acc/aha guidelines for the management of patients with stemi--2004 presenter: r5 李政翰 r5...

ACC/AHA Guidelines for the Management of Patients With

STEMI--2004

Presenter: R5 李政翰 R5 李威廷

Circulation 2004;110:588-636

Management before STEMI

A. Identification of patients at risk of STEMI

Class I

1. Every 3-5 years, evaluate major risk factors

2. For ≧2 risk factors, calculate 10-year risk of CHD

3. For CHD risk equivalent (DM, CRI, or 10-year risk>20%), intensive risk intervention as CHD

Management before STEMI

B. Education for early recognition and response to STEMI

Class I

1. Patients with symptoms of ACS taken to ER by ambulance rather than by relatives

2. If NTG 1#SL does not relieve chest pain, recommend call EMS

<note> NTG--->NTG--->NTG--->EMS in 1999 guideline

Onset of STEMI

A. Out-of-hospital cardiac arrest

Class I

1. Early activation of EMS, early CPR, early defibrillation and early ACLS

2. For families of patients experiencing STEMI, they should take CPR training and familiarize AED

Prehospital Issues A. Emergency Medical Services Systems Class I EMS equipped to provide early defibrillation Public safety AEDS B. Prehospital Chest Pain Evaluation and Treatment Class I EMS give 162—325mg aspirin to suspecting ACS

Class IIa 9-1-1 dispatcher advice 162—325mg aspirin to suspecting ACS while waiting EMS ACLS provider perform 12-lead ECG ACLS provider review reperfusion checklists

Prehospital Fribrinolysis

Class IIa

under 1) physicians are in ambulance

2) well-organized EMS

(training in ECG reading, STEMI

treatment)

Prehospital destination Protocols

Class I1. STEMI/Killip IV and ≤75 y/o transfer to PCI and

CABG facilities if within 18hrs of shock2. STEMI with contraindications to thrombolysis tra

nsfer to PCI and CABG facilities (<30 mins departure)

Class IIa

1. STEMI/Killip IV and >75 y/o transfer to PCI and CABG facilities if within 18hrs of shock

2. STEMI with severe CHFtransfer to PCI and CABG facilities (<30 mins departure)

Initial Recognition and Management in the ED

A. Optimal strategiesClass I- establish protocol for STEMIB. Initial evaluationClass I Door to fibrinolysis <30 mins Door to balloon < 90 mins2. The choice of initial STEMI treatment ER physi

cian based on CV specialtist protocol

History

Class I

acquire whether the patient had prior stable, unstable angina, MI, CABG or PCI, CAD risk factors, possibility of aortic dissection, risk of bleeding and CNS disease

Physical Examination

Class I

1. Evaluate the extent, location and complications of STEMI

2. A brief NE for evidence of new or old neurologic deficits

ECG

Class I

1. ECG within 10 mins

2. Symptomatic non-diagnostic ECG serial ECG q5-10 mins follow-ups

3. Inferior STEMI, do right side ECG to rule out RV infarction

Laboratory Examinations

Class I1. Should be performed but should not delay the use of rep

erfusion therapyBiomarkers of cardiac damageClass I1. Troponins should be used for coexistent skeletal muscle i

njuryClass IIa

1. Serial biomarker can be used to evaluate the reperfusion after fibrinolysis within first 24 hrs

Class III1. Serial biomarkers should not be used to diagnose reinfar

ction within 18 hrs after STEMI

Imaging

Class I1. Portable chest x-ray, but do not delay reperfusion therap

y2. Portable chest x-ray, TTE or TEE, and contrast CT shoul

d be used to rule out aortic dissectionClass IIa

1. TTE to clarify the diagnosis of STEMI and risk stratification of patients with chest pain especially with LBBB or pacing or suspect posterior STEMI with anterior ST depression

Class III1. SPECT should not be performed under the diagnosis of

STEMI is evident on ECG

Management Oxygen Class I O2 supply when SaO2<90% Class IIa O2 supply to all patients with uncomplicated STEMI during the first 6 hrs NTG Class I 1. NTG (0.4mg) sublingual per 5 mins for total 3 doses, after which give IV form2. IV NTG ongoing chest pain, control HTN or pulmonary edema

Class III1. SBP<90mmHg or ≥30mmHg below baseline, HR

<50/min or >100/min or suspected RV infarction2. Take phosphodiesterase inhibitor within the last 24 hrs

(48hrs for tadalafil)

Management

Analgesia

Class I morphine (2-4mg with increments of 2-8mg per 5-15 mins) for chest pain

Aspirin

Class I 162-325mg be chewed for who have not taken it before STEMI

Management

B-blockers

Class I promptly given without contraindication irrespective of fibrinolysis or primary PCI

Class IIa IV form promptly to STEMI patients without contraindication, especially tachyarrhythmia or HTN

Reperfusion

Selection of reperfusion strategy Time from onset of symptoms1. Fibrinolytic therapy administered within the first 2

hours (especially the first hour) can occasionally abort MI and dramatically reduce mortality

