Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Management of ST Elevation Myocardial Infarction with Hospital Transfer Guidelines Dunedin and Community Hospitals (District) Guidelines for the management of ST elevation. Note: This document is for staff at Dunedin Hospital and those at Southern DHB community hospitals from where STEMI patients are transferred to Dunedin. It does not apply to Southland Hospital. Associated Policy None. Background ST elevation myocardial infarction (STEMI) is the highest risk acute coronary syndrome for short-term (30 days) adverse outcomes. Outcomes in terms of mortality, heart failure, arrhythmia, length of hospital stay, left ventricular ejection fraction, longterm quality of life, symptoms, etc. are highly influenced by treatment, particularly delays to successful reperfusion. A 60-minute hospital delay (from 90 minutes to 150 minutes) will more than double in-hospital mortality from 3.0% to 7.4% (equating to 1-2 extra deaths from STEMI annually in Dunedin Hospital). Each 15-minute decrease in reperfusion time will result in 6.3 fewer deaths per 1000 patients treated. Other adverse outcomes/complications (as listed above) will also be unfavourably affected by delay. Acute reperfusion, when indicated, may either be mechanical or pharmacological, and is optimally determined by a cardiologist tailoring it to the patient’s individual clinical circumstances. It is Cardiology Unit policy to provide primary percutaneous coronary intervention (PCI) for all suitable patients presenting to Dunedin Hospital. Those patients presenting to other hospitals (where primary PCI cannot be performed at Dunedin Hospital within 120 minutes), are treated with thrombolysis and early transfer to Dunedin Hospital. Strategy Triage 1. Immediate triage of patients with symptoms suggestive of myocardial infarction to have a 12-lead electrocardiogram (ECG) with correct interpretation within 10 minutes of triage time. The appropriate staff member sighting / interpreting will document their initials, date, and time of doing so. 2. Possible fast-tracking of patients with early notification of the Emergency Department (ED) and Cardiology Unit by the Ambulance Service or peripheral hospital / GP, if they have obtained a diagnostic ECG. Early discussion between ambulance staff or the peripheral service with the on-call cardiologist - whether direct transfer to the Catheter Laboratory or Coronary Care Unit (CCU) - is appropriate. Medical registrars out of working hours should direct outside calls relating to STEMI or shock directly to the on-call cardiologist and, as a backup, obtain phone contact (preferably mobile) details. 3. During working hours (8.00am to 5.00pm, Monday to Friday), immediate notification of the CCU registrar. Other periods: immediate page or phone contact with on-call cardiologist by the ED physician, or appropriate delegate, to discuss reperfusion strategy. A focused medical history and physical examination needs to be discussed to determine appropriate reperfusion strategy and adjunctive treatments - see the STEMI Protocol Flowchart (District) (73644). 4. A single call from the ED to a cardiologist (or CCU registrar between 8.00am and 5.00pm normal weekdays) may then be followed by a single call by the cardiologist to activate the Cath Lab, if catheter-based reperfusion is opted for. It is policy that primary PCI should be routinely offered to patients judged suitable for treatment with this method of revascularisation. Patients not meeting this criterion will be assessed for treatment with thrombolysis. 5. The progress of every STEMI will be tracked routinely and prospectively with regular rapid-cycle audit and performance feedback to all team members and stakeholders. Refer to the STEMI Protocol Flowchart (District) (73644). Reperfusion Overview Indications Clinical history consistent with acute myocardial infarction (MI) within the last 12 hours (chest pain for more than 20 minutes that started less than 12 hours previously); and ECG changes: ≥1mm ST elevation in two contiguous limb leads; or Males ≥ 2mm and females ≥1.5mm ST elevation in two contiguous chest leads V1 to V3; or ≥1mm in two contiguous chest leads V4 to V6; or Left bundle branch block (LBBB) not known to be old Consideration should be given for reperfusion therapy in patients with left bundle branch block that is not known to be old, and who have a convincing clinical history for acute MI. The ST-elevation myocardial infarction: New Zealand management guidelines 2013, outline the additional ECG evidence for acute MI in the presence of LBBB. These patients should be discussed with the on-call cardiologist before proceeding. Patients with an inferior MI should have an ECG with a V4R lead. Contraindications to Thrombolysis Prior to proceeding with fibrinolysis the following should be checked for in all cases: Absolute contraindications Previous haemorrhagic stroke (or stroke with haemorrhage not excluded by scanning) Known intracranial or spinal tumour or arteriovenous malformation Ischaemic stroke within six months Neurosurgery within six months Recent lumbar puncture Suspected aortic dissection Active bleeding or bleeding diathesis (excluding menses) Significant