DOOR 2 DOOR MANAGEMENT OF

STEMI

Disclosure

Amgen FOURNIER Clinical Trial-Lipitor Janssen MARINER Clinical Trial- Xarelto

Acute Myocardial Infarction remains a leading cause of morbidity and mortality world wide.

450,000 die in the U. S. yearly

95% survival rate in the U. S. for hospitalized patients. This is related to the EMS response times and

in field treatment. Advanced treatment strategies like the D2B

initiative.

Myocardial Infarction Categories

Trans mural Ischemic necrosis

of the full thickness of the heart muscle distal to the obstruction. Endocardium Myocardium Epicardium

Myocardial Infarction Categories

Non Trans mural Ischemia usually

limited to the endocardium

Universal Definition of

Myocardial Infarction

Type 1- spontaneous MI related to ischemia from a primary plaque rupture.

Type 2- ischemia from supply/demand mismatch. Ao stenosis Anemia Vasospasm Low Cardiac Output States

Type 3- MI resulting in sudden cardiac death Type 4a- MI associated with PCI Type 4b- MI associated with stent thrombosis Type 5 – MI associated with CABG

EKGClassification of MI

STEMI

NSTEMI

TIME

STEMI

Immediate reperfusion

PCI Thrombolytic therapy

30% of the patients in the U.S. with STEMI never receive treatment!

90 minutes40%

“You can not know where you are going,until you know where you have been.”

Unknown

Antonio Egas Moniz1874-1955

Portuguese physician who developed the technique of angiography

1927 –first cerebral angiogram

Won the Nobel Prize for physiology and medicine

Werner Forssman1904-1979

German physician inserted a rubber catheter into his own antecubital vein, walked to the xray machine and guided it into his right heart.

1929 – first heart catheterization

Nobel Prize for physiology and medicine.

Mason Sones1918-1985

The most important contributor to modern invasive cardiology.

Coronary angiography is born!

1958 in the angiography lab at CCF

Dr. Sones unintentionally engaged the RCA while doing an aortic angiogram. The RCA was injected before the cath could be pulled back……

Vae Lucile Van Derwyst

RN present during the first coronary angiogram.

World’s first cath lab nurse.

She was in charge of a 40 nurse staff that traveled the world to speak and teach.

Rene Favaloro1923-2000

Pioneer in Cardiothoracic Surgery

1967- first CABG at CCF

Saphenous Vein Graft

Heart Catheterization Lab

Before the 1970’s coronary angiography was diagnostic

1977 balloon angioplasty

1986 angioplasty with stents

Treatment of MI D2B is born

Door to Balloon Initiative

Launched November 2006

ACC/AHA guidelines recommend a D2B of 90 min. (JCAHO core quality measurement)

Time starts when an EKG showing STEMI is obtained and analyzed.

Time ends when the catheter crosses the lesion and the balloon is inflated.

Evidence Based Strategies to Reduce D2B Times

ED or Prehospital EKG is obtained within 10 minutes of patient encounter (1B)

ED Physician activates the Cath Lab Single-call activation system activates

the cath lab team. Cath lab team arrives within 20-30 min. Prompt data feedback Senior Management commitment Team Approach/Community Leaders

Team Effort

All communities should create and maintain a regional system of STEMI care. (1B) Door to EKG time EKG to Lab time Lab to Device time

EMS >98% of the US

population is covered by 9-1-1 service

2011 ACTION Registry 60% of 37K STEMI

patients used EMS Older surveys

EMS activation 23-53% with substantial geographic variability

EKG

EKG

GOOD BAD

EKG

GOOD BAD

EKG

STEMI Location

One More

Primary PCI in STEMI.

WRITING COMMITTEE MEMBERS* et al. Circulation. 2013;127:e362-e425

Copyright © American Heart Association, Inc. All rights reserved.

