ACD 9/4/14Evan Watts

Simulated Case ~70 y/o AAW w DM2, CAD, CABG years ago presents to

clinic 3 days after chest pressure, indigestion, dyspnea on exertion episode. Feeling much better now.

Simulated Case Exam Vitals: T 98.6 HR 120 RR 16 BP 145/85 Pox 98% RA Gen: Well appearing, no distress HEENT: PERRL, EOMI, no icterus Neck: No JVD, no bruits Chest: CTAB, no w/r/r CV: Irregularly irregular, normal s1, s2, no S3 or S4 Abd: Soft, nt, nd, active bs Ext: no c/c/e Neuro: AAO X 3, no focal deficits

Sim labs and images Labs: CBC and BMP unremarkable, Trop I 1.1 CXR no acute abnormality

Diagnosis?

Diagnosis? 2 day old STEMI, now w no symptoms, no signs of CHF, also

Afib RVR now. So what now?

Cath lab STAT? Medical management in CCU w possible cath in AM? Medical management w no left heart cath?

What do the guidelines say? ACC/AHA Guidelines for the Management of STEMI Class I Reperfusion therapy should be administered to all eligible patients with

STEMI with symptom onset within the prior 12 hours. (Level of Evidence: A)

Primary PCI should be performed in patients with STEMI and ischemic symptoms of less than 12 hours’ duration.

(Level of Evidence: A) Primary PCI should be performed in patients with STEMI

and cardiogenic shock or acute severe HF, irrespective of time delay from myocardial infarction (MI) onset (Section 8.1). (Level of Evidence: B)

What do the guidelines say? Class IIa Primary PCI is reasonable in patients with

STEMI if there is clinical and/or ECG evidence of ongoing ischemia between 12 and 24 hours after symptom onset. (Level of Evidence: B)

What do the guidelines say? Delayed Invasive Management: Recommendations 5.2. PCI of an Infarct Artery in Patients Who Initially Were Managed

With Fibrinolysis or Who Did Not Receive Reperfusion Therapy Class I PