitating
cardiogenic shock
(1) Exclude patients with heart failure, hypotension (SBP <90 mm Hg),
bradycardia (HR <60 beats/min),or significant AV block.
(2) Administer metoprolol in three 5-mg intravenous boluses.
(3) Observe the patient for 2 to 5 minutes after each bolus, and if the
HR falls below 60 beats/min or SBP falls below 100 mm Hg, do not
administer any further drug.
(4) If hemodynamic stability continues 15 minutes after the last
intravenous dose, begin oral metoprolol tartrate, 25 to 50 mg every 6
hours for 2 to 3 days as tolerated, and then switch to 100 mg twice
daily. Lower doses may be used in patients who have a partial decline
in blood pressure with the initial dosing or who appear to be at higher
risk (e.g., larger infarction) for the development of heart failure because
of poor left ventricular performance.
Infusion of an extremely short-acting beta blocker, such as esmolol, 50
to 250 mg/kg/min, may be useful in patients with relative
contraindications to the administration of a beta blocker and in whom
slowing of the heart rate is considered highly desirable
augmentation of the fraction of oxygen in the inspired
air does not elevate oxygen delivery significantly in
patients who are not hypoxemic. Furthermore, it may
increase systemic vascular resistance and arterial
pressure and thereby lower cardiac output slightly.
arterial oxygen saturation can be estimated by pulse
oximetry, and oxygen therapy can be omitted if the
oximetric findings are normal. On the other hand, patients
with STEMI and arterial hypoxemia should receive oxygen.
In patients with severe pulmonary edema, endotracheal
intubation and mechanical ventilation may be necessary to
correct the hypoxemia and reduce the work of breathing.
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Efforts to limit infarct size have been divided
among several different (sometimes overlapping)
approaches:
 (1) early reperfusion
 (2) reduction of myocardial energy demands
 (3) manipulation of energy production sources
in the myocardium
 (4) prevention of reperfusion injury
Critical factors that weigh into selection of a
reperfusion strategy include
 the time elapsed since the onset of
symptoms
 the risk associated with STEMI
 the risk related to administering a
fibrinolytic
 the time required to initiate an invasive
strategy
Major components of the delay from the onset of
ischemic symptoms to reperfusion include the
following:
 (1) the time for the patient to recognize the
seriousness of the problem and seek medical
attention
 (2) prehospital evaluation, treatment, and
transportation
 (3) the time for diagnostic measures and initiation
of treatment in the hospital (e.g.,“door-to-needle”
time for patients receiving a fibrinolytic agent and
“door-to-balloon” time for patients undergoing a
catheter-based reperfusion strategy)
 (4) the time from initiation of treatment to
restoration of flow.
*Patients with cardiogenic shock or severe heart failure initially seen at a non–PCI-capable hospital should be transferred for cardiac
catheterization and revascularization as soon as possible, irrespective of time delay from MI onset (Class I, LOE: B). †Angiography and
revascularization should not be performed within the first 2 to 3 hours after administration of fibrinolytic therapy.
I IIaIIbIII
Reperfusion therapy should be administered to all eligible patients
with STEMI with symptom onset within the prior 12 hours.
I IIaIIbIII
I IIaIIbIII
Primary PCI is the recommended method of reperfusion when it
can be performed in a timely fashion by experienced operators.
EMS transport directly to a PCI-capable hospital for primary PCI is
the recommended triage strategy for patients with STEMI with an
ideal FMC-to-device time system goal of 90 minutes or less.*
*The proposed time windows are system goals. For any individual patient, every effort should be
made to provide reperfusion therapy as rapidly as possible.
I IIaIIbIII
I IIaIIbIII
Immediate transfer to a PCI-capable hospital for primary PCI is the
recommended triage strategy for patients with STEMI who initially
arrive at or are transported to a non–PCI-capable hospital, with an
FMC-to-device time system goal of 120 minutes or less.*
In the absence of contraindications, fibrinolytic therapy should be
administered to patients with STEMI at non–PCI-capable hospitals
when the anticipated FMC-to-device time at a PCI-capable hospital
exceeds 120 minutes because of unavoidable delays.
