Download III - Clinical Trial Results

This slide set was adapted from the ACC/AHA
Guidelines for Management of Patients With STElevation Myocardial Infarction (Journal of the
American College of Cardiology 2004;44:671719, e1-e211 and Circulation 2004;44:671-619,
e82-e292)
The full-text guidelines and executive summary
are also available on the Web sites:
ACC (www.acc.org) and,
AHA (www.americanheart.org)
2
Introduction
ACC/AHA Guidelines for the
Management of Patients with
ST-Elevation Myocardial Infarction
3
ACC/AHA Guidelines for the Management
of Patients With ST-Elevation Myocardial
Infarction
Writing Committee Members
Elliott M. Antman, MD, FACC, FAHA, Chair
Daniel T. Anbe, MD, FACC, FAHA
Frederick G. Kushner, MD, FACC, FAHA
Paul Wayne Armstrong, MD, FACC,
FAHA
Gervasio A. Lamas, MD, FACC
Eric R. Bates, MD, FACC, FAHA
Lee A. Green, MD, MPH
Mary Hand, MSPH, RN, FAHA
Judith S. Hochman, MD, FACC, FAHA
Charles J. Mullany, MB, MS, FACC
Joseph P. Ornato, MD, FACC, FAHA
David L. Pearle, MD, FACC, FAHA
Michael A. Sloan, MD, FACC
Sidney C. Smith, Jr., MD, FACC, FAHA
Harlan M. Krumholz, MD, FACC, FAHA
4
Applying Classification of
Recommendations and Level of Evidence
Class I
Class IIa
Class IIb
Class III
Benefit >>> Risk
Benefit >> Risk
Additional studies with
focused objectives
needed
Benefit ≥ Risk
Additional studies with
broad objectives needed;
Additional registry data
would be helpful
Risk ≥ Benefit
No additional studies
needed
Procedure/ Treatment
SHOULD be
performed/
administered
IT IS REASONABLE to
perform
procedure/administer
treatment
Procedure/Treatment
MAY BE CONSIDERED
should
is recommended
is indicated
is useful/effective/
beneficial
is reasonable
can be useful/effective/
beneficial
is probably recommended or
indicated
may/might be considered
may/might be reasonable
usefulness/effectiveness is
unknown /unclear/uncertain
or not well established
Procedure/Treatment
should NOT be
performed/administered
SINCE IT IS NOT
HELPFUL AND MAY BE
HARMFUL
is not recommended
is not indicated
should not
is not
useful/effective/beneficial
may be harmful
5
Applying Classification of
Recommendations and Level of Evidence
Level A
Multiple (3-5)
population risk
strata evaluated
General
consistency of
direction and
magnitude of
effect
Class I
Class IIa
Class IIb
Class III
• Recommendation that
procedure or
treatment is
useful/
effective
• Sufficient
evidence from
multiple
randomized
trials or metaanalyses
• Recommendation in favor
of treatment or
procedure
being useful/
effective
• Some
conflicting
evidence from
multiple
randomized
trials or metaanalyses
• Recommendation’s
usefulness/
efficacy less
well
established
• Greater
conflicting
evidence from
multiple
randomized
trials or metaanalyses
• Recommendation that
procedure or
treatment not
useful/effective
and may be
harmful
• Sufficient
evidence from
multiple
randomized
trials or metaanalyses
6
Applying Classification of
Recommendations and Level of Evidence
Level B
Limited (2-3)
population risk
strata evaluated
Class I
Class IIa
• Recommen• Recommendation that
dation in favor
procedure or
of treatment or
treatment is
procedure
useful/effective being useful/
effective
• Limited
evidence from • Some
single
conflicting
randomized
evidence from
trial or nonsingle
randomized
randomized
studies
trial or nonrandomized
studies
Class IIb
Class III
• Recommen• Recommendation’s
dation that
usefulness/
procedure or
efficacy less
treatment not
well established
useful/effective
• Greater
and may be
harmful
conflicting
evidence from
• Limited
single
evidence from
randomized trial
single
or nonrandomized trial
randomized
or nonstudies
randomized
studies
7
Applying Classification of
Recommendations and Level of Evidence
Level C
Very limited (12) population
risk strata
evaluated
Class I
• Recommendation that
procedure or
treatment is
useful/
effective
• Only expert
opinion, case
studies, or
standard-ofcare
Class IIa
Class IIb
Class III
• Recommendation in favor
of treatment or
procedure
being
useful/effective
• Only diverging
expert opinion,
case studies, or
standard-ofcare
• Recommendation’s
usefulness/
efficacy less
well established
• Only diverging
expert opinion,
case studies, or
standard-ofcare
• Recommendation that
procedure or
treatment not
useful/effective
and may be
harmful
• Only expert
opinion, case
studies, or
standard-ofcare
8
Pathology
ACC/AHA Guidelines for the
Management of Patients with
ST-Elevation Myocardial Infarction
9
Onset of STEMI
- Prehospital issues
- Initial recognition and management
in the Emergency Department (ED)
- Reperfusion
Hospital Management
- Medications
- Arrhythmias
- Complications
- Preparation for discharge
Secondary Prevention/
Long-Term Management
Management
Before STEMI
1
Modified from Libby. Circulation 2001;104:365,
Hamm et al. The Lancet 2001;358:1533 and
Davies. Heart 2000;83:361.
2
3
4
5
6
4
Presentation
Working Dx
ECG
Cardiac
Biomarker
Final Dx
Ischemic Discomfort
Acute Coronary Syndrome
No ST Elevation
UA
ST Elevation
Chronology of the
interface between the
patient and the
clinician through the
progression of plaque
formation and the
onset of complications
of STEMI.
NSTEMI
Unstable
Angina
NQMI
QwMI
Myocardial Infarction
10
Prevention of Coronary Heart Disease (CHD)
Campaigns and Statements

National Cholesterol Education Program (NCEP) Adult Treatment
Panel (ATP) III
 LDL goals, CHD risk equivalent, metabolic syndrome

Joint National Committee (JNC)-7
 Hypertension management

World Heart Federation (WHF), World Health Organization (WHO)
 Cigarette smoking

National Heart, Lung, and Blood Institute (NHLBI), Food and
Drug Administration (FDA), Centers for Disease Control (CDC)
 Obesity

AHA/NHLBI Go Red for Women, AHA Guidelines on Prevention
of Cardiovascular Disease (CVD) in Women
 Women and CVD
11
Management Before STEMI
ACC/AHA Guidelines for the
Management of Patients with
ST-Elevation Myocardial Infarction
12
Identification of Patients at Risk of STEMI
I IIa IIb III
I IIa IIb III
The presence and status of control of major
risk factors for CHD should be evaluated
approximately every 3 to 5 years.
10-year risk of developing symptomatic CHD
should be calculated for all patients with ≥ 2
major risk factors to assess the need for
primary prevention strategies.
13
Identification of Patients at Risk of STEMI
I IIa IIb III
Patients with established CHD or a CHD risk
equivalent (diabetes mellitus, chronic kidney
disease, > 20% 10-year Framingham risk)
should be identified for secondary prevention.
14
Onset of STEMI
ACC/AHA Guidelines for the
Management of Patients with
ST-Elevation Myocardial Infarction
15
Patient Education for Early Recognition and
Response to STEMI
I IIa IIb III
Patients should understand their risk of
STEMI and how to recognize symptoms of
STEMI.
I IIa IIb III
Patients should understand the advisability
of calling 9-1-1 if symptoms are unimproved
or worsening after 5 minutes.
16
ACT in TIME
If you have any heart
attack symptoms,
CALL 9-1-1
immediately.
Don’t wait for more than
a few minutes – 5 at
most – to call 9-1-1.
http://www.nhlbi.nih.gov/actintime/index.htm.
Accessed December 20, 2004.