closed head or facial trauma within three months Uncontrolled hypertension (SBP >180mmHg or DPB >110mHg). (Repeat after GTN/morphine and reconsider fibrinolysis) Internal bleeding within six weeks of major surgery, trauma or bleeding within six weeks Relative contraindications Traumatic pulmonary resuscitation <three weeks Non-compressible vascular puncture Pregnancy Active peptic ulcer Advanced liver disease Diabetic retinopathy Current use of anticoagulants with INR >2 : the higher the INR the greater the risk of bleeding Note: The risk of giving thrombolysis needs to be weighed against the benefits. For example, it is possible a patient with a large anterior STEMI with cardiogenic shock, who presents early, may benefit from fibrinolysis despite apparent (even absolute) contraindications. The on-call cardiologists should be consulted to discuss the risks and benefits before deciding not to give fibrinolytics to a patient on the basis of contraindications. The following are not contraindications to fibrinolysis: Hypotension Menstruation Age Primary PCI and Rescue PCI There is increasing evidence for the role of primary percutaneous coronary intervention (Primary PCI) as first line therapy when it can be offered rapidly by an experienced team. PCI should also be considered when fibrinolysis is contraindicated or has not achieved reperfusion. Primary PCI Primary PCI should be considered immediately (including transfer from outside centres) in the presence of cardiogenic shock (or a high likelihood of cardiogenic shock on the basis of involvement of massive territory). In peripheral centres, the on-call cardiologist should be consulted and retrieval initiated at the same time as fibrinolysis is being given. Immediate transfer from a remote site should be considered whenever fibrinolysis is contraindicated and a high-risk situation exists. Be aware that fibrinolytics work less well on an older more organised clot (> about 4hrs) and the advantage of primary PCI vs. fibrinolytics is greater in this group of patients. It may be appropriate to immediately transfer some patients who present late, for primary PCI, although this decision should be made on a case-by-case basis. Rescue PCI Rescue PCI should be considered in patients who fail to reperfuse, particularly if a large territory is involved (this would apply to patients in remote centres also). Indicators that a large territory is involved: Extensive anterior MIs or inferior MIs with posterior extension as indicated by marked ST depression in the septal leads or left bundle branch block or right bundle branch block. Indicators of failed reperfusion include: Ongoing chest pain and failure to see a reduction of at least 50% in the amount of ST elevation, in the lead with the most initial ST elevation, at 90 minutes after administration of the fibrinolytic. Transfer of Patients from Other Facilities to Dunedin Hospital The ability of rural hospitals to safely manage patients with myocardial infarction varies - both between hospitals and at different times in the same hospital. This depends on the physical resources available (including laboratory and radiology services) as well as the skill and experience of the clinical staff on duty. Transfer should be discussed with the cardiologist on call at the time of administering thrombolysis. Later transfer for angiography and intervention (PCI or CABG) is indicated for most STEMI patients, particularly those with recurrent pain / ischaemia post-infarction. Fibrinolytic Agent Tenecteplase is the preferred fibrinolytic agent. Procedure Insert two IV lines (avoid using the right wrist, which is the preferred arterial access site for PCI) — one for drugs and the other for drawing blood. Draw blood for troponin, full blood screen, glucose, U&Es, LFTs, prior to therapy. Bloods for lipids should also be taken, preferably fasting, but definitely within 12 hours of the onset of pain. Tenecteplase is administered as a single intravenous bolus over 5-10 seconds. Tenecteplase is incompatible with dextrose-containing solutions. IV lines should be flushed before and after administration of tenecteplase with normal saline. Dosage is based on weight of patient For example: 30mg 35mg 40mg 45mg 50mg for for for for for patients weighing <60 kg those weighing 60 to 69 kg those weighing 70 to 79 kg those weighing 80 to 89 kg those weighing ≥90 kg If weight is not readily available, it should be estimated. The syringe is pre-marked according to patient weight. After mixing, the appropriate volume of reconstituted tenecteplase solution should be drawn back into the syringe from the vial. Complications of Fibrinolysis Bleeding This can be minimised by the avoidance of unnecessary punctures and careful history taking (see 'Contraindications' above). Unsuccessful IV access sites or blood gas sites should have compression bandages applied. Treatment with fresh frozen plasma and protamine should be considered if serious haemorrhage occurs. Any deterioration in the level of consciousness needs to be treated as a cerebral bleed until proven otherwise by CT [computed tomography]. Arrhythmias Reperfusion arrhythmias are common and include: Bradycardia / complete heart block - occurs most commonly