accaha guidelines for the management of patients with st1510

8/4/2019 Accaha Guidelines for the Management of Patients With St1510

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ACC/AHA Guidelines for the

Management of Patients with STElevation Myocardial Infarction;

2004 (Part II)Ahmad Aslam, M.D.

Prasantha Bathini, M.D.

Robert Smith, M.D.

Cardiac Cath Conference

July 20, 2004



Summary of Initial Management

• Prehospital Issues

• Initial ER Evaluation

• Targeted History• Targeted Physical

Exam

• Laboratory

Evaluations• ECG

• Imaging

• Oxygen

• Nitrates

• Morphine

• ASA

• Beta Blockers

• Selection of Reperfusion Strategy



Initial Recognition and

Management in the ED“Hospitals should establish multidisciplinary teams(including primary care physicians, emergencymedicine physicians, cardiologists, nurses, andlaboratorians) to develop guideline-based,institution-specific written protocols for triagingand managing patients who are seen in theprehospital setting or present to the ED with

symptoms suggestive of STEMI.”

Class I, Level of Evidence: B



Step II: Determine whether fibrinolysis or invasive strategy is preferred

Step I: Assess time and risk

- Time since onset of symptoms

- Risk from STEMI

- Risk of fibrinolysis- Time required for transport to a skilled PCI lab

Fibrinolysis is generally preferred if

- Early presentation (3 hours or less

and delay to invasive strategy)

- Invasive strategy is not an option

- Cath lab not available

- Vascular access difficulties- Lack of access to a skilled lab

- Delay to invasive strategy

Invasive strategy is generally preferred if

- Skilled PCI lab available withsurgical backup

- High risk from STEMI

- Cardiogenic shock

- Killip class > or = to 3

- Contraindications to fibrinolysisincluding increased risk of bleeding

and ICH

- Late presentation

- Symptom onset more than 3 hours

- Diagnosis of STEMI is in doubt



TIMI Risk Score for UA/NSTEMI

Historical

Age > or = to 65

> or = to 3 CAD Risk Factors

Known CAD (> or = to 50% stenosis)

ASA use in the last 7 days

Presentation

Recent Angina (> or = to 24 hours)

Elevated Cardiac Markers

ST Deviation > 0.5mm

Points

1

1

1

1

1

1

1

RISK SCORE = TOTAL POINTS (0-7)



TIMI Risk Score for UA/NSTEMI

Antman et al., JAMA 2000;284:835-842



TIMI STEMI Risk ScoreApplies to patients with chest pain >30 min, symptom onset <6 hrs, ST elevation

HistoryAge > or = to 75

Age 65-74

Previous Angina, HTN, or DM

ExaminationWeight < 67 kg (150#)

HR > 100

Systolic BP < 100mmHg

Killip Class II – IV

PresentationAnterior ST Elevation or LBBB

Time to Treatment > 4 hours

Points3

2

1

1

2

3

2

1

1

RISK SCORE = TOTAL POINTS (0-14)



TIMI STEMI Risk Score

Morrow et al. Circ. 2000;102:2031-2037



Fibrinolytic Therapy

Class I

STEMI patients presenting to a facility without the capacity for expert,

prompt intervention (primary PCI with 90 minutes of first medical

contact) should undergo fibrinolytic therapy. (Level of Evidence: A)

In the absence of contraindications, fibrinolytic therapy should beadministered to STEMI patients with symptom onset within the prior12 hours and ST elevation greater than 0.1mV in at least 2 contiguous

precordial leads or at least 2 adjacent limb leads. (Level of Evidence:A)

In the absence of contraindications, fibrinolytic therapy should beadministered to patients with symptom onset within the prior 12 hoursand new or presumably new LBBB. (Level of Evidence: A)




Class IIa

In the absence of contraindications, it is reasonable to administer

fibrinolytic therapy to STEMI patients with symptom onset within the

prior 12 hours and ECG findings consistent with true posterior MI.