2. Several reports claim no influence of time delay on mortality rates when PCI is performed after 2 to 3 hours of symptom duration

3. a target of medical contact–to-balloon or door-to-balloon time within 90 minutes

Reperfusion

Risk of STEMI mortality with fibrinolysis is extremely high, a

s cardiogenic shock, favors a PCI strategy

Risk of bleeding the higher the patient’s risk of bleeding with f

ibrinolytic therapy, the more strongly the decision should favor PCI

Reperfusion

Time required for transport to skilled PCI If time delay for PCI > 60mins than immediat

e fibrinolysis, no extra benefit of primary

Determine whether fibrinolysis or primary PCI is preferred

If onset < 3hrs, there is no preferrence. Prefer fibrinolysis if1. Early onset (<3 hrs) and delay to primary P

CI2. Primary PCI is unavailable, vascular acces

s difficulties, lack of skilled PCI lab.3. Delay to primary PCI prolonged transpor

t, TPCI-Tfibrinolysis>1 hr, door-to-balloon > 90mins

Skilled lab operator: >75 primary PCI per year; team experience>36 PCI per year

Determine whether fibrinolysis or primary PCI is preferred

Primary PCI is preferred if1. Skilled PCI Lab available with surgical bac

k-up2. High risk Killip ≥33. Contraindications to fibrinolysis, include inc

reased risk of bleeding and ICH4. Late presentation > 3hrs5. Diagnosis of STEMI is in doubt

Lancet 2003;361:13-20

Absolute contraindications of fibrinolysis

Any prior ICH Known structural cerebral vascular lesion Known malignant intracranial neoplasm (primary or metastatic) Ischemic stroke within 3 months EXCEPT acute ischemic stroke within 3 hours Suspected aortic dissection Active bleeding or bleeding diathesis (excluding menses) Significant closed head or facial trauma within 3 months

Relative contraindications of fibrinolysis

History of chronic severe, poorly controlled hypertension Severe uncontrolled hypertension on presentation (> 180/110mmHg) History of prior ischemic stroke greater than 3 months, dementia,

or known intracranial pathology not covered in contraindications Traumatic or prolonged (greater than 10 minutes) CPR or major surger

y (less than 3 weeks) Recent (within 2 to 4 weeks) internal bleeding Noncompressible vascular punctures For streptokinase/anistreplase: prior exposure (more than 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

Indications for fibrinolysis

Class I1. Onset< 12hrs, ST elevation> 0.1mv in at least 2 contiguo

us precordial leads or at least 2 adjacent limb leads or new LBBB and no contraindications.

Class IIa

1. Onset< 12hrs, no contraindications with posterior MI ECG change

2. Onset 12-24 hrs, ongoing chest pain with ST elevation> 0.1mv in at least 2 contiguous precordial leads or at least 2 adjacent limb leads and no contraindications

Class III1. Asymptomatic patients with onset >24hrs2. ST depression except posterior MI

Complications of fibrinolysis

Class I1. Conscious change during or after reperfusi

on, particularly within 24 hrs after therapy stop antiplatelete, fribrinolysis and anticoagulant until brain imaging

2. Consult neurologiest or neurosurgeon when suspecting ICH

3. If ICH (+), give cryo, FFP, protamine and platelets

Complications of fibrinolysis

Class IIa

In patients with ICH optimize BP and sugar, reduce IICP with mannitol, hyperventilation and consider neurosurgical evacuation.

Combination therapy with Gp IIb/IIIa inhibitor

Class IIb

1. If patients with anterior MI, <75yrs and no risk of bleeding, half dose of reteplase or tenecteplase with abciximab may prevent reinfarction; however, no survival benefit at either 30 days or 1 year

2. If patients with anterior MI, <75yrs and no risk of bleeding, half dose of reteplase or tenecteplase with abciximab were given for early referral for primary PCI

Class III

combination therapy is given to age >75ys

PCI

Coronary angiographyClass I1. Candidates for primary PCI or rescue PCI2. Cardiogenic shock who are candidates for revasculizatio

n3. Candidates for surgical repair of VSD or severe MR relat

ed AMI4. Persistent hemodynamic or electrical instabilityClass IIIExtensive comorbidities in which risk outweighbenefit

Primary PCI

Class I1. General considerations: primary PCI

should be performed in patients with STEMI within 12 hours, (balloon inflation within 90 minutes of presentation) by persons skilled in the procedure

Primary PCI Class I2. Specific considerations:

a. door-to-balloon time of within 90 minutes.

b. If symptom within 3 hours and the expected door-to-balloon time minus the expected door-to-needle time is: i) within 1 hour, primary PCI is generally preferred.

ii) greater than 1 hour, favor fibrinolytic therapy (fibrin-specific agents) c. If symptom duration is greater than 3 hours, primary PCI is generally prefe

rred.

d. Primary PCI for patients < 75 yrs who develop shock within 36 hours of MI and are suitable for revascularization that can be performed within 18 hours of shock.

e. Patients with at least Killip III and onset of symptoms within 12 hours.