PCI vs Fibrinolytic Therapy

Higher rates of infarct artery patency Lower rates of

Recurrent ischemia Re-infarction Emergency repeat revascularization

procedures Intracranial hemorrhage death

ED to CATH LAB

Platelet Clotting Cascade

BMS or DES

Class 1 Stent Recommendations

Placement of a DES or BMS in STEMI (1A)

BMS (1C) High bleeding risk Inability to comply

with 1 year of dual antiplatelet therapy (DAPT)

Anticipated surgery within one year

Stent Class 3:Harm

DES should not be used if the patient can not comply with one year of dual antiplatelet therapy because of increased risk of stent thrombosis. (3B)

Stent Delivery

Antiplatelet Therapy

Aspirin 162 to 325mg should be given before PCI (1B)

After PCI should be continued indefinitely (1A)

81mg maintenance does is preferred after PCI (2aB)

P2Y12 Receptor Inhibitors

A loading dose should be given as early as possible or at the time of PCI to patients with STEMI (1B)

DAPT should be given for one year for patients with STEMI who receive DES or BMS (1B)

Effient (Prasugrel) should not be given to patients with a history of prior stroke or TIA (3B)

P2Y12 Receptor Inhibitors

Problems with Plavix

PPI and Plavix

Interferes with Plavix metabolism diminishing the antiplatelet effect.

At this time it does not appear this effect has lead to worse clinical outcomes

Take Home

DO NOT STOP antiplatelet medication unless cleared by patient’s interventional cardiologist.

Monitor your patient’s compliance with DAPT

Medical Management

Beta Blockers

Oral beta blockers should be initiated in the first 24 hours in patients with STEMI who do not have any of the following: signs of HF, evidence of a low output state, increased risk for cardiogenic shock,* or other contraindications to use of oral beta blockers (PR interval >0.24 seconds, second- or third-degree heart block, active asthma, or reactive airways disease).

Beta blockers should be continued during and after hospitalization for all patients with STEMI and with no contraindications to their use.

I IIa IIb III

I IIa IIb III

*Risk factors for cardiogenic shock (the greater the number of risk factors present, the higher the risk of developing cardiogenic shock) are age >70 years, systolic BP <120 mm Hg, sinus tachycardia >110 bpm or heart rate <60 bpm, and increased time since onset of symptoms of STEMI.

Beta Blockers

Patients with initial contraindications to the use of beta blockers in the first 24 hours after STEMI should be reevaluated to determine their subsequent eligibility.

It is reasonable to administer intravenous beta blockers at the time of presentation to patients with STEMI and no contraindications to their use who are hypertensive or have ongoing ischemia.

I IIa IIb III

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Renin-Angiotensin-Aldosterone System Inhibitors

An ACE inhibitor should be administered within the first 24 hours to all patients with STEMI with anterior location, HF, or EF less than or equal to 0.40, unless contraindicated.

An ARB should be given to patients with STEMI who have indications for but are intolerant of ACE inhibitors.

I IIa IIb III

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Renin-Angiotensin-Aldosterone System Inhibitors

An aldosterone antagonist should be given to patients with STEMI and no contraindications who are already receiving an ACE inhibitor and beta blocker and who have an EF less than or equal to 0.40 and either symptomatic HF or diabetes mellitus.

ACE inhibitors are reasonable for all patients with STEMI and no contraindications to their use.

I IIa IIb III

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Lipid Management

High-intensity statin therapy should be initiated or continued in all patients with STEMI and no contraindications to its use.

It is reasonable to obtain a fasting lipid profile in patients with STEMI, preferably within 24 hours of presentation.

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Risk Assessment

DELAYS TO TREATMENT SHORTER TREATMENT TIME

Women African Americans Elderly Medicaid-only

Medicare, when compared to privately insured patients

Patients taken directly to the hospital by EMS

Risk Management

Post Hospitalization Plan of Care

A clear, detailed, and evidence-based plan of care that promotes medication adherence, timely follow-up with the healthcare team, appropriate dietary and physical activities, and compliance with interventions for secondary prevention should be provided to patients with STEMI.

Encouragement and advice to stop smoking and to avoid secondhand smoke should be provided to patients with STEMI.

I IIa IIb III

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Post Hospitalization Plan of Care

Post hospital systems of care designed to prevent hospital readmissions should be used to facilitate the transition to effective, coordinated outpatient care for all patients with STEMI.

I IIa IIb III

Exercise-based cardiac rehabilitation/secondary prevention programs are recommended for patients with STEMI.

I IIa IIb III

Risk ManagementNew Hypertensive Guidelines

>60 yrs., treat to goal <150/90 <60 yrs., treat to goal <140/80 Diabetes or CKD, treat to goal <140/80

(23% STEMI have DM, 75% of DM deaths are from CAD)

Report from Panel Members Appointed to Eighth Joint National Committee (JNC8)