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Antman et al
Management of Patients With STEMI: Executive Summary
Table of Contents
I. Introduction
II. Pathology ......................................................................590
A. Epidemiology ...........................................................590
III. Management Before STEMI.......................................590
A. Identification of Patients at Risk of STEMI ...........590
B. Patient Education for Early Recognition and
Response to STEMI .................................................590
IV. Onset of STEMI .........................................................592
A. Out-of-Hospital Cardiac Arrest ...............................592
V. Prehospital Issues .........................................................592
A. Emergency Medical Services Systems ....................592
B. Prehospital Chest Pain Evaluation and Treatment ..592
C. Prehospital Fibrinolysis ............................................592
D. Prehospital Destination Protocols ............................593
VI. Initial Recognition and Management in the
Emergency Department ..............................................593
A. Optimal Strategies for Emergency Department
Triage........................................................................593
B. Initial Patient Evaluation..........................................593
1. History ...................................................................595
2. Physical Examination............................................595
3. Electrocardiogram .................................................595
4. Laboratory Examinations ......................................595
5. Biomarkers of Cardiac Damage ...........................595
a. Bedside Testing for Serum
Cardiac Biomarkers...........................................596
6. Imaging..................................................................596
C. Management .............................................................596
1. Routine Measures..................................................596
a. Oxygen...............................................................596
b. Nitroglycerin .....................................................596
c. Analgesia ...........................................................596
d. Aspirin ...............................................................597
e. Beta-Blockers ....................................................597
f. Reperfusion ........................................................597
• General Concepts............................................597
• Selection of Reperfusion
Strategy ...........................................................597
• Pharmacological Reperfusion.........................598
• Percutaneous Coronary Intervention ..............600
• Acute Surgical Reperfusion............................605
• Patients With STEMI Not Receiving
Reperfusion .....................................................605
• Assessment of Reperfusion ............................605
• Ancillary Therapy...........................................605
• Other Pharmacological Measures...................607
VII. Hospital Management................................................608
A. Location ....................................................................608
1. Coronary Care Unit...........................................608
2. Stepdown Unit...................................................608
B. Early, General Measures ..........................................609
1. Level of Activity ...............................................609
2. Diet.....................................................................609
3. Patient Education in the Hospital Setting.........609
4. Analgesia/Anxiolytics ........................................609
C. Risk Stratification During Early Hospital
Course .......................................................................609
589
D. Medication Assessment............................................610
1. Beta Blockers.....................................................609
2. Nitroglycerin ......................................................610
3. Inhibition of the Renin-AngiotensinAldosterone System ..........................................610
4. Antiplatelets .......................................................611
5. Antithrombotics .................................................611
6. Oxygen ...............................................................611
E. Estimation of Infarct Size ....................................611
1. Electrocardiographic Techniques ......................611
2. Cardiac Biomarker Methods .............................611
3. Radionuclide Imaging........................................611
4. Echocardiography ..............................................611
5. Magnetic Resonance Imaging ...........................611
F. Hemodynamic Disturbances .................................611
1. Hemodynamic Assessment ................................611
2. Hypotension .......................................................612
3. Low-Output State...............................................612
4. Pulmonary Congestion.......................................612
5. Cardiogenic Shock.............................................613
6. Right Ventricular Infarction ..............................614
7. Mechanical Causes of Heart Failure/LowOutput Syndrome ..............................................614
a. Diagnosis .......................................................614
b. Mitral Valve Regurgitation...........................614
c. Ventricular Septal Rupture After
STEMI ...........................................................615
d. Left Ventricular Free-Wall Rupture .............615
e. Left Ventricular Aneurysm ...........................615
f. Mechanical Support of the Failing Heart .....615
• Intra-Aortic Balloon
Counterpulsation .........................................615
G. Arrhythmias After STEMI...................................615
1. Ventricular Arrhythmias ...................................615
a. Ventricular Fibrillation..................................615
b. Ventricular Tachycardia................................616
c. Ventricular Premature Beats .........................616
d. Accelerated Idioventricular Rhythms and
Accelerated Junctional Rhythms ..................616
e. ICD Implantation in Patients After
STEMI ...........................................................617
2. Supraventricular Arrhythmias/Atrial
Fibrillation .........................................................617
3. Bradyarrhythmias ..............................................618
a. Acute Treatment of Conduction Disturbances
and Bradyarrhythmias ...................................618
• Ventricular Asystole ...................................618
b. Use of Permanent Pacemakers .....................618
• Permanent Pacing for Bradycardia or
Conduction Blocks Associated With
STEMI.........................................................618
• Sinus Node Dysfunction After
STEMI.........................................................618
• Pacing Mode Selection in Patients
With STEMI ...............................................618
H. Recurrent Chest Pain After STEMI ....................618
1. Pericarditis.........................................................618
2. Recurrent Ischemia/Infarction...........................620
I. Other Complications ..............................................621