17
Patient Education for Early Recognition and
Response to STEMI
I IIa IIb III
Healthcare providers should instruct patients
previously prescribed nitroglycerin (NTG) on use
for chest discomfort or pain and to call 9-1-1 if
symptoms do not improve or worsen 5 minutes
after ONE sublingual NTG dose*.
(* Nitroglycerin Dose: 0.4 mg sublingually)
18
Prehospital Chest Pain Evaluation
and Treatment
I IIa IIb III
Prehospital EMS providers should administer 162 to 325 mg of
aspirin (chewed) to chest pain patients suspected of having STEMI
unless contraindicated or already taken by the patient. Although
some trials have used enteric-coated aspirin for initial dosing, more
rapid buccal absorption occurs with non–enteric-coated
formulations.
I IIa IIb III
It is reasonable for all 9-1-1 dispatchers to advise patients without a
history of aspirin allergy who have symptoms of STEMI to chew
aspirin (162 to 325 mg) while awaiting arrival of prehospital EMS
providers. Although some trials have used enteric-coated aspirin for
initial dosing, more rapid buccal absorption occurs with non–entericcoated formulations.
19
Instructions for Nitroglycerin
Use and EMS Contact
Patient experiences
chest pain/discomfort
Has the patient been previously
prescribed nitroglycerin?
No
Is Chest Discomfort/Pain Unimproved or Worsening
5 Minutes After It Starts?
Yes
No
CALL 9-1-1
IMMEDIATELY.
Notify Physician.
Follow 9-1-1 instructions.
[Patients may receive instructions to chew aspirin
(162-325 mg) if not contraindicated or may receive
aspirin en route to the hospital.]
20
Instructions for Nitroglycerin
Use and EMS Contact
Patient experiences
chest pain/discomfort
Has the patient been previously
prescribed nitroglycerin?
Yes
Take ONE Nitroglycerin
Dose Sublingually.
Is Chest Discomfort/Pain Unimproved or Worsening
5 Minutes After Taking ONE Nitroglycerin Dose*
Sublingually?
No
Yes
CALL 9-1-1
IMMEDIATELY.
See ACC/AHA Guidelines for
the Management of Patients
with Chronic Stable Angina.
* Nitroglycerin Dose: 0.4 mg sublingually
21
Prehospital Issues
ACC/AHA Guidelines for the
Management of Patients with
ST-Elevation Myocardial Infarction
22
Prehospital Issues
I IIa IIb III
I IIa IIb III
All public safety first responders trained and
equipped to provide early defibrillation with
AEDs.
Prehospital aspirin 162 to 325 mg (chewed)
administration:
By prehospital providers
Advice by dispatchers
23
Prehospital Issues
I IIa IIb III
Prehospital 12-lead ECG by ACLS
Prehospital fibrinolysis
I IIa IIb III
Reperfusion “checklist” by ACLS providers that
is relayed with the ECG to a predetermined
medical control facility and/or receiving
hospital
24
Prehospital Issues
I IIa IIb III
Prehospital destination protocols
Patients with STEMI who have cardiogenic
shock and are <75 yrs old should be brought
immediately or secondarily transferred to
facilities capable of cardiac catheterization and
rapid revascularization with 18 hrs of shock
25
Prehospital Issues
I IIa IIb III
Prehospital destination protocols:
Patients with STEMI who have contraindications
to fibrinolytic therapy should be brought
immediately or secondarily transferred promptly
(primary-receiving hospital door-to-departure time
less than 30 min.) to facilities capable of cardiac
catheterization and rapid revascularization
26
Options for Transport of Patients With
STEMI and Initial Reperfusion Treatment
Hospital fibrinolysis:
Door-to-Needle
within 30 min.
Not PCI
capable
Onset of
symptoms of
STEMI
9-1-1
EMS
Dispatch
EMS on-scene
• Encourage 12-lead ECGs.
• Consider prehospital fibrinolytic if
capable and EMS-to-needle within
30 min.
InterHospital
Transfer
PCI
capable
GOALS
5
min.
Patient
8
min.
EMS
Dispatch
1 min.
EMS Transport
Prehospital fibrinolysis
EMS transport
EMS-to-needle
EMS-to-balloon within 90 min.
within 30 min.
Patient self-transport
Hospital door-to-balloon
within 90 min.
Golden Hour = first 60 min.
Total ischemic time: within 120 min.
27
Options for Transport of Patients With STEMI and
Initial Reperfusion Treatment
•
Patients receiving fibrinolysis should be risk-stratified to identify need
for further revascularization with percutaneous coronary intervention
(PCI) or coronary artery bypass graft surgery (CABG).
•
All patients should receive late hospital care and secondary
prevention of STEMI.
Fibrinolysis
Not
PCI Capable
Noninvasive Risk
Stratification
Rescue Ischemia
driven
PCI Capable
Late
Hospital Care
and Secondary
Prevention
PCI or CABG
Primary PCI
28
Initial Recognition and
Management in the
Emergency Department
ACC/AHA Guidelines for the
Management of Patients with
ST-Elevation Myocardial Infarction
29
ED Evaluation of
Patients With STEMI
Brief Physical Examination in the ED
1. Airway, Breathing, Circulation (ABC)
2. Vital signs, general observation
3. Presence or absence of jugular venous distension
4. Pulmonary auscultation for rales
5. Cardiac auscultation for murmurs and gallops
6. Presence or absence of stroke
7. Presence or absence of pulses
8. Presence or absence of systemic hypoperfusion (cool, clammy,
pale, ashen)
30
ED Evaluation of
Patients With STEMI
Differential Diagnosis of STEMI: Life-Threatening
Aortic dissection
Tension pneumothorax
Pulmonary embolus
Boerhaave syndrome
Perforating ulcer
(esophageal rupture with
mediastinitis)
31
ED Evaluation of
Patients With STEMI
Differential Diagnosis of STEMI: Other Cardiovascular and
Nonischemic
Pericarditis
Atypical angina
Early repolarization
Wolff-Parkinson-White
syndrome
Deeply inverted T-waves
suggestive of a central
nervous system lesion
or apical hypertrophic
cardiomyopathy
LV hypertrophy with strain
Brugada syndrome
Myocarditis
Hyperkalemia
Bundle-branch blocks
Vasospastic angina
Hypertrophic
cardiomyopathy
32
ED Evaluation of
Patients With STEMI
Differential Diagnosis of STEMI: Other Noncardiac
Gastroesophageal reflux
(GERD) and spasm
Cervical disc or neuropathic
pain
Chest-wall pain
Biliary or pancreatic pain
Pleurisy
Somatization and
psychogenic pain disorder
Peptic ulcer disease
Panic attack
33
Electrocardiogram
I IIa IIb III
If the initial ECG is not diagnostic of STEMI, serial
ECGs or continuous ST-segment monitoring should
be performed in the patient who remains
symptomatic or if there is high clinical suspicion for
STEMI.
34
Electrocardiogram
I IIa IIb III
Show 12-lead ECG results to emergency physician
within 10 minutes of ED arrival in all patients with
chest discomfort (or anginal equivalent) or other
symptoms of STEMI.
I IIa IIb III
In patients with inferior STEMI, ECG leads should
also be obtained to screen for right ventricular
infarction.
35
Laboratory Examinations
I IIa IIb III
Laboratory examinations should be performed as part of the
management of STEMI patients, but should not delay the
implementation of reperfusion therapy.









Serum biomarkers for cardiac damage
Complete blood count (CBC) with platelets
International normalized ratio (INR)
Activated partial thromboplastin time (aPTT)
Electrolytes and magnesium
Blood urea nitrogen (BUN)
Creatinine
Glucose
Complete lipid profile
36
Biomarkers of Cardiac Damage
I IIa IIb III
Cardiac-specific troponins should be used as the
optimum biomarkers for the evaluation of patients
with STEMI who have coexistent skeletal muscle
injury.
I IIa IIb III
For patients with ST elevation on the 12-lead ECG
and symptoms of STEMI, reperfusion therapy
should be initiated as soon as possible and is not
contingent on a biomarker assay.