(Level of Evidence: C)

In the absence of contraindications, it is reasonable to administer

fibrinolytic therapy to patients with symptoms of STEMI beginningwithin the prior 12-24 hours who have continuing ischemic symptoms

and ST elevation greater than 0.1mV in at least 2 contiguous precordial

leads or at least 2 adjacent limb leads. (Level of Evidence: B)




Class III

Fibrinolytic therapy should not be administered to

asymptomatic patients whose initial symptoms of STEMI began more than 24 hours earlier. (Levelof Evidence: C)

Fibrinolytic therapy should not be administered topatients whose ECG shows only ST segmentdepression unless true posterior MI is suspected.(Level of Evidence: A)



Contraindications and Cautions for Fibrinolysis use in STEMI

Absolute Contraindications- Any prior ICH

- Known structural cerebral

vascular lesion (e.g., AVM)

- Known malignant intracranial

neoplasm (1o

or 2o

)- Ischemic stroke within 3 months

except acute ischemic stroke

within 3 hours

- Suspected aortic dissection

- Active bleeding or bleeding diathesis

(except menses)

- Significant closed head or facial

trauma within 3 months

Relative Contraindications- History of chronic, severe,

poorly controlled HTN- Severe, uncontrolled HTN on

presentation (SBP>180, DBP>110)

- Hx of prior ischemic stroke >3 months,

dementia, or known IC pathology not

listed in contraindications- Traumatic or prolonged CPR (>10 min)

or major surgery (<3 weeks)

- Recent internal bleeding (2-4 weeks)

- Noncompressible vascular punctures

- For Streptokinase/Anistreplase: prior

exposure (>5 days) or prior allergic rxn

- Pregnancy

- Active peptic ulcer

- Current use of anticoagulants;

the higher the INR, the higher

the risk



Percutaneous Coronary Intervention

Class I

If immediately available, primary PCI should be performed

in patients with STEMI (including posterior MI), or inpatients with new LBBB who can undergo PCI of the

infarct artery within 12 hours of onset of symptoms. (Level

of Evidence: A)

PCI must be performed in a timely fashion (door

balloon time 90 minutes) by persons skilled in the

procedure (greater than 75/year). (Level of Evidence: A)




Class I

Primary PCI should be performed for patients youngerthan 75 years with STEMI or LBBB who develop shock within 36 hours of MI and are suitable forrevascularization that can be performed within 18 hours of shock. (Level of Evidence: A)

Primary PCI should be performed in patients with severeCHF and/or pulmonary edema (Killip class III) and onsetof symptoms within 12 hours. Door balloon should bewithin 90 minutes. (Level of Evidence: B)




Class IIa

Primary PCI is reasonable for patients >75 yrs whodevelop shock within 36 hours of MI and are suitable forrevascularization that can be performed within 18 hours of shock. (Level of Evidence: B)

It is reasonable to perform primary PCI for patients with

onset of symptoms in prior 12-24 hours and severe CHF(Level of Evidence: C), hemodynamic or electricalinstability (Level of Evidence: C), or persistent ischemicsymptoms (Level of Evidence: C)




Class III

PCI should not be performed in a non-infarct

artery at the time of PCI in patients withouthemodynamic compromise. (Level of Evidence:C)

Primary PCI should not be performed inasymptomatic patients more than 12 hours afteronset of STEMI if they are hemodynamically andelectrically stable. (Level of Evidence: C)



Acute Surgical Reperfusion

Class I

Failed PCI with persistent pain or hemodynamic

instability in patient with suitable anatomy. (Levelof Evidence: B)

Persistent or refractory ischemia in patients with

suitable anatomy, with significant myocardium atrisk, and who are not candidates for fibrinolysis orPCI. (Level of Evidence: B)



Acute Surgical Reperfusion

Class I

At the time of surgical repair of post-infarction ventricularseptal rupture or mitral valve insufficiency. (Level of Evidence: B)

Cardiogenic shock in patients <75yrs with STEMI, LBBB,posterior MI who develop shock within 36 hours of

STEMI and have severe multivessel or LM disease. (Levelof Evidence: A)

Life threatening ventricular arrhythmias in the presence of

severe multivessel or LM disease. (Level of Evidence: B)



Ancillary Therapy: UFH

Class I

Patients undergoing PCI or surgical

Revascularization should be given UFH. (Level of Evidence: C)

UFH should be given intravenously to patients

undergoing reperfusion therapy with alteplase,reteplase, or tenecteplase. (Level of Evidence: C)



Ancillary Therapy: UFH

Class I

UFH should be given intravenously to patients treated with

nonselective fibrinolytic agents (streptokinase, anistreplase, urokinase)

who are at high risk for systemic emboli (e.g., AFIB, large anterior MI,known LV thrombus). (Level of Evidence: C)