with reperfusion of inferior MI. Usually it resolves within minutes. If necessary treat with atropine and fluids. Idioventricular rhythm - no treatment is necessary if the heart rate is <120 and the patient is not hypotensive. Keep potassium between 45mmol/L. Non-sustained VT - runs are common and usually subside with time. Observe for 10 minutes before contemplating antiarrhythmics. Keep potassium between 4-5 mmol/L. Sustained VT / VF - defibrillation and intravenous amiodarone 300mg bolus. (Routine use of IV Mg is not recommended as no benefit in randomised trials of VF; there may be a role in torsades de pointes with prolonged QT interval.) Adjuvant Medications Medication Directions Aspirin 300mg chewed: should be given immediately, if not already given. Continue 100-150mg per day. Consideration should be given to giving additional doses of aspirin to patients on NSAIDs [non-steroidal anti-inflammatory drug] until the effect of the NSAID wears off. P2Y12 Inhibitors Ticagrelor Primary PCI pathway. Ticagrelor is the preferred agent:180mg stat, then 90mg twice daily. This dosing is also used in patients already treated with clopidogrel. Thrombolysis pathway. Ticagrelor has not been studied as an adjunct to fibrinolysis and should not be used in the first 24 hours. Ticagrelor can be started >24 hours after fibrinolysis with a loading dose of 180mg and continued 90mg twice daily for one year. Clopidogrel Thrombolysis pathway. 300mg stat for patients ≤75yrs, 75mg stat for patients >75 yrs, followed by 75mg daily. Can be changed to ticagrelor > 24 hours after fibrinolysis. Primary PCI pathway. 600mg stat followed by 75mg daily. Used in selected patient cohorts: those on dialysis, those with severe lung disease, advanced conduction disease, those at very high bleeding risk. Morphine As needed for pain control. Oxygen Supplemental oxygen is indicated for patients who are hypoxic (saturation < 93%) and those with cardiogenic shock to correct tissue hypoxia. O2 is a coronary vasoconstrictor and as such may have detrimental effects. It should be administered with caution to patients with COPD [chronic obstructive pulmonary disease] and CO2 retention. Heparin Enoxaparin is the heparin of choice with tenecteplase. Enoxaparin Patient is <75 years of age: Enoxaparin 30mg intravenous bolus to be given before the administration of tenecteplase. 15 minutes later - enoxaparin 1mg/kg (up to a maximum dose of 100mg) subcut and continue this 12-hourly up to eight days or until the patient is discharged. 30mg enoxaparin should be injected as 0.4mL into a tuberculin syringe. Waste 0.1mL and inject the remainder that is 30mg (0.3mL) into the line and flush. Patient is ≥75 years of age: Note: Older patients who received full doses of enoxaparin during fibrinolysis trials had an excess amount of bleeding. Do not give the IV dose of enoxaparin. 15 minutes after tenecteplase, administer sub-cut enoxaparin 0.75mg per kg (up to a maximum dose of 75mg) and continue this at 12-hourly intervals up to eight days or until the patient is discharged. Renal impairment: Unfractionated Heparin Enoxaparin dosing should be reduced in renal impairment. Patients with an eGFR of <30mL per minute should have the dosing interval extended to q24 hours. Occasionally, it may be preferable to administer a heparin infusion rather than enoxaparin. This is likely to be for patients who have very severely impaired renal function or for whom there is a high likelihood of bleeding (and it is preferable to use an agent which will both wear off quickly and can be reversed). Initially administer an IV bolus of heparin - 60 units per kg up to a maximum of 4000 units. Commence the heparin infusion at 12 units per kg per hr up to a maximum of 1000 units per hour. Perform the first APTT at six hours and reduce the dose if the APTT is >150. After 12 hours, aim for an APTT in the range of 50-70 seconds. Adjust the rate according to the ward protocol. Continue the heparin infusion for up to 48 hours. Beware of the risk of reactivation of thrombosis in the first 10 hours after heparin withdrawal. Beta Blockers It may be harmful to administer IV beta-blockers to STEMI patients who have contraindications to beta blockade, signs of heart failure (HF) or low-output state, or other risk factors for cardiogenic shock. Beta blockers still have a role in secondary prevention. CHF/poor LV function is an indication for the use of beta-blockers, but only with careful titration. Oral beta-blocker therapy should be initiated in the first 24 hours for patients who do not have any of the following: 1. Signs of heart failure. 2. Evidence of a low output state.