37
Cardiac Biomarkers in STEMI
Multiples of the URL
100
50
Cardiac troponin-no reperfusion
20
Cardiac troponin-reperfusion
10
CKMB-no reperfusion
CKMB-reperfusion
5
2
Upper reference limit
1
0
1
2
3
4
5
Days After Onset of STEMI
Alpert et al. J Am Coll Cardiol 2000;36:959.
Wu et al. Clin Chem 1999;45:1104.
6
7
8
URL = 99th %tile of
Reference Control Group
38
Imaging
I IIa IIb III
I IIa IIb III
Patients with STEMI should have a portable chest
X-ray, but this should not delay implementation of
reperfusion therapy (unless a potential
contraindication is suspected, such as aortic
dissection).
Imaging studies such as a high quality portable chest
X-ray, transthoracic and/or transesophageal
echocardiography, and a contrast chest CT scan or
an MRI scan should be used for differentiating STEMI
from aortic dissection in patients for whom this
distinction is initially unclear.
39
Oxygen
I IIa IIb III
Supplemental oxygen should be administered to
patients with arterial oxygen desaturation (SaO2
< 90%).
I IIa IIb III
It is reasonable to administer supplemental
oxygen to all patients with uncomplicated STEMI
during the first 6 hours.
40
Nitroglycerin
I IIa IIb III
Patients with ongoing ischemic discomfort should
receive sublingual NTG (0.4 mg) every 5 minutes for a
total of 3 doses, after which an assessment should be
made about the need for intravenous NTG.
I IIa IIb III
Intravenous NTG is indicated for relief of ongoing
ischemic discomfort that responds to nitrate therapy,
control of hypertension, or management of pulmonary
congestion.
41
Nitroglycerin
I IIa IIb III
Nitrates should not be administered to patients with:
• systolic pressure < 90 mm Hg or ≥ to 30 mm Hg
below baseline
• severe bradycardia (< 50 bpm)
• tachycardia (> 100 bpm) or
• suspected RV infarction.
I IIa IIb III
Nitrates should not be administered to patients who
have received a phosphodiesterase inhibitor for
erectile dysfunction within the last 24 hours (48
hours for tadalafil).
42
Analgesia
I IIa IIb III
Morphine sulfate (2 to 4 mg intravenously with
increments of 2 to 8 mg intravenously repeated at
5 to 15 minute intervals) is the analgesic of choice
for management of pain associated with STEMI.
43
Aspirin
I IIa IIb III
Aspirin should be chewed by patients who have
I IIa IIb III
not taken aspirin before presentation with
STEMI. The initial dose should be 162 mg (Level
of Evidence: A) to 325 mg (Level of Evidence: C)
Although some trials have used enteric-coated aspirin for
initial dosing, more rapid buccal absorption occurs with
non–enteric-coated formulations.
44
Beta-Blockers
I IIa IIb III
I IIa IIb III
Oral beta-blocker therapy should be administered
promptly to those patients without a contraindication,
irrespective of concomitant fibrinolytic therapy or
performance of primary PCI.
It is reasonable to administer intravenous betablockers promptly to STEMI patients without
contraindications, especially if a tachyarrhythmia or
hypertension is present.
45
Summary of Trials of Beta-Blocker Therapy
Phase of
Treatment
Total No.
Patients
RR (95% CI)
Acute
treatment
28,970
0.87 (0.77-0.98)
Secondary
prevention
24,298
0.77 (0.70-0.84)
Overall
53,268
0.81 (0.75-0.87)
2
1
0.5
Relative risk (RR) of death
Placebo
Beta blocker
better
better
Antman E, Braunwald E. Acute Myocardial Infarction. In:
Braunwald E, Zipes DP, Libby P, eds. Heart Disease: A
textbook of Cardiovascular Medicine, 6th ed.,
Philadelphia, PA: W.B. Sanders, 2001, 1168.
46
Reperfusion
• Given the current literature, it is not possible to say
definitively that a particular reperfusion approach is
superior for all pts, in all clinical settings, at all times of
day
• The main point is that some type of reperfusion therapy
should be selected for all appropriate pts with suspected
STEMI
• The appropriate & timely use of some reperfusion
therapy is likely more important than the choice of
therapy
47
Reperfusion
The medical system goal is to facilitate rapid recognition
and treatment of patients with STEMI such that door-toneedle (or medical contact–to-needle) time for initiation
of fibrinolytic therapy can be achieved within 30
minutes or that door-to-balloon (or medical contact–to-
balloon) time for PCI can be kept within 90 minutes.
48
Reperfusion
Patient
Transport
Inhospital
Reperfusion
Goals
D-N ≤ 30 min
5 min
< 30 min
D-B ≤ 90 min
Prehospital
ECG
MI protocol
Critical pathway
Bolus lytics
Quality
Greater use of
improvement Dedicated
9-1-1
PCI team
program
Prehospital Rx
Media campaign
Patient education
Methods of
Speeding
Time to
Reperfusion
49
Treatment Delayed is Treatment Denied
Symptom
Recognition
Call to
Medical System
PreHospital
ED
Cath Lab
Increasing Loss of Myocytes
Delay in Initiation of Reperfusion Therapy
50
PCI vs Fibrinolysis for STEMI:
Short Term Clinical Outcomes
35
PCI
Fibrinolysis
Frequency (%)
30
25
P < 0.0001
21
20
15
P < 0.0001
P=0.0002
P=0.0003
10
13
P < 0.0001
P=0.032
9
7
7
7
4.5
5
2.2
6
P=0.0004
1 2
P < 0.0001
8
7
5
0 1
0
Death
Death, Recurr. Recurr. Total Hemorrh. Major
no
MI Ischemia Stroke Stroke Bleed
SHOCK
data
Death
MI
CVA
N = 7739
Keeley et al. The Lancet 2003;361:13.
51
Overview of PCI vs Lysis: Issues to Consider
•
•
•
•
Sample Size = 7739
Data span 10–15 years
Selection bias of pts enrolled
2% mortality benefit with PCI depends on lytic –
(not significant vs tPA if SHOCK is excluded)
• Composite endpoint is driven by reMI –
potential biases against lytic arms:
Hard to diagnose peri-PCI MI
UFH used in lytic arms--? Better antithrombins
Dependent on use of PCI post-lysis
JACC 2004;44: 671.
Circulation 2004;110: 588.
52
Contraindications and Cautions
for Fibrinolysis in STEMI
• Any prior intracranial hemorrhage
Absolute
Contraindications • 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.
53
Contraindications and Cautions
for Fibrinolysis in STEMI
Absolute
• Suspected aortic dissection
Contraindications
• Active bleeding or bleeding diathesis
(excluding menses)
• Significant closed-head or facial trauma
within 3 months
54
Contraindications and Cautions
for Fibrinolysis in STEMI
Relative
• History of chronic, severe, poorly controlled
Contraindications 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)
55
Contraindications and Cautions
for Fibrinolysis in STEMI
Relative
• Recent (< 2 to 4 weeks) internal bleeding
Contraindications • 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
56
Absolute Risk Difference in Death (%)
PCI versus Fibrinolysis with Fibrin-Specific
Agents: Is Timing (Almost) Everything?
10 −
13 RCTs
N = 5494
P = 0.04
5−
Favors
PCI
0−
Favors fibrinolysis with
a fibrin-specific agent
-5 −
┬
30
┬
┬
┬
40
50
60
PCI-Related Time Delay (minutes)
┬
┬
70
80
Nallamothu and Bates. Am J Cardiol 2003;92:824.
57
One-year mortality, %
Symptom Onset to Balloon Time and
Mortality in Primary PCI for STEMI
6 RCTs of Primary PCI by Zwolle Group 1994 – 2001
N = 1791
P < 0.0001
12
10
8
6
4
RR = 1.08 [1.01 – 1.16] for each 30 min delay
(P = 0.04)
2
0 0
60
120
180
240
300
360
Symptoms to balloon inflation (minutes)
DeLuca et al. Circulation 2004;109:1223.