Primary PCI

Class IIa 1. Primary PCI for selected patients >75 yrs who develop shoc

k within 36 hours of MI and revascularization that can be performed within 18 hours of shock. Patients with good prior functional status who are suitable for revascularization.

2. 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:

a. Severe CHF

b. Hemodynamic or electrical instability c. Persistent ischemic symptoms.

“SHOCK” trial absolute 9% reduction in mortality with primary PCI

Primary PCI Class IIb The benefit of primary PCI eligible for fibrinolysis is not well est

ablished when performed by an operator who performs fewer than 75 PCI procedures per year.

Class III

PCI should not be performed in a noninfarct artery at the time of primary PCI in patients without hemodynamic compromise.

Primary PCI should not be performed in asymptomatic patients more than 12 hours after onset of STEMI if they are hemodynamically and electrically stable.

The goal of the interventional cardiologists

1. Door-to-balloon times less than 90 minutes

2. TIMI 2/3 flow rates obtained in more than 90% of patients

3. Emergency CABG rate less than 2%

4. Actual performance of PCI in a high percentage of patients (85%) brought to the laboratory

5. Risk-adjusted in-hospital mortality rate less than 7% in patients without cardiogenic shock

Primary PCI in fibrinolyitc-ineligible patients

Class I: onset s/s < 12 hours Class IIa: onset s/s 12--24 hours and

CHF

Hemodynamic instability

Persistent ischemic s/s

Primary PCI without CVS back-up

Class IIb: STEMI / new LBBB

rapid transport to OR

door-to-balloon time < 90 minutes

operator > 75 PCIs per year

hospital > 36 primary PCIs per year

(direct transport the patient to the CPI centers)

Class III: others

Facilitated PCI

Class IIb: PCI is not available in the first time

receiving initial pharmacological Tx

bleeding risk is low

(facilitated PCI: planned immediate PCI after an initial pharmacological regimen)

(increase bleeding in >75y/o, and added cost)

Rescue PCI

Class I: < 75 y/o develop shock within MI 36 hours revascularization within 18 hours of shock

Class I: Killip III s/s onset <12 hours

(Rescue PCI: PCI within 12 hours after failed fibrinolysis for patients with continuing or recurrent myocardial ischemia)

Rescue PCI

Class IIa: > 75 y/o

develop shock within MI 36 hours

revascularization within 18 hours of shock

hemodynamic or electrical instability

persistent ischemic s/s

PCI for cardiogenic shock

Class I: < 75 y/o



(level of evidence: A)

Class IIa: > 75 y/o



PCI after fibrinolysis

Class I: recurrent MI post –AMI angina cardiogenic shock, unstable hemodynamics Class IIa: CHF LVEF <40% serious ventricular arrhythmias Calss IIb: routine PCI after fibrinolysis

(no benefit of routine PCI immediate after fibrinolytic therapy)(not salvage myocardium, not improve LV, not prevent

re-infarction, not prevent death)(increase adverse events)

Acute surgical intervention (CABG)

Class I: failed PCI with persistent pain or unstable hemodynamics

persistent or recurrent or refractory ischemia and contra-

incandicated for PCI or fibrinolytic therapy

surgical repair of post-MI ventricular septal rupture or

mitral insufficiency

life-threatening ventricular arrhythmia and L’t main / 3-V-D

<75 y/o, Lt’ main or multi-vessels, shock <36h MI, and

surgery < 18h shock onset (level of evidence: A)

Acute surgical intervention (CABG)

Class IIa: >75 y/o, Lt’ main or multi-vessels, shock

<36h post-MI, and surgery < 18h

shock-onset

<6—12 hour onset, not candidate for PCI

or fibrinolysis

(especially L’t main or multi-vessels)

Class III: persistent angina but hemodynamic stable

or successful epicardial reperfusion but

unsuccessful microvascular reperfusion

Assessment of reperfusion

Class IIa:

monitor rhythm ST elevation, rhythm, and s/s over 60—180 minutes after initial fibrinolytic therapy

relief s/s, stable hemodynamics, reduction of at least 50% of the initial ST elevation means successful noninvasive evaluation of reperfusion

Heparin

Class I: perform PCI or CABG combine thrombolytic therapy (streptokinase: IIb) combine thrombolytic therapy at high risk for systemic emboli (large or anterior MI, Af, previous embolus, known LV embolus) (streptokinase: IIa)

60U/kg bolus (<= 4000U), then 12U/kg/hour (<= 1000U)

keep APTT: 1.5—2.0X (50—70s), and follow PLT count qd Class IIb: for DVT prophylaxis (7500—12500U bid)

Low-Molecular-Weight Heparin (LMWH)

Class IIb: <75y/o, receiving fibrinolytic therapy

(especially )

Cr < 2.5 in male and <2.0 in female (Enoxaparin 30mg bolus, then 1.0mg/kg q12h s.c. till discharge)

prophylaxis for DVT Class III: >75y/o, receiving fibrinolytic therapy

<75y/o, but with poor renal function

Direct anti-thrombins (bivalirudin)