* 3. Increased risk of cardiogenic shock; or 4. Other contraindication to beta-blockade (PR interval greater than 0.24 seconds, second or third degree heart block, active asthma or reactive airways disease. IV Metoprolol IV metoprolol can be considered for STEMI patients who are also hypertensive or have a tachyarrhythmia or have ongoing chest pain. IV metoprolol 15mg (total) — administer as three doses, each 5mg, with two minutes between doses. Monitor rhythm, rate and BP. Patients who have initial contraindications in the first 24 hours after STEMI should be re-evaluated for beta-blockade for secondary prevention later in the admission. Oral Metoprolol The usual starting dose is short acting metoprolol 25mg tds, though 12.5mg tds may be more appropriate if there are concerns about tolerance. Aim for metoprolol CR 95mg daily by discharge, but titrate slowly if there are concerns about haemodynamic stability or poor LV function. Continue indefinitely. * Risk factors for cardiogenic shock (the greater the number of risk factors present, the higher the risk of developing cardiogenic shock) are age greater than 70 years, systolic blood pressure less than 120mmHg, sinus tachycardia greater than 110 bpm or heart rate less than 60 bpm, and increased time since onset of symptoms of STEMI. GTN Infusion This may be considered for 24-48 hours, particularly if there is any ongoing chest pain or left ventricular failure. Renin / Angiotensin / Aldosterone Inhibitors ACE-inhibitors should be considered for all patients. Cilazapril Initially 0.5mg - 1.25mg daily depending on blood pressure / age / renal function. Aim for 5mg daily. Patients with evidence of CHF, anterior infarction, EF < 40% should start ACE-inhibitors within 24hrs after admission if SBP > 100 mmHg. Other patients can be started the following morning. Continue for six weeks or indefinitely if the MI is large and anterior, or there is evidence of impaired LV function. Because of its shorter half life, consider using low-dose captopril rather than cilazapril as the initial ACE-inhibitor, when hypotension or increased sensitivity to ACE-inhibitors, is likely (e.g. frail, elderly). Angiotensin receptor blockers (ARB) should be given to patients with STEMI with indications for but who are intolerant of ACE inhibitors. Spironolactone should be given to those without contraindications who are already treated with a beta blocker and ACE inhibitor with an EF < 40%. Insulin Infusion All patients with a BSL > 11mmol/L (regardless of whether or not they are a known diabetic) should be considered for an insulin infusion to maintain their BSL in the range of 7.7-10mmol/L. Monitor K closely. Statins Commence Atorvastatin 80mg daily within 24 hours. Aim to reduce LDL to < 2.0mmol/L but continue on at least 40mg Atorvastatin regardless of lipid levels. Potassium Supplements Serum K should be maintained at ≥4.0 mmol/L with K supplements. Fluids Patients with RV infarction (as evidenced by inferior MI, low BP, high JVP and no LV failure and supported by ST elevation on V4R lead) may need additional fluids. Aim for oral intake of 2000mL daily. Additional fluid boluses (250mL N/Saline) may be needed to maintain the BP. Hypertension NSAIDs should be stopped. If it is essential to use an NSAID longer term, then a non-selective agent (e.g. naproxen) should be used. HRT [hormone replacement therapy] should be discontinued. Associated Documents: STEMI Protocol Flowchart - Dunedin and Community Hospitals (District) (73644) Preparation and Administration of Tenecteplase to Acute Myocardial Infarction Patients (District) (57503) References: ST-Elevation Acute Coronary Syndrome Guidelines Group and the New Zealand Branch of the Cardiac Society of Australia and New Zealand. 2013. ST-elevation myocardial infarction: New Zealand management guidelines; New Zealand Medical Journal (NZMJ) 126-1387; NZMA http://www.nzma.org.nz/journal/read-thejournal/all-issues/2010-2019/2013/vol-126-no-1387/5953 O'Gara, Patrick T., et al. 2013. ACCF/AHA Guideline for the Management of STElevation Myocardial Infarction, Journal of the American College of Cardiology (JACC); 61:e78-140; doi:10.1016/j.jacc.2012.11.019 Steg, Ph Gabriel, et al. 2012. ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. European Heart Journal; 33; 2569-2619. doi;10.1093/eurheartj/ehs215. General Notes Scope of Practice: Ensure you are fully qualified to perform the role specified in any document. Deviations: If you need to deviate from any procedure, policy, or guideline, make notes and follow up. Caution - Printed Copies: Printed copies of this document cannot be relied on after the date at the bottom of the page. Check issue date and version number against the electronic version on MIDAS to ensure that they are current. Disclaimer: This document meets the Southern District Health Board's specific requirements. The Southern DHB makes no representations as to its suitability for use by others, and accepts no responsibility for the consequences of such use. Document Data for 57502 V4 Applies to: Medical staff - Otago and community hospitals (Global: Yes) What has Changed: AMENDED: Several changes throughout - specifically chapter titled fibrinolysis changed to reperfusion and removed some text in PCI section. Service Actions: Replace any older printed copies with this version. MIDAS ID: 57502 Version 4 (Old ID: n/a), Document Type: Guidelines Issued: 22/10/2014, Released: 22/10/2014, Due for Review: 1/10/2016, Authorised by: Chief Medical Officer Document Owner: Medical Directorate (2510 - Ward 7C Cardiology/Nephrology ) Author: Michael Williams, Contact Name: Janette Gilder, Contact Phone: 8960 (Otago) Keywords: ST elevation, acute myocardial infarction, STEMI thrombolysis, fibrinolysis, tenecteplase, enoxaparin, reperfusion Reviewed By: Michael Williams