58
Reperfusion Options for STEMI Patients
Step One: Assess Time and Risk.
Time Since
Symptom
Onset
Risk of STEMI
Risk of
Fibrinolysis
Time Required
for Transport to
a Skilled PCI
Lab
59
Reperfusion Options for STEMI Patients
Step 2: Select Reperfusion Treatment.
If presentation is < 3 hours and there is no delay to an invasive
strategy, there is no preference for either strategy.
Fibrinolysis generally preferred
 Early presentation ( ≤ 3 hours from symptom
onset and delay to invasive strategy)
 Invasive strategy not an option
 Cath lab occupied or not available
 Vascular access difficulties
 No access to skilled PCI lab
 Delay to invasive strategy
 Prolonged transport
 Door-to-balloon more than 90 minutes
 > 1 hour vs fibrinolysis (fibrin-specific agent) now
60
Reperfusion Options for STEMI Patients
Step 2: Select Reperfusion Treatment.
If presentation is < 3 hours and there is no delay to an invasive strategy,
there is no preference for either strategy.
Invasive strategy generally preferred
 Skilled PCI lab available with surgical backup
 Door-to-balloon < 90 minutes
• High Risk from STEMI
 Cardiogenic shock, Killip class ≥ 3
 Contraindications to fibrinolysis, including
increased risk of bleeding and ICH
 Late presentation
 > 3 hours from symptom onset
 Diagnosis of STEMI is in doubt
61
PCI vs Lysis: Additional Data
• Mortality advantage of PCI diminishes:
As risk with lytic decreases: PCI = Lysis at 3%
With increasing delay:
PCI = Fibrin spec lytic with 60 min delay
RR = 1.08 for every 30 min from onset of sx
The earlier patient is seen: PCI = Lysis in < 3 h from sx
• Outcomes with PCI are influenced by time of day and
operator/institution volume and experience
• Trials of transfer for PCI:
Had very short transport and D-B times
PCI mortality higher than prehospital lysis in pts
treated early (2h)
JACC 2004;44: 671
Circ 2004;110: 588
62
Fibrinolysis
I IIa IIb III
I IIa IIb III
In the absence of contraindications, fibrinolytic
therapy should be administered to STEMI
patients with symptom onset within the prior 12
hours.
In the absence of contraindications, fibrinolytic
therapy should be administered to STEMI
patients with symptom onset within the prior 12
hours and new or presumably new left bundle
branch block (LBBB).
63
Fibrinolysis
I IIa IIb III
I IIa IIb III
In the absence of contraindications, it is
reasonable to administer fibrinolytic therapy to
STEMI patients with symptom onset within the
prior 12 hours and 12-lead ECG findings
consistent with a true posterior MI.
In the absence of contraindications, it is
reasonable to administer fibrinolytic therapy to
patients with symptoms of STEMI beginning in
the prior 12 to 24 hours who have continuing
ischemic symptoms and ST elevation > 0.1 mV
in ≥ 2 contiguous precordial leads or ≥ 2 adjacent
limb leads.
64
Fibrinolysis
I IIa IIb III
Fibrinolytic therapy should not be administered to
asymptomatic patients whose initial symptoms of
STEMI began more than 24 hours earlier.
I IIa IIb III
Fibrinolytic therapy should not be administered to
patients whose 12-lead ECG shows only STsegment depression, except if a true posterior MI
is suspected.
65
Evolution of PCI for STEMI
AngioJet
Platelet
GP IIb/IIIa inhibitor
Balloon
Antiplatelet
Rx
Antman. Circulation 2001;103:2310.
Embolization
Protection Device
Stent
DES
Thrombus
Removal and
Distal
Embolization
Protection
Devices
66
Primary PCI for STEMI:
General Considerations
 Patient with STEMI (including posterior MI) or MI
with new or presumably new LBBB
 PCI of infarct artery within 12 hours of symptom
onset
I IIa IIb III
 Balloon inflation within 90 minutes of presentation
 Skilled personnel available (individual performs > 75
procedures per year)
 Appropriate lab environment (lab performs > 200
PCIs/year of which at least 36 are primary PCI for
STEMI)
 Cardiac surgical backup available
67
Primary PCI for STEMI:
Specific Considerations
I IIa IIb III
Medical contact–to-balloon or door-to-balloon
should be within 90 minutes.
I IIa IIb III
PCI preferred if > 3 hours from symptom onset.
I IIa IIb III
Primary PCI should be performed in patients with
severe congestive heart failure (CHF) and/or
pulmonary edema (Killip class 3) and onset of
symptoms within 12 hours.
68
Primary PCI for STEMI:
Specific Considerations
Primary PCI should be performed in patients less
I IIa IIb III
than 75 years old with ST elevation or LBBB who
develop shock within 36 hours of MI and are
suitable for revascularization that can be
performed within 18 hours of shock.
69
Primary PCI for STEMI:
Specific Considerations
Primary PCI is reasonable in selected patients 75
I IIa IIb III
years or older with ST elevation or LBBB who
develop shock within 36 hours of MI and are suitable
for revascularization that can be performed within 18
hours of shock.
70
Primary PCI for STEMI:
Specific Considerations
It is reasonable to perform primary PCI for
patients with onset of symptoms within the prior
12 to 24 hours and 1 or more of the following:
I IIa IIb III
a. Severe CHF
b. Hemodynamic or electrical instability
c. Persistent ischemic symptoms.
71
Rescue PCI
I IIa IIb III
Rescue PCI should be performed in patients less
than 75 years old with ST elevation or LBBB who
develop shock within 36 hours of MI and are
suitable for revascularization that can be
performed within 18 hours of shock.
I IIa IIb III
Rescue PCI should be performed in patients with
severe CHF and/or pulmonary edema (Killip class
3) and onset of symptoms within 12 hours.
72
Rescue PCI
I IIa IIb III
Rescue PCI is reasonable for selected patients 75
years or older with ST elevation or LBBB or who
develop shock within 36 hours of MI and are
suitable for revascularization that can be performed
within 18 hours of shock.
It is reasonable to perform rescue PCI for patients
with one or more of the following:
I IIa IIb III
a. Hemodynamic or electrical instability
b. Persistent ischemic symptoms.
73
PCI for Cardiogenic Shock
I IIa IIb III
I IIa IIb III
Primary PCI is recommended for patients less than
75 years with ST elevation or LBBB or who develop
shock within 36 hours of MI and are suitable for
revascularization that can be performed within 18
hours of shock.
Primary PCI is reasonable for selected patients
75 years or older with ST elevation or LBBB or
who develop shock within 36 hours of MI and
are suitable for revascularization that can be
performed within 18 hours of shock.
74
PCI for Cardiogenic Shock
Cardiogenic Shock
Early Shock, Diagnosed on
Hospital Presentation
Fibrinolytic therapy if all of the
following are present:
1. Greater than 90 minutes to PCI
2. Less than 3 hours post STEMI
onset
3. No contraindications
IABP
Arrange prompt transfer to invasive
procedure-capable center
75
PCI for Cardiogenic Shock
Cardiogenic Shock
Early Shock, Diagnosed on
Hospital Presentation
Delayed Onset Shock
Echocardiogram to Rule Out
Mechanical Defects
Fibrinolytic therapy if all of the
following are present:
1. Greater than 90 minutes to PCI
2. Less than 3 hours post STEMI
onset
3. No contraindications
IABP
Arrange rapid transfer to invasive
procedure-capable center
Arrange prompt transfer to invasive
procedure-capable center
76
PCI for Cardiogenic Shock
Cardiogenic Shock
Early Shock, Diagnosed on
Hospital Presentation
Delayed Onset Shock
Echocardiogram to Rule Out
Mechanical Defects
Fibrinolytic therapy if all of the
following are present:
Arrange prompt transfer to invasive
procedure-capable center
Arrange rapid transfer to invasive
procedure-capable center
IABP
1. Greater than 90 minutes to PCI
2. Less than 3 hours post STEMI
onset
3. No contraindications
Cardiac Catheterization and Coronary
Angiography
1-2 vessel CAD
Moderate 3-vessel CAD
PCI IRA
PCI IRA
Staged Multivessel
PCI
Severe 3-vessel CAD
Left main CAD
Immediate CABG
Staged CABG
Cannot be
performed
77
PCI After Fibrinolysis
In patients whose anatomy is suitable, PCI should be
performed for the following:
I IIa IIb III
Objective evidence of recurrent MI
I IIa IIb III
Moderate or severe spontaneous/provocable
myocardial ischemia during recovery from STEMI
I IIa IIb III
Cardiogenic shock or hemodynamic instability.