Platelet counts should be monitored daily in patients receiving UFH.(Level of Evidence: C)

Class IIB

It may be reasonable to administer UFH to patients undergoing

reperfusion therapy with streptokinase



Ancillary Therapy: LMWH

Class IIB

LMWH may be acceptable alternative to UFH for patients<75yrs who are receiving fibrinolytic therapy. (Level of Evidence: B)

Class III

Should not be used for patients >75yrs who are receivingfibrinolytic therapy. (Level of Evidence: B)

Should not be used in patients with significant renaldysfunction (SCr <2.5 for men, 2.0 for women). (Level of Evidence: B)



Ancillary Therapy: Bivalirudin

Class IIa

In patients with known HIT, it is reasonable to

consider bivalirudin as an alternative to UFH to beused with streptokinase. (Level of Evidence: B)

Dosing is 0.25mg/kg followed by IV infusion of

0.5mg/kg/hr for the first 12 hours and 0.25mg/kg/hr for the

subsequent 36 hours. The infusion rate should be reduced

if the PTT is <75 seconds within the first 12 hours.



Ancillary Therapy: Thienopyridines

Class I

In patients who have undergone diagnostic LHC and forwhom PCI is planned, clopidogrel should be started and

continued for at least 1 month for bare metal stents andseveral months for DES’s (at least 3 months for SES and 6months for PES). If patients are not at high risk for bleeding, it should be given for up to 12 months for DES’s.(Level of Evidence: B)

In patients taking clopidogrel in whom CABG is planned,the drug should be withheld for at least 5 days (andpreferably 7), unless the urgency of CABG outweighs therisk of bleeding. (Level of Evidence: B)



Ancillary Therapy: Thienopyridines

Class IIa

Clopidogrel is probably indicated in patients receiving fibrinolytic

therapy who are unable to take aspirin because of hypersensitivity ormajor GI intolerance. (Level of Evidence: C)

General Statements:

Clopidogrel combined with ASA is recommended for patients

undergoing stent implantation

There are no safety data comparing 300mg vs. 600mg loading doses

Routine administration of clopidogrel is not recommended in patientswho have not undergone LHC and in whom CABG might be

performed if necessary



Ancillary Therapy: GP IIb/IIIa Inhibitors

Class IIa

It is reasonable to start therapy with abciximab asearly as possible before primary PCI (with or

without stenting) in patients with STEMI. (Levelof Evidence: B)

Class IIb

Treatment with tirofiban or eptifibatide may beconsidered before primary PCI (with or withoutstenting) in patients with STEMI. (Level of Evidence: C)



Ancillary Therapy: Inhibition of RAAS

Class I

In the absence of hypotension (SBP <100) or othercontraindications, an oral ACE-I should be administeredwithin the first 24 hours to patients with anterior MI,pulmonary congestion, or LVEF <40%. (Level of Evidence: A)

An ARB should be administered to patients who areintolerant of ACE-I and who have either clinical orradiographic signs of CHF or if LVEF <40%. Valsartanand Candesartan have established efficacy for thisrecommendation. (Level of Evidence: C)



Ancillary Therapy: Inhibition of RAAS

Class IIa

In the absence of hypotension (SBP <100) or othercontraindications, an oral ACE-I administered within thefirst 24 hours can be useful in patients without anterior MI,pulmonary congestion, or LVEF <40%. (Level of Evidence: B)

Class IIIAn IV ACE-I should not be given to patients within 24hours of STEMI because of the risk of hypotension. (Levelof Evidence: B)



Strict Glucose Control During STEMI

Class I

An insulin infusion to normalize blood glucose is recommended for

patients with STEMI and complicated courses. (Level of Evidence: B)

Class IIa

During the acute phase (first 24-48 hrs) of the management of STEMI

in patients with hyperglycemia, it is reasonable to administer an insulininfusion, even in patients with an uncomplicated course. (Level of

Evidence: B)

After the acute phase of STEMI, it is reasonable to individualizetreatment, selecting from insulin, insulin analogs, and oralhypoglycemics. (Level of Evidence: C)



Magnesium

Class IIaIt is reasonable that documented Mg deficits be corrected, especially inpatients receiving diuretics before the onset of STEMI. (Level of Evidence: C)