Heparin-induced thrombocytopenia Combine Streptokinase Class IIa: 0.25mg/kg bolus

then 0.5mg/kg for 12 hours

then 0.25mg/kg for 36 hours

(reduction of the infusion rate in the first 12 hours if APTT >75s)

Aspirin

Class I: 162—325mg bolus,

75—162mg maintain dose


Thienpyridines (Plavix)

Class I: 1-month for bare stent

3-month for Sirolimus (Cypher)

6-month for Taclitaxel (Taxus)

stop 5—7 days before CABG

Class IIa: aspirin intolerance

Glycoprotein IIb/IIIa inhibitors

Class IIa: abciximab in primary PCI

(level of evidence: B)

Class IIb: tirofiban (Aggrastat) in promary PCI

cetifibatide in primary PCI

(level of evidence: C)

Beta-blocker

Class I: within 24 hours without adverse effects

start in early convalescent phase if

no use in the first 24 hours


re-evaluate in the patients with contra-

indicated in the first 24 hours

(level of evidence: C)

Nitroglycerin

Class I: <48 hours on persistent ischemia, CHF,

or hypertension

>48 hour on recurrent angina, CHF Class IIb: >24—48 hours without s/s

Class III: hypotension, severe bradycardia,

tachycardia, or RV infarction

ACEI & ARB

Class I: < 24 hours

anterior infarction, pulmonary congestion,

LVEF<0.4 without hypotension

Long-term use if no significant renal diseases

(Cr<2.5 in men and Cr<2.0 in women)


ARB for ACEI intolerance (Diovan, Blopress) (SBP <100mmHg or >30mmHg below baseline)

ACEI & ARB

Class IIa: no LVEF<0.4, no anterior infarction,

no pulmonary congestion

(Valsartan, Candesartan)

Class III: intravensou ACEI in the first 24 hours

Metabolic modulation of the glucose-insulin axis

Class I: insulin infusion in complicated course

Class IIa: uncomplicated, only hyperglycemia

control sugar after acute phase

Magnesium

Class IIa: correct hypomagnesemia (esp in diuretics)

torsade de pointes-type VT with long-QT

with trying 1-2g, bolus over 5 minutes

Class III: give Mg without the above condition

Calcium channel blocker

Class IIa: Verapamil / Dildiazed in beta-blocker

ineffective or contraindication

no CHF, no low LVEF, no AV block

Class III: Verapamil / Dildiazed in LV dysfunction

Nifedipine (immediate-release form) is

contraindicated

Hospital management

EKG, pulse oximeter, hemodynamic monitor Aspirin,, beta-blocker, or nitroglycerin Oxygenation for at least 6 hours to keep SpO2 >90

% Monitor to detect ST deviation, axis shift, conductio

n defect, and dysrhythmias Admission to step-down unit when low risk STEMI s

/p successful PCI Transfer to step-down unit after 12—24 hour stabilit

y at CCU course

Hospital management

IIa: beside activity after 12-24 hours on hymodynamic instability patients

III: beside activity after 12-24 hours on symptoms/ signs free patients

Analgesia / anxiolytics: IIa

Estimate for infarction size

EKG: at 24 hours and at discharge

CK / CKMB Radionucleotide image Echocardiography MRI

Hemodynamic Disturbances

1. Hemodynamic AssessmentClass I PA catheter monitoring for A. progressive hypotension, when unreponsive t

o fluid or contraindication of fluid supply B. Suspected mechanical complications ( VSR, p

apillary muscle rupture, or free wall rupture with pericardial tamponade) if unavailable echocardiogram


Class I

A-line monitoring Hypotension (SBP<80mmHg) Receiving vasopressor/inotropic agents Cardiogenic shock


Class IIa

1. PA catheter monitoring: A. hypotension without pul. Congestion and unresponsive to initial

fluid B. Cardiogenic shock C. Severe CHF or pul. Edema that do not respond rapidly to therapy D. Persistent signs of hypoperfusion without hypotension or pul congestion E. receiving vasopressor/inotropic agents

2. A-line monitoring receiving IV nitroprusside or other potent vasodilator


Class IIb

A-line monitoring might be considered in patients receiving

intravenous inotropic agents

Class III1. PA catheter not recommended without evidence of hemo

dynamic instability or respiratory compromise

2. A-line not recommended without pulmonary congestion and have adequate tissue perfusion without use of circulatory support measures

Hypotension

Class I1. Rapid volume loading administered without clinical evidence for

volume overload.

2. Correct rhythm disturbances or conduction abnormalities

3. IABP performed not respond to other interventions

4. Vasopressor support for hypotension that does not resolve after volume loading.

5. Echocardiography evaluate mechanical complications unless these are assessed by invasive measures.

Low-Output State

Class I1. Echocardiography for LV function and mechanical complication if these hav

e not been evaluated by invasive measures

2. Recommended treatments for low-output states include:

A. Inotropic support

B. Intra-aortic counterpulsation

C. Mechanical reperfusion with PCI or CABG

D. Surgical correction of mechanical complications

Class III1. BB or CCB should not be administered to patients in a low-output state due to pu

mp failure.