78
PCI After Fibrinolysis
I IIa IIb III
I IIa IIb III
It is reasonable to perform routine PCI in patients
with left ventricular ejection fraction (LVEF) ≤ 0.40,
CHF, or serious ventricular arrhythmias.
It is reasonable to perform PCI when there is
documented clinical heart failure during the acute
episode, even though subsequent evaluation
shows preserved LV function (LVEF > 0.40).
I IIa IIb III
Routine PCI might be considered as part of
an invasive strategy after fibrinolytic therapy.
79
Assessment of Reperfusion
I IIa IIb III
It is reasonable to monitor the pattern of ST elevation,
cardiac rhythm and clinical symptoms over the 60 to 180
minutes after initiation of fibrinolytic therapy.
Noninvasive findings suggestive of reperfusion include:
 Relief of symptoms
 Maintenance and restoration of hemodynamic and/or
electrical instability
 Reduction of ≥ 50% of the initial ST-segment elevation
pattern on follow-up ECG 60 to 90 minutes after
initiation of therapy.
80
Ancillary Therapy to Reperfusion
I IIa IIb III
Unfractionated heparin (UFH) should be given
intravenously in:
 Patients undergoing PCI or surgical
revascularization
 After alteplase, reteplase, tenecteplase
 After streptokinase, anistreplase, urokinase in
patients at high risk for systemic emboli.
81
Ancillary Therapy to Reperfusion
I IIa IIb III
Platelet counts should be monitored daily in patients
taking UFH.
I IIa IIb III
Low molecular-weight heparin (LMWH) might be considered
an acceptable alternative to UFH in patients less than 75 years
who are receiving fibrinolytic therapy in the absence of
significant renal dysfunction.
Enoxaparin used with tenecteplase is the most
comprehensively studied.
82
Aspirin
A daily dose of aspirin (initial dose of 162 to
I IIa IIb III
325 mg orally; maintenance dose of 75 to 162
mg) should be given indefinitely after STEMI to
all patients without a true aspirin allergy.
83
Thienopyridines
I IIa IIb III
In patients for whom PCI is planned, clopidogrel
should be started and continued:
• ≥ 1 month after bare-metal stent
• ≥ 3 months after sirolimus-eluting stent
• ≥ 6 months after paclitaxel-eluting stent
• Up to 12 months in absence of high risk for
bleeding.
84
Thienopyridines
In patients taking clopidogrel in whom CABG is
I IIa IIb III
planned, the drug should be withheld for at
least 5 days, and preferably for 7 days, unless
the urgency for revascularization outweighs the
risk of excessive bleeding.
85
Thienopyridines
I IIa IIb III
Clopidogrel is probably indicated in patients
receiving fibrinolytic therapy who are unable
to take aspirin because of hypersensitivity or
gastrointestinal intolerance.
86
Glycoprotein IIb/IIIa Inhibitors
I IIa IIb III
It is reasonable to start treatment with
abciximab as early as possible before primary
PCI (with or without stenting) in patients with
STEMI.
I IIa IIb III
Treatment with tirofiban or eptifibatide may be
considered before primary PCI (with or
without stenting) in patients with STEMI.
87
Other Pharmacological Measures
Inhibition of
the renin angiotensin aldosterone
system
Angiotensin converting enzyme (ACE)
inhibitors
Angiotensin receptor blockers (ARB)
Aldosterone blockers
Glucose control
Magnesium
Calcium channel blockers
88
SAVE
AIRE
Radionuclide
EF  40%
Clinical and/or
radiographic
signs of HF
Echocardiographic
EF  35%
All-Cause Mortality
0.4
Probability of Event
TRACE
0.35
0.3
0.25
Placebo
0.2
ACE-I
Placebo: 866/2971 (29.1%)
0.15
ACE-I: 702/2995 (23.4%)
0.
1
0.05
0
Years
OR: 0.74 (0.66–0.83)
0
1
2
4
3
ACE-I
2995
2250
1617
892
223
Placebo
2971
2184
1521
853
138
Flather MD, et al. Lancet. 2000;355:1575–1581
89
Mortality by Treatment
0.3
Captopril
Valsartan
Probability of Event
0.25
Valsartan + Captopril
0.2
0.15
0.1
0.05
Valsartan vs. Captopril: HR = 1.00; P = 0.982
Valsartan + Captopril vs. Captopril: HR = 0.98; P = 0.726
0
Months
0
Captopril 4909
Valsartan 4909
Valsartan + Cap 4885
6
12
18
24
30
36
4428
4464
4414
4241
4272
4265
4018
4007
3994
2635
2648
2648
1432
1437
1435
364
357
382
Pfeffer, McMurray, Velazquez, et al. N Engl J Med 2003;349
90
EPHESUS: All-Cause Mortality
Cumulative Incidence (%)
25
Eplerenone
Placebo
20
15
10
5
P = 0.008
RR = 0.85 (95% CI, 0.75–0.96)
0
Month
0
6
12
18
24
30
36
Eplerenone
3319
3044
2463
1260
336
0
0
Placebo
3313
2983
2418
1213
323
2
0
Pitt et al. N Engl J Med 2003;348:1309-1321
91
ACE/ARB: Within 24 Hours
I IIa IIb III
An ACE inhibitor should be administered orally
within the first 24 hours of STEMI to the following
patients without hypotension or known class of
contraindications:
• Anterior infarction
 Pulmonary congestion
 LVEF < 0.40
I IIa IIb III
An ARB should be given to ACE-intolerant patients
with either clinical or radiological signs of HF or LVEF
< 0.40.
92
ACE/ARB: Within 24 Hours
I IIa IIb III
An ACE inhibitor administered orally can be useful
within the first 24 hours of STEMI to the following
patients without hypotension or known class
contraindications:
 Anterior infarction
 Pulmonary congestion
 LVEF < 0.40.
I IIa IIb III
An intravenous ACE inhibitor should not be given to
patients within the first 24 hours of STEMI because
of the risk of hypotension (possible exception:
refractory hypotension).
93
Strict Glucose Control During STEMI
I IIa IIb III
An insulin infusion to normalize blood glucose
is recommended for patients and complicated
courses.
I IIa IIb III
It is reasonable to administer an insulin
infusion to normalize blood glucose even in
patients with an uncomplicated course.
94
Hospital Management
ACC/AHA Guidelines for the
Management of Patients with
ST-Elevation Myocardial Infarction
95
Sample Admitting Orders for the
Patient With STEMI
1.
2.
3.
4.
Condition: Serious
Normal Saline or D5W intravenous to keep vein open
Vital signs: Heart rate, blood pressure, respiratory rate
Monitor: Continuous ECG monitoring for arrhythmia/STsegment deviation
5. Diet: NCEP ATP III Therapeutic Lifestyle Changes, low
sodium diet
96
Sample Admitting Orders for the
Patient With STEMI
6. Activity: Bed rest with bedside commode, light
activity when stable
7. Oxygen: 2 L/min when stable for 6 hrs, reassess
need (i.e., O2 sat < 90%). Consider discontinuing
if O2 saturation is > 90%.