It is reasonable that episodes of torsades de pointes associated with aprolonged QT interval be treated with 1-2 grams of IV Mgadministered as an IV bolus over 5 minutes. (Level of Evidence: C)

Class III

In the absence of electrolyte abnormalities or documented torsades,

routine IV Mg should not be administered to STEMI patients at anylevel of risk. (Level of Evidence: A)



Calcium Channel Blockers

Class IIa

It is reasonable to give verapamil or diltiazem to

patients in whom beta blockers are ineffective orcontraindicated (e.g., bronchospastic disease) for

relief of ongoing ischemia or control of a rapid

ventricular response with AFIB or flutter after

STEMI. This should be done only in the absenceof CHF, LV dysfunction, or AV block. (Level of

Evidence: C)



Calcium Channel Blockers

Class III

Diltiazem and verapamil are contraindicated inpatients with STEMI and associated LV systolicdysfunction or AV block. (Level of Evidence: A)

Nifedipine (immediate release form) is

contraindicated in treatment of STEMI because of the reflex sympathetic activation, tavhycardia, andhypotension associated with its use. (Level of Evidence: B)



Hospital Management: CCU

Class I

STEMI patients should be admitted to a quiet andcomfortable environment that provides continuous ECG

monitoring, pulse oximetry, and has ready access tofacilities for hemodynamic monitoring and defibrillation.(Level of Evidence: C)

The patients medication regimen should be reviewed toconfirm the administration of ASA and beta blockers in anadequate dose to control heart rate and to assess the needfor IV NTG for control of angina, HTN, or CHF. (Level of Evidence: A)




Class I

The ongoing need for oxygen therapy should be assessedby monitoring arterial oxygen saturation. When stable for6 hours, the patient should be reassessed for oxygen need(SaO2 <90%) and discontinuation of supplemental O2 should be considered. (Level of Evidence: C)

Nursing care should be provided by individuals certified incritical care, with staffing based on the specific needs of the patients and provider competencies, as well asorganizational priorities. (Level of Evidence: C)




Class III

It is not an effective use of the CCU

environment to admit terminally ill, “do notresuscitate” patients with STEMI, because

clinical and comfort needs can be provided

outside of a critical care environment.(Level of Evidence: C)



Hospital Management: Stepdown

Class I

It is a useful triage strategy to admit low-risk STEMIpatients who have undergone successful PCI directly to the

stepdown unit for post PCI care rather than to the CCU.(Level of Evidence: C)

STEMI patients originally admitted to the CCU who

demonstrate 12-24 hours of clinical stability (absence of recurrent ischemia, heart failure, or hemodynamicallycompromising dysrhythmias) should be transferred to thestepdown unit. (Level of Evidence: C)




Class IIa

It is reasonable for patients recovering from STEMI whohave clinically symptomatic heart failure to be managed onthe stepdown unit, provided that facilities for continuousmonitoring of pulse oximetry and appropriately skillednurses are available. (Level of Evidence: C)

It is reasonable for patients recovering from STEMI who

have arrhythmias that are well tolerated (AFIB, NSVT) tobe managed on the stepdown unit, provided that facilitiesfor continuous monitoring of the ECG, defibrillators, andappropriately skilled nurses are available. (Level of Evidence: C)




Class IIb

Patients recovering from STEMI who have clinically

significant pulmonary disease requiring high flowsupplemental oxygen or non-invasive mask

ventilation/BiPAP/CPAP may be considered for care on a

stepdown unit, provided that facilities for continuous

monitoring of pulse oximetry and appropriately skillednurses with a sufficient nurse:patient ratio are available.

(Level of Evidence: C)



Summary

• Targeted History

• Physical (include neuro)

• ECG (RV, Posterior)

• Lab

• CXR

• O2

• Nitrates

• MSO4

• ASA

• Beta Blockers

• Select ReperfusionStrategy

• UFH/LMWH

• Thienopyridines• GPIIb/IIIa

• ACE-I

• Glucose Control

• Magnesium• CCB

• CCU/Stepdown



PCI FibrinolysisAdvantages Superior patency rate Widely available

Reduced Mortality,

RI, MI

Operator experience

Less ICH Prompt on site

Lower early mortality Simple to give a bolus

Superior in CG shock

Probably superior tofibrinolysis overall

Disadvantages Expertise required Systemic bleeding

Limited access / time ICH

Summary

accaha guidelines for the management of patients with st1510

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