Pulmonary Congestion

Class I1. O2 for SaO2>90% with pulmonary congestion

2. Morphine for pulmonary congestion

3. ACE inhibitors, beginning with titration of a short-acting ACE inhibitor with a low initial dose unless SBP< 100 mm Hg or more than 30 mm Hg below baseline. Pulmonary congestion and marginal or low blood pressure often need inotropic and vasopressor agents and/or IABP

4. Nitrates for pulmonary congestion unless the SBP< 100 mm Hg or more than 30 mm Hg below baseline.


Class I5 Diuretic for pulmonary congestion if there is volume overload.

Caution is advised for patients who have not received volume expansion

6. Beta-blockade should be initiated before discharge for secondary prevention. For active heart failure, low doses should be initiated, with gradual titration on an outpatient basis.

7. Long-term aldosterone blockade for post-STEMI without significant renal dysfunction (creatinine <= 2.5 mg/dL in men and <= 2.0 in women) or hyperkalemia (K<= 5.0 mEq/L) already receiving ACE inhibitor, have an LVEF<= 0.40, and have either symptomatic heart failure or diabetes

8. Echocardiography urgently to estimate LV and RV function and exclude a mechanical complication


Class IIb

IABP for refractory pulmonary congestion

Class III

BB or CCB should not be administered acutely to STEMI patients with frank cardiac failure or signs of a low-output state.

Cardiogenic Shock

Class I1. IABP for cardiogenic shock is not quickly reversed with pharma

cological therapy. The IABP is a stabilizing measure for angiography and prompt revascularization

2. A-line for cardiogenic shock

3. Early revascularization, either PCI or CABG, for < 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

4. Fibrinolytic therapy for cardiogenic shock who are unsuitable for further invasive care and no contraindications to fibrinolysis

5. Echocardiography should be used to evaluate mechanical complications unless these are assessed by invasive measure

Cardiogenic Shock

Class IIa1. PA catheter monitoring for cardiogenic shock

2. Early revascularization, either PCI or CABG, is reasonable for >= 75 years who develop shock within 36 hours of MI and are suitable for revascularization that can be performed within 18 hours of shock. Patients with good prior functional status who agree to invasive care may be selected for such an invasive strategy

RV Infarction Class I1. Inferior STEMI and hemodynamic compromise shoul

d be assessed with a right precordial V4R lead and an echocardiogram2. The following principles for STEMI and RV infar

ction and ischemic dysfunction:

Early reperfusion Achieve AV synchrony and correct bradycardia

Optimize RV preload Optimize RV afterload

Inotropic support for hemodynamic instability not responsive to fluid

Class IIaReasonable to delay CABG surgery for 4 weeks

Mechanical Causes of CHF/Low-output Syndrome

the presence of a new cardiac murmur

indicates the possibility of either a VSR or MR

Mitral regurgitationClass I1. Acute papillary muscle rupture should be considered

for urgent cardiac surgical repair2. CABG surgery should be undertaken at the same

time as mitral valve surgery


Ventricular septal rupture after STEMI

Class I

1. Urgent surgical repair

2. CABG at the same time


LV free wall rupture

Class I

1. Urgent surgical repair

2. CABG at the same time


LV aneurysm

Class IIa

If associated with intractable VT/Vf and/or

pump failure which unresponsive to medical

and catheter-based therapy, consider

aneurectomy and CABG


IABP Class I1. Hypotension (SBP< 90 mm Hg or 30 mm Hg below ba

seline) who do not respond to other interventions

2. Low-output state

3. Cardiogenic shock is not quickly reversed with pharmacological therapy. IABP is a stabilizing measure for angiography and prompt revascularization

4. Recurrent angina and signs of hemodynamic instability, poor LV function, or a large area of myocardium at risk

IABP

Class IIa

Refractory polymorphic VT Class IIb

Refractory pulmonary congestion

Arrhythmias after STEMI VfClass I

VF or pulseless VT unsynchronized electric shock with an initial monophasic shock energy of 200 J 200 to 300 J 360 J

Class IIa amiodarone (300 mg or 5 mg/kg, IV bolus) followed by a repeat unsynch

ronized electric shock. For refractory eletrical shock

Keep potassium >4.0 mEq/L and magnesium > 2.0 mg/dL)

Class IIb

boluses of intravenous procainamide for refractory eletrical shock

Class III Prophylactic administration of antiarrhythmic therapy

VT Class I

1 Sustained polymorphic VT or hemodynamic collapse unsynchronized shock with 200 J 200 to 300 J 360 J.

2. Sustained monomorphic VT associated with angina, pulmonary edema, or hypotension (blood pressure less than 90 mm Hg) synchronized electric shock of 100 J