8. Medications: NTG, ASA, beta-blocker, ACE, ARB,
pain meds, anxiolytics, daily stool softener
9. Laboratory tests: cardiac biomarkers, CBC
w/platelets, INR, aPTT, electrolytes, Mg2+, BUN,
creatinine, glucose, serum lipids
97
Emergency Management of Complicated STEMI
Clinical signs: Shock, hypoperfusion, congestive heart failure, acute pulmonary edema
Most likely major underlying disturbance?
Hypovolemia
Third line of action
Second line of action
First line of action
Acute Pulmonary Edema
Administer
• Furosemide IV 0.5 to 1.0 mg/kg
• Morphine IV 2 to 4 mg
• Oxygen/intubation as needed
• Nitroglycerin SL, then 10 to 20 mcg/min IV if SBP
greater than 100 mm Hg
• Dopamine 5 to 15 mcg/kg per minute IV if SBP 70 to
100 mm Hg and signs/symptoms of shock present
• Dobutamine 2 to 20 mcg/kg per minute IV if SBP 70
to 100 mm Hg and no signs/symptoms of shock
Check Blood Pressure
Systolic BP
Greater than 100 mm Hg
and not less than 30 mm Hg
below baseline
Low Output Cardiogenic Shock
Administer
• Fluids
• Blood transfusions
• Cause-specific
interventions
Consider vasopressors
Arrhythmia
Bradycardia
Tachycardia
Check Blood Pressure
See Section 7.7
in the ACC/AHA Guidelines for
Patients With ST-Elevation
Myocardial Infarction
Systolic BP
Greater than 100 mm Hg
Systolic BP
70 to 100 mm Hg
NO signs/symptoms
of shock
Systolic BP
70 to 100 mm Hg
Signs/symptoms
of shock
Systolic BP
less than 70 mm Hg
Signs/symptoms of shock
Nitroglycerin
10 to 20 mcg/min IV
Dobutamine
2 to 20
mcg/kg per
minute IV
Dopamine
5 to 15
mcg/kg per
minute IV
Norepinephrine
0.5 to 30 mcg/min IV
ACE Inhibitors
Short-acting agent such as
captopril (1 to 6.25 mg)
Further diagnostic/therapeutic considerations (should be considered in
nonhypovolemic shock)
Diagnostic
Therapeutic
♥ Pulmonary artery catheter
♥ Intra-aortic balloon pump
♥ Echocardiography
♥ Reperfusion/revascularization
♥ Angiography for MI/ischemia
♥ Additional diagnostic studies
Circulation 2000;102(suppl I):I-172-I-216.
98
Right Ventricular Infarction
V4R
Clinical findings:
Shock with clear lungs, elevated JVP
Kussmaul sign
Hemodynamics:
Increased RA pressure (y descent)
Square root sign in RV tracing
ECG:
ST elevation in R sided leads
Echo:
Depressed RV function
Rx:
Maintain RV preload
Lower RV afterload (PA---PCW)
Inotropic support
Reperfusion
Modified from Wellens. N Engl J Med
1999;340:381.
99
Ventricular
Septal Rupture
Incidence
Timing
Phy Exam
Thrill
Echo
PA cath
1-2%
3-5 d p MI
murmur 90%
Common
Shunt
O2 step up
Free Wall
Rupture
Mitral Regurgitation
(Pap. M. dysfunction)
1-6%
3-6 d p MI
JVD, EMD
No
Peric. Effusion
Diast Press Equal.
Images:Courtesy of W D Edwards (Mayo Foundation)
Data: Lavocitz. CV Rev Rpt 1984;5:948; Birnbaum. NEJM 2002;347:1426.
1-2%
3-5 d p MI
murmur 50%
Rare
Regurg. Jet
c-v wave in PCW
100
“Warning Arrhythmias”
Antman and Rutherford. Coronary Care Medicine.
Boston, MA: Martinus Nijhoff Publishing;1986:81.
101
Arrhythmias During Acute Phase of STEMI:
Electrical Instability
Arrhythmia
Treatment
VPBs
K+ , Mg++, beta blocker
VT
Antiarrhythmics, DC shock
AIVR
Observe unless hemodynamic
compromise
NPJT
Search for cause (e.g., dig toxicity)
102
Arrhythmias During Acute Phase of STEMI:
Pump Failure / Excess Sympathetic Tone
Arrhythmia
Treatment
Sinus Tach
Treat cause; beta blocker
Afib / Flutter
Treat cause; slow ventricular rate; DC shock
PSVT
Vagal maneuvers; beta blocker,
verapamil / diltiazem; DC shock
103
Arrhythmias During Acute Phase of STEMI:
Bradyarrhythmias
Arrhythmia
Treatment
Sinus Brady
Treat if hemodynamic compromise;
atropine / pacing
Junctional
Treat if hemodynamic compromise;
atropine / pacing
104
Arrhythmias During Acute Phase of STEMI:
AV Conduction Disturbances
Escape Rhythm
Proximal
His Bundle
< 120 ms
45 - 60
Distal
Distal
> 120 ms
Often < 30
Duration of AVB
2 - 3 days
Transient
Mortality
Low
High (CHF, VT)
Rx
Observe
PM (ICD)
105
Recommendations for Treatment of
Atrioventricular and Intraventricular Conduction
Disturbances During STEMI
Atrioventricular Conduction
INTRAVENTRICULAR
First degree AV block
Mobitz I second degree AV block
CONDUCTION
Normal
ANTERIOR MI
NON-ANTERIOR
ANTERIOR MI
NON-ANTERIOR
ACTION CLASS ACTION CLASS ACTION CLASS ACTION CLASS ACTION CLASS
Normal
Observe
I
Observe
I
Observe
I
Observe
IIb
Observe
IIa
A
III
A
III
A
III
A*
III
A
III
TC
III
TC
IIb
TC
IIb
TC
I
TC
I
TV
III
TV
III
TV
III
TV
III
TV
III
Observe
I
Observe
IIb
Observe
IIb
Observe
IIb
Observe
IIb
Old or New
III
A
III
A
III
A*
III
A
III
Fascicular block A
IIb
TC
I
TC
IIa
TC
I
TC
I
(LAFB or LPFB) TC
TV
III
TV
III
TV
III
TV
III
TV
III
Observe
I
Observe
III
Observe
III
Observe
III
Observe
III
Old bundle
A
III
A
III
A
III
A*
III
A
III
branch block
TC
IIb
TC
I
TC
I
TC
I
TC
I
TV
III
TV
IIb
TV
IIb
TV
IIb
TV
IIb
Observe
III
Observe
III
Observe
III
Observe
III
Observe
III
New bundle
A
III
A
III
A
III
A*
III
A
III
branch block
TC
I
TC
I
TC
I
TC
I
TC
I
TV
IIb
TV
IIa
TV
IIa
TV
IIa
TV
IIa
Observe
III
Observe
III
Observe
III
Observe
III
Observe
III
Fascicular
A
III
A
III
A
III
A*
III
A
III
block + RBBB
TC
I
TC
I
TC
I
TC
I
TC
I
TV
IIb
TV
IIa
TV
IIa
TV
IIa
TV
IIa
Observe
III
Observe
III
Observe
III
Observe
III
Observe
III
Alternating
A
III
A
III
A
III
A*
III
A
III
left and right
TC
IIb
TC
IIb
TC
IIb
TC
IIb
TC
IIb
bundle branch
TV
I
TV
I
TV
I
TV
I
TV
I
block
Mobitz II second degree AV block
ANTERIOR MI
NON-ANTERIOR
ACTION CLASS ACTION CLASS
Observe
III
Observe
III
A
III
A
III
TC
I
TC
I
TV
IIa
TV
IIa
Observe
III
Observe
III
A
III
A
III
TC
I
TC
I
TV
IIa
TV
IIb
Observe
III
Observe
III
A
III
A
III
TC
I
TC
I
TV
IIa
TV
IIa
Observe
III
Observe
III
A
III
A
III
TC
IIb
TC
IIb
TV
I
TV
I
Observe
III
Observe
III
A
III
A
III
TC
IIb
TC
IIb
TV
I
TV
I
Observe
III
Observe
III
A
III
A
III
TC
IIb
TC
IIb
TV
I
TV
I
106
ICD Trials in Post-MI Patients
Study
Name
Year
Number Days
of
post-MI
patients
Qualifying
arrhythmia
EF
Upper limit,
mean
EPS
Mortality hazard
ICD versus no
ICD (95%CI)
3-30 VPBs
rate greater
than 120
MADIT
1996
196
Greater
than 20
35%, 26%
Yes
0.46 (0.26-0.82)
MUSTT
1999
704
Greater Greater than 2 40%, 30%
than 3
VPS
rate greater
than 100
Yes
0.42 (0.28-0.62)
MADIT 2
2002
1232
Greater
than 29
No
0.69 (0.51-0.93)
None
necessary
30%, 23%
NEJM 1996;335:1933-40.