*The proposed time windows are system goals. For any individual patient, every effort should be
made to provide reperfusion therapy as rapidly as possible.
I IIaIIbIII
When fibrinolytic therapy is indicated or chosen as the primary
reperfusion strategy, it should be administered within 30 minutes of
hospital arrival.*
I IIaIIbIII
Reperfusion therapy is reasonable for patients with STEMI and
symptom onset within the prior 12 to 24 hours who have clinical
and/or ECG evidence of ongoing ischemia. Primary PCI is the
preferred strategy in this population.
*The proposed time windows are system goals. For any individual patient, every effort should be
made to provide reperfusion therapy as rapidly as possible.
Guideline for STEMI
Reperfusion at a Non–PCICapable Hospital
Reperfusion at a Non–PCI-Capable
Hospital
Fibrinolytic Therapy When
There Is an Anticipated Delay
to Performing Primary PCI
Within 120 Minutes of FMC
I IIaIIbIII
In the absence of contraindications, fibrinolytic therapy should be
given to patients with STEMI and onset of ischemic symptoms
within the previous 12 hours when it is anticipated that primary
PCI cannot be performed within 120 minutes of FMC.
I IIaIIbIII
In the absence of contraindications and when PCI is not
available, fibrinolytic therapy is reasonable for patients with
STEMI if there is clinical and/or ECG evidence of ongoing
ischemia within 12 to 24 hours of symptom onset and a large
area of myocardium at risk or hemodynamic instability.
I IIaIIbIII
Harm
Fibrinolytic therapy should not be administered to patients with
ST depression except when a true posterior (inferobasal) MI is
suspected or when associated with ST elevation in lead aVR.
Reperfusion at a Non–PCI-Capable
Hospital
Adjunctive Antithrombotic
Therapy With Fibrinolysis
I IIaIIbIII
Aspirin (162- to 325-mg loading dose) and clopidogrel (300-mg
loading dose for patients ≤75 years of age, 75-mg dose for
patients >75 years of age) should be administered to patients
with STEMI who receive fibrinolytic therapy.
I IIaIIbIII
I IIaIIbIII
In patients with STEMI who receive fibrinolytic therapy:
• aspirin should be continued indefinitely and
• clopidogrel (75 mg daily) for at least 14 days
I IIaIIbIII
o and up to 1 year
I IIaIIbIII
It is reasonable to use aspirin 81 mg per day in preference to
higher maintenance doses after fibrinolytic therapy.
Reperfusion at a Non–PCI-Capable
Hospital
Transfer to a PCI-Capable
Hospital After Fibrinolytic
Therapy
Reperfusion at a Non–PCI-Capable
Hospital
Transfer of Patients With
STEMI to a PCI-Capable
Hospital for Coronary
Angiography After Fibrinolytic
Therapy
I IIaIIbIII
Immediate transfer to a PCI-capable hospital for coronary
angiography is recommended for suitable patients with STEMI
who develop cardiogenic shock or acute severe HF, irrespective
of the time delay from MI onset.
I IIaIIbIII
Urgent transfer to a PCI-capable hospital for coronary
angiography is reasonable for patients with STEMI who
demonstrate evidence of failed reperfusion or reocclusion after
fibrinolytic therapy.
I IIaIIbIII
Transfer to a PCI-capable hospital for coronary angiography is
reasonable for patients with STEMI who have received fibrinolytic
therapy even when hemodynamically stable* and with clinical
evidence of successful reperfusion. Angiography can be performed
as soon as logistically feasible at the receiving hospital, and ideally
within 24 hours, but should not be performed within the first 2 to 3
hours after administration of fibrinolytic therapy.
*Although individual circumstances will vary, clinical stability is defined by the absence of low output,
hypotension, persistent tachycardia, apparent shock, high-grade ventricular or symptomatic
supraventricular tachyarrhythmias, and spontaneous recurrent ischemia.
*Although individual circumstances will vary, clinical stability is defined by the
absence of low output, hypotension, persistent tachycardia, apparent shock, high-grade
ventricular or symptomatic supraventricular tachyarrhythmias, and spontaneous
recurrent ischemia.