3. Sustained monomorphic VT not associated with angina, pulmonary edema, or hypotension :

a. Amiodarone: 150 mg infused over 10 minutes (alternative dose 5 mg/kg); repeat 150 mg every 10 to 15 minutes as needed. Alternative infusion: 360 mg over 6 hours (1 mg/min), then 540 mg over the next 18 hours (0.5 mg/min). The total cumulative dose, including additional doses given during cardiac arrest, must not exceed 2.2 g over 24 hours

b. Synchronized electrical cardioversion 50 J

Class IIa 1. It is reasonable to manage refractory polymorphic VT by:

a. Reduce myocardial ischemia and adrenergic stimulation, including therapies such as beta-adrenoceptor blockade, IABP use, and consideration of emergency PCI/CABG surgery

b. potassium to greater than 4.0 mEq/L and of magnesium to greater than 2.0 mg/dL.

c. bradycardia to HR< 60/min or long QTc, temporary pacing at a higher rate may be instituted

VT Class IIb

1. sustained monomorphic VT not associated with angina, pulmonary edema, or hypotension (blood pressure less than 90 mm Hg) with a procainamide bolus and infusion.

Class III

1. routine prophylactic antiarrhythmic drugs for VPCs, couplets, runs of AIVR, or nonsustained VT

2. routine prophylactic antiarrhythmic therapy when fibrinolytic agents are administered

VPCs

Class III Treatment of isolated ventricular prematur

e beats, couplets, and nonsustained VT is not recommended unless they lead to hemodynamic compromise

AIVR and accelerated junctional rhythm

Class IIIAntiarrhythmic therapy is not indicated for AIVR and accelerated junctional rhythm

ICD for post-STEMI Class I

1. VF or hemodynamically significant sustained VT more than 2 days after STEMI, provided the arrhythmia is not judged to be due to transient or reversible ischemia or reinfarction

2. patients without spontaneous VF or sustained VT more than 48 hours after STEMI whose STEMI occurred at least 1 month previously, who have an LVEF between 0.31 and 0.40, demonstrate additional evidence of electrical instability (eg, nonsustained VT), and have inducible VF or sustained VT on electrophysiological testing

Class IIa

1. If there is reduced LVEF (0.30 or less), at least 1 month after STEMI and 3 months after

coronary artery revascularization, it is reasonable to implant an ICD in post STEMI patients without spontaneous VF or sustained VT more than 48 hours after STEMI.

ICD for post-STEMI

Class IIb

1. not well established in STEMI patients without spontaneous VF or sustained VT more than 48 hours after STEMI who have a reduced LVEF (0.31 to 0.40) at least 1 month after STEMI but who have no additional evidence of electrical instability (eg, nonsustained VT).

2. not well established in STEMI patients without spontaneous VF or sustained VT more than 48 hours after STEMI who have a reduced LVEF (0.31 to 0.40) at least 1 month after STEMI and additional evidence of electrical instability (eg, nonsustained VT) but who do not have inducible VF or sustained VT on electrophysiological testing

Class III

1. not indicated in STEMI patients who do not experience spontaneous VF or sustained VT more than 48 hours after STEMI and in whom the LVEF is greater than 0.40 at least 1 month after STEMI

Supraventricular arrhythmias/Af

Class ISustained Af/AF with hemodynamic compromise or ongoing ischemia:

a. Synchronized cardioversion with an initial monophasic shock of 200 J for

atrial fibrillation and 50 J for flutter

b. Af that do not respond to electrical cardioversion or recur after a brief period of sinus rhythm

i. Intravenous amiodarone.

ii. Intravenous digoxin for rate control principally for patients with severe LV dysfunction and heart failure.


Class ISustained Af/AF with ongoing ischemia but without hemodynamic co

mpromise

a. Beta-adrenergic blockade is preferred, unless contraindicated.

b. Intravenous diltiazem or verapamil.

c. Synchronized cardioversion with an initial monophasic shock of 200 J for atrial fibrillation and 50 J for flutter

3. For sustained Af/AF without hemodynamic compromise or ischemia, rate control is indicated. anticoagulant therapy. Consideration of cardioversion to sinus rhythm with a history of Af or AF prior to STEMI


Class IReentrant paroxysmal supraventricular tachycardia should be treated with the following in the sequence shown:

a. Carotid sinus massage. b. Intravenous adenosine (6 mg 12 mg 12mg c. Intravenous metoprolol (2.5 to 5.0 mg every 2 to 5 minutes to a total of 15 mg over 10 to 15 minutes) or atenolol (2.5 to 5.0 mg over 2 minutes to a total of 10 mg in 10 to 15 minutes). d. Intravenous diltiazem (20 mg [0.25 mg/kg]) over 2 minutes followed by an infusion of 10 mg/h) e. Intravenous digoxin( a delay of at least 1 hour before effects appear) (8 to 15 mcg/kg [0.6 to 1.0 mg in a person weighing 70 kg])

Class III Treatment of APCs is not indicated

Bradyarrhythmia

Ventricular asystole

Class I

Prompt resuscitative measures, including

chest compressions, atropine, vasopressin,

epinephrine, and temporary pacing

The requirement for temporary pacing in STEMI does not by itself constitute an indication

for permanent pacing

Use of permanent pacemaker

Class I persistent 2nd AV block in the His-Purkinje syste

m with bilateral BBB or 3rd AV block within or below the His-Purkinje system after STEMI.

transient advanced 2nd or 3rd infranodal AV block and associated BBB. If the site of block is uncertain, an EPS may be necessary.

persistent and symptomatic 2nd or 3rd AV block

Use of permanent pacemaker Class IIb

persistent 2nd or 3rd AV block at the AV node level.