NEJM 1999;341;1882-90.
NEJM 2002;346:877-93.
107
ICD Implantation After STEMI
One Month After STEMI;
No Spontaneous VT or VF 48 hours post-STEMI
EF < 0.30
EF > 0.40
EF 0.31 - 0.40
Additional Marker of
Electrical Instability?
Yes
+
EPS
No
-
No ICD.
Medical Rx
NEJM 349:
1836,2003
108
Algorithm for Management of Recurrent
Ischemia/Infarction After STEMI
Recurrent ischemic-type discomfort at rest after STEMI
Obtain 12-lead ECG
• Escalation of medical therapy (nitrates, beta
blockers)
• Anticoagulation if not already given
• Consider IABP for hemodynamic instability,
poor LV function, or a large area of
myocardium at risk
• Correct secondary causes of ischemia
ST-segment elevation?
109
Algorithm for Management of Recurrent
Ischemia/Infarction After STEMI
Recurrent ischemic-type discomfort at rest after STEMI
Obtain 12-lead ECG
• Escalation of medical therapy (nitrates, beta
blockers)
• Anticoagulation if not already given
• Consider IABP for hemodynamic instability,
poor LV function, or a large area of
myocardium at risk
• Correct secondary causes of ischemia
ST-segment elevation?
YES
Is patient
a candidate for
revascularization
revascularization?
?
YES
NO
Can
Can
catheterization
catheterization
be
be performed
performed promptly?
promptly?*
promptly?*
YES
YES
Coronary
Coronary
angiography
angiography
Revascularization
Revascularization with
with PCI
PCI
and/or
and/or CABG
CABG as
as dictated
dictated by
by
anatomy
anatomy
Consider
Consider
(re) administration
(re)
of
administration
fibrinolytic therapy
of
NO
NO
Modified from Braunwald. Heart Disease: A Textbook
of Cardiovascular Medicine. 6th ed. Philadelphia, PA:
WB Saunders Co. Ltd. 2001:1195.
Consider (re) administration
of fibrinolytic therapy
110
Algorithm for Management of Recurrent
Ischemia/Infarction After STEMI
Recurrent ischemic-type discomfort at rest after STEMI
Obtain 12-lead ECG
• Escalation of medical therapy (nitrates, beta
blockers)
• Anticoagulation if not already given
• Consider IABP for hemodynamic instability,
poor LV function, or a large area of
myocardium at risk
• Correct secondary causes of ischemia
ST-segment elevation?
YES
NO
Is patient
a candidate for
revascularization
revascularization?
?
Is
Is ischemia
ischemia
controlled
controlled by
by escalation
escalation
of
of medical
medical therapy?
therapy?
YES
YES
YES
NO
Can
Can
catheterization
catheterization
be
be performed
performed promptly?
promptly?*
promptly?*
YES
YES
Coronary
Coronary
angiography
angiography
Revascularization
Revascularization with
with PCI
PCI
and/or
and/or CABG
CABG as
as dictated
dictated by
by
anatomy
anatomy
NO
NO
Consider
Consider
(re) administration
(re)
of
administration
fibrinolytic therapy
of
NO
NO
Refer
Refer for
for
nonurgent
nonurgent
catheterization
catheterization
Refer
Refer for
for urgent
urgent
catheterization
catheterization (consider
(consider
IABP)
IABP)
Modified from Braunwald. Heart Disease: A Textbook
of Cardiovascular Medicine. 6th ed. Philadelphia, PA:
WB Saunders Co. Ltd. 2001:1195.
Consider (re) administration
of fibrinolytic therapy
111
Evidence-Based Approach to Need for
Catheterization and Revascularization After STEMI
STEMI
Primary Invasive Strategy
Fibrinolytic Therapy
Cath
Performed
No Cath
Performed
EF greater
than 0.40
Revascularization as
Indicated
No High -Risk
Features †
No Reperfusion Therapy
EF less
than 0.40
High-Risk
Features †
EF less
than 0.40
Catheterization and
Revascularization as
Indicated
EF greater
than 0.40
High-Risk
Features †
No High -Risk
Features †
Functional
Evaluation
ECG Interpretable
Able to Exercise
ECG Uninterpretable
Unable to Exercise
Able to Exercise
Pharmacological Stress
Submaximal
Symptom-Limited
Symptom-Limited
Adenosine
Exercise Test
Exercise Test
or Dipyridamole
Before Discharge Before or After Discharge Nuclear Scan
Catheterization and
Revascularization as
Indicated
Clinically Significant
Ischemia*
Ischemia
Dobutamine
Echo
No Clinically Significant
Ischemia*
Ischemia
Exercise
Echo
Exercise
Nuclear
Medical
Therapy
112
Long-Term Antithrombotic Therapy at
Hospital Discharge After STEMI
STEMI Patient at Discharge
No Stent Implanted
No ASA allergy
ASA Allergy
No Indications
for Anticoagulation
Indications
for Anticoagulation
No Indications
for Anticoagulation
Preferred:
ASA 75 to 162 mg
Class I; LOE: A
ASA 75 to 162 mg
Warfarin
(INR 2.0 to 3.0)
Class I; LOE B
Preferred:
Clopidogrel 75 mg
Class I; LOE: C
Alternative:
ASA 75 to 162 mg
Warfarin
(INR 2.0 to 3.0)
Class: IIa; LOE: B
OR
Warfarin
(INR 2.5 to 3.5)
Class I; LOE: B
Indications
for Anticoagulation
Warfarin
INR (2.5 to 3.5)
Class I; LOE: B
Alternative:
Warfarin
INR (2.5 to 3.5)
Class I; LOE: B
OR
Warfarin
(INR 2.5 to 3.5)
Class IIa; LOE: B
113
Long-Term Antithrombotic Therapy at
Hospital Discharge After STEMI
STEMI Patient at Discharge
Stent Implanted
No ASA Allergy
ASA Allergy
No Indications
for
Anticoagulation
Indications
for Anticoagulation
ASA 75 to 162 mg
Clopidogrel 75 mg
Class: I; LOE: B
ASA 75 to 162 mg
Clopidogrel 75 mg
Warfarin
(INR 2.0 to 3.0)
Class: IIb; LOE: C
No Indications
for
Anticoagulation
Indications
for
Anticoagulation
Clopidogrel 75 mg
Class I; LOE: B
Clopidogrel 75 mg
Warfarin
(INR 2.0 to 3.0)
Class I; LOE: C
114
Long-Term Management
ACC/AHA Guidelines for the
Management of Patients with
ST-Elevation Myocardial Infarction
115
Secondary Prevention and Long Term Management
Goals
Smoking
Goal:
Complete
Cessation
Recommendations
• Assess tobacco use.
• Strongly encourage patient and family to
stop smoking and to avoid secondhand
smoke.
• Provide counseling, pharmacological
therapy (including nicotine replacement and
bupropion), and formal smoking cessation
programs as appropriate.