Class III

not recommended for transient AV block in the absence of IVCD

not recommended for transient AV block in the presence of isolated LAFB

is not recommended for acquired LAFB in the absence of AV block

not recommended for persistent 1st AV block in the presence of BBB that is old or of indeterminate age.

Sinus node dysfunction after STEMI

Class ISymptomatic sinus bradycardia, sinus pauses greater than 3 seconds, or sinus bradycardia with a heart rate less than 40 bpm and associated hypotension or signs of systemic hemodynamic compromise atropine 0.6 to 1.0 mg. If bradycardia is persistent and maximal (2 mg) doses of atropine have been used, transcutaneous or transvenous (preferably atrial) temporary pacing should be instituted

Pacing mode selection in STEMI

Class I indication for permanent pacing after STEMI shoul

d be evaluated for ICD indications.

Class IIa

implant a permanent dual-chamber pacing system in STEMI patients who need permanent pacing and are in sinus rhythm. patients in permanent atrial fibrillation or flutter receive a single-chamber ventricular device.

evaluate all patients who have an indication for permanent pacing after STEMI for CRT

Recurrent chest pain after STEMI Pericarditis

Class I Aspirin as high as 650 mg orally (enteric) every 4 to 6 hours may

be needed.

Anticoagulation should be immediately discontinued if pericardial effusion develops or increases.

Class IIa

not adequately controlled with aspirin, administer 1 or more of the following: a. Colchicine 0.6 mg q12h. b. Acetaminophen 500 mg q6h

Class IIb

NSAIDs should not be used for extended periods because of their continuous effect on platelet function, an increased risk of myocardial scar thinning, and infarct expansion.

Corticosteroids a last resort refractory to aspirin or nonsteroidal drugs. associated with an increased risk of scar thinning and myocardial rupture

Class III

Ibuprofen should not be used for pain relief

Recurrent ischemia/infarction Class I

nitrates and beta-blockers . anticoagulation if not already accomplished.

signs of hemodynamic instability, poor LV function, or a large area of myocardium at risk urgently for revascularization as needed. Insertion of an IABP should also be considered.

candidates for revascularization should undergo PCI or CABG as dictated by coronary anatomy.

Class IIa

readminister fibrinolytic therapy with recurrent ST elevation not considered candidates for revascularization or for whom coronary angiography and PCI cannot be rapidly (ideally within 60 minutes from the onset of recurrent discomfort) implemented.

Class III

Streptokinase should not be given who received a non–fibrin-specific fibrinolytic agent more than 5 days previously

Tea time

Other complications – ischemic stroke

Class I: consult neurologist

cardiac echo, neuroimaging, vascular image

Warfarin (APTT-INR= 2-3x ) in Af patients

Warfarin (APTT-INR= 2-3x ) in suspect

embolism patients (LV mural thrombus

or akinetic segment: 3 months; persistent

Af: indefinitely)

Other complications – ischemic stroke

Class IIa: supportive care in non-fatal acute ischemic

stroke to minimize complications

Class IIb: carotid angioplasty / stenting

STEMI with high surgical risk

Acute stroke due to carotid a. > 50% stenosis

perform 4—6 weeks after stroke

Other complications – DVT and pulmonary embolism

Class IIa: full-dose LMWH >= 5 days,

low dose heparin prophylaxis (prefer

LMWH): in prolonged hospitalization,

unable to ambulate, high risk groups)

Warfarin (PT-INR= 2-3x)

CABG after STEMI: timing

Class IIa: increased in the first 3-7 days

benefit vs. risk

CABG after STEMI: arterial grafting

Class I: internal mammary artery graft in

significant LAD lesions

CABG after STEMI: recurrent ischemia

Class I: urgent CABG when the anatomy is

unsuitable for PCI

CABG after STEMI: elective

Class I: significant L’t main with stable angina

equivalent L’t main, significant LAD-P,

significant LCX-P with stable angina

3-V-D with stable angina (esp. LVEF<50%)

1- or 2-V-D with high risk group or large

viable tissue under perfusion image

2-V-D, significant LAD-P, LVEF <50%,

with stable angina

CABG after STEMI: antiplatelet agents

Class I: aspirin should not be withheld before op

aspirin use as soon as possible after op

(75—325mg qd)

Plavix should be withheld 5—7 days

before op

Exercise testing

Class I: refuse cath, high risk group

echocardiography or myocardial perfusion

image for the baseline abnormalities that

compromise EKG interpretation

Class IIb: evaluate coronary function after cath Class III: within MI 2-3 days without successful

reperfusion

post-MI angina, decompensated CHF, life-

threatening arrhythmia, exercise limiting

patient agree cath

Echocardiography

Class I: evaluate LV in patients refusing cath

(especially unstable hemodynamic)

inferior wall MI and suspect RV invlove

post-MI complications (MR, cardiogenic

shock, VSR, intracardiac thrombus,

pericardioal effusion)

stress cardioechography

Echocardiography

Class IIa: re-evaluate LVEF during recovery

Dobutamine echocardiography (or perfusion)

for 4 or more days after AMI to define

revascularzation efficacy

assess LVEF after revascularzation without

contrast echocardiography Class III: re-evaluate LV in patients without clinical

revascularzation (30—90 days is better)