116
Secondary Prevention and Long Term Management
Goals
Blood pressure
control:
Goal: < 140/90
mm Hg or
<130/80 mm Hg
if chronic kidney
disease or
diabetes
Recommendations
If blood pressure is 120/80 mm Hg or greater:
• Initiate lifestyle modification (weight control, physical
activity, alcohol moderation, moderate sodium restriction, and
emphasis on fruits, vegetables, and low-fat dairy products) in
all patients.
If blood pressure is 140/90 mm Hg or greater or 130/80
mm Hg or greater for individuals with chronic kidney
disease or diabetes:
• Add blood pressure-reducing medications, emphasizing the
use of beta-blockers and inhibitors of the renin-angiotensinaldosterone system.
117
Secondary Prevention and Long Term Management
Goals
Physical activity:
Minimum goal:
30 minutes 3 to 4
days per week;
Optimal daily
Recommendations
• Assess risk, preferably with exercise test, to guide
prescription.
• Encourage minimum of 30 to 60 minutes of activity,
preferably daily but at least 3 or 4 times weekly (walking,
jogging, cycling, or other aerobic activity) supplemented by
an increase in daily lifestyle activities (e.g., walking breaks
at work, gardening, household work).
• Cardiac rehabilitation programs are recommended for
patients with STEMI.
118
Secondary Prevention and Long Term Management
Goals
Lipid
management:
(TG less than
200 mg/dL)
Primary goal:
LDL-C << than
100 mg/dL
Recommendations
• Start dietary therapy in all patients (< 7% of total calories as
saturated fat and < 200 mg/d cholesterol). Promote physical
activity and weight management. Encourage increased
consumption of omega-3 fatty acids.
• Assess fasting lipid profile in all patients, preferably within
24 hours of STEMI. Add drug therapy according to the
following guide:
LDL-C < 100 mg/dL (baseline or on treatment):
Statins should be used to lower LDL-C.
LDL-C ≥ 100 mg/dL (baseline or on
treatment):
Intensify LDL-C–lowering therapy with drug treatment,
giving preference to statins.
119
Secondary Prevention and Long Term Management
Goals
Lipid
management:
(TG 200 mg/dL
or greater)
Primary goal:
Non–HDL-C <<
130 mg/dL
Recommendations
If TGs are ≥ 150 mg/dL or HDL-C is < 40 mg/dL:
Emphasize weight management and physical
activity. Advise smoking cessation.
If TG is 200 to 499 mg/dL:
After LDL-C–lowering therapy, consider adding
fibrate or niacin.
If TG is ≥ 500 mg/dL:
Consider fibrate or niacin before LDL-C–lowering
therapy.
Consider omega-3 fatty acids as adjunct for high
TG.
120
Secondary Prevention and Long Term Management
Goals
Weight
management:
Goal:
BMI 18.5 to 24.9
kg/m2
Waist
circumference:
Women: < 35 in.
Men: < 40 in.
Recommendations
Calculate BMI and measure waist circumference
as part of evaluation. Monitor response of BMI
and waist circumference to therapy.
Start weight management and physical activity as
appropriate. Desirable BMI range is 18.5 to 24.9
kg/m2.
If waist circumference is ≥ 35 inches in women or
≥ 40 inches in men, initiate lifestyle changes and
treatment strategies for metabolic syndrome.
121
Secondary Prevention and Long Term Management
Goals
Diabetes
management:
Goal:
HbA1c < 7%
Recommendations
Appropriate hypoglycemic therapy to
achieve near-normal fasting plasma
glucose, as indicated by HbA1c.
Treatment of other risk factors (e.g.,
physical activity, weight management,
blood pressure, and cholesterol
management).
122
Secondary Prevention and Long Term Management
Goals
Recommendations
Antiplatelet
• In the absence of contraindications, start aspirin
agents/
75 to 162 mg/d and continue indefinitely.
anticoagulants
• If aspirin is contraindicated, consider clopidogrel
75 mg/day or warfarin.
• Manage warfarin to INR 2.5 to 3.5 in postSTEMI patients when clinically indicated or for
those not able to take aspirin or clopidogrel.
123
Secondary Prevention and Long Term Management
Goals
ReninAngiotensinAldosterone
System
Blockers
Recommendations
ACE inhibitors in all patients indefinitely; start early in
stable, high-risk patients (ant. MI, previous MI, Killip class
≥ 2 [S3 gallop, rales, radiographic CHF], LVEF < 0.40).
Angiotensin receptor blockers in patients who are
intolerant of ACE inhibitors and with either clinical or
radiological signs of heart failure or LVEF < 0.40.
Aldosterone blockade in patients without significant renal
dysfunction or hyperkalemia who are already receiving
therapeutic doses of an ACE inhibitor, have LVEF ≤ 0.40,
and have either diabetes or heart failure.
124
Secondary Prevention and Long Term Management
Goals
BetaBlockers
Recommendations
Start in all patients. Continue indefinitely.
Observe usual contraindications.
125
Summary of Pharmacologic Rx: Ischemia
1st
24 h
During
Hosp
Hosp DC +
Long Term
Aspirin
162-325 mg
chewed
75-162
mg/d p.o.
75-162
mg/d p.o.
Fibrinolytic
tPA,TNK,
rPA, SK
UFH
60U/kg (4000)
12 U/kg/h (1000)
aPTT 1.5 - 2 x C
aPTT
1.5 - 2 x C
Beta-blocker
Oral daily
Oral daily
JACC 2004;44: 671
Circulation 2004;110: 588
Oral daily
126
Summary of Pharmacologic Rx: LVD, Sec. Prev.,
ACEI
ARB
1st
24 h
Anterior MI,
Pulm Cong., EF < 40
ACEI intol.,
HF, EF < 40
Aldo
Blocker
Statin
JACC 2004;44:671
Circ 2004;110:588
During Hosp
Oral
Daily
Hosp DC +
Long Term
Oral
Daily
Indefinitely
No renal dysf,
Same as
K+ < 5.0 mEq/L
during
On ACEI,
Hosp.
HF or DM
Start w/o lipid Indefinitely,
profile
LDL << 100
127
Hormone Therapy
Hormone therapy with estrogen plus progestin
I IIa IIb III
should not be given de novo to postmenopausal
women after STEMI for secondary prevention of
coronary events.
128
Hormone Therapy
I IIa IIb III
Postmenopausal women who are already taking
estrogen plus progestin at the time of STEMI should
not continue hormone therapy.
However, women who are beyond 1 to 2 years after
initiation of hormone therapy who wish to continue
such therapy for another compelling indication
should weigh the risks and benefits.
129
Antioxidants
Antioxidant vitamins such as vitamin E and/or
I IIa IIb III
vitamin C supplements should not be prescribed to
patients recovering from STEMI to prevent
cardiovascular disease.
130
Psychosocial Impact of STEMI
I IIa IIb III
The psychosocial status of the patient should be evaluated,
including inquiries regarding symptoms of depression, anxiety,
or sleep disorders and the social support environment.
I IIa IIb III
Treatment with cognitive-behavioral therapy and selective
serotonin reuptake inhibitors can be useful for STEMI patients
with depression that occurs in the year after hospital discharge.
131
Cardiac Rehabilitation
I IIa IIb III
Cardiac rehabilitation/secondary prevention
programs, when available, are recommended
for patients with STEMI, particularly those
with multiple modifiable risk factors and/or
those moderate- to high-risk patients in whom
supervised exercise training is warranted.
132
Follow-Up Visit With Medical Provider
• Delineate cardiovascular symptoms and
functional class.
• Evaluate current medications and titrate if needed.
I IIa IIb III
• Review and continue predischarge risk
assessment.
• Review secondary prevention principles.
• Check psychosocial status.
• Discuss resumption of daily activities.
• Address plan for recognizing and responding to
potential cardiac event.
• Refer to a cardiac rehabilitation program.
133