Myocardial perfusion image

Class I: induce ischemia in patients refusing cath

and unable to exercise (persantin or

adenosine) Class IIa: for 4 or more days after AMI to define

revascularzation efficacy

Invasive evaluation

Class I: post-MI angina

intermediate or high-risk in non-invasive

testing

stable condition before definite therapy of

mechanical complications

persistent unstable hemodynamics

transient heart failure with recovered LV

Invasive evaluation

Class IIa: not thrombotic AMI,

routine in DM, LVEF<40%, CHF, prior

revascularization, life-threatening

ventricular arrhythmia Class IIb: routine Class III: not candidate in PCI

Assessment of ventricular arrhythmia

Class IIb: EKG monitor, Holter, heart-rate

variability, T-wave variability

Secondary prevention: education

Class I: lifestyle

NTG

119 if angina progression or no improve 5

minutes after NTG 1# sl use

AED, CPR

Secondary prevention: lipid management

Class I: low saturated fat (<7% total calories)

cholesterol (<200mg/d)

fasted, within 24-hour admission

statin use in LDL>100 mg/dL

non-pharmacological Tx in non-HDL>130

and HDL<40 Class IIa: statin in non-HDL>130

statin in LDL<100, non-HDL>130, HDL>40

niacin or fibrate in trigleceride >500 (goal:

non-HDL<130)

Secondary prevention: weight management

Class I: body mass index: from 18.5 to 24.9 kg/m2

evaluate metabolic syndrome in

M>40 in. waist circumstance or

F>35 in. waist circumstance

physical activity + cardiac rehabilitation

Secondary prevention: smoking cessation

Class I: avoid secondhand smoke

assess for history of smoking in all patients

Secondary prevention: antipletelet agents

Class I: aspirin 75—162mg qd

Plavix 75mg qd or Ticlopidine 250mg bid

in aspirin allergy

Warfarin (INR: 2.5—3.5x) in <75y/o,

low bleeding risk, aspirin allergy Class III: ibuprofen because it blocks the

antiplatelet effects of aspirin

Secondary prevention: ACEI and ARB

Class I: all patients at discharge P’t without significant renal dysfunction or

hyperkalemia, LVEF<40%, CHF, DM

long-term use

valsartan or candesartan in ACEI intolerance

Class IIa: direct ARB use in ACEI tolerance Class IIb: ACEI + ARB in symptomatic CHF and

LVEF<40%

Secondary prevention: beta-blocker

Class I: all patients except low risk (normal LVEF,

successful reperfusion, absence of

significant ventricular arrhythmia) or

contraindication

titrate dose in moderate or severe CHF Class IIa: low risk patients without contraindication

Secondary prevention: BP control

Class I: 140/90 and 130/80 (DM, chronic kidney

disease)

lifestyle modification Class IIb: 120/80mmHg Class III: short-term dihydropyridine CCB

Secondary prevention: sugar control

Class I: HbA1C <7% Class III: thiazolidinediones (Avandia, Actos) in CHF

Fc III or IV

Secondary prevention: hormone therapy

Class III: new prescription estrogen + progestin

should not be given in postmenopausal

women for secondary prevention

women already took estrogen + progestin

should not continue hormone therapy

bed-rest in the hospital

Benefit and risk evaluation in the women more than

1-2 years initiation of hormone therapy and

wish to continue

Secondary prevention: Coumadin

Class I: For aspirin allergy

stent (+): INR= 2.0—3.0 + Plavix 75mg/d

stent (-): INR= 2.5—3.5, no Plavix

No aspirin allergy, combine anticoagulation

stent (-): INR= 2.0—3.0 + Aspirin

INR= 2.5—3.5 alone

Persistent or paroxysmal Af , INR= 2.0—3.0

LV thrombus post-MI: >= 3 months

Secondary prevention: Coumadin

Class IIa: No aspirin allergy, no anticoagulation indication

<75 y/o: INR= 2.0—3.0 + Aspirin

INR= 2.5—3.5 alone LV dysfunction and extensive regional wall-

motion abnormalities Class IIb: severe LV dysfunction, with or without CHF

Secondary prevention: physical activity

Class I: exercise >=30 minutes, 3-4 times / week

cardiac rehabilitation

Secondary prevention: antioxidant

Class III: vitamin C or E

Long term management

Psychosocial impact: Class I: depression, anxiety, sleep disorder po

st MI Class IIa: SSRI for depression patients post MI

Cardiac rehabilitation Class IIa: multiple modificable risk factors,

moderate to high-risk group

acc/aha guidelines for the management of patients with stemi--2004 presenter: r5 李政翰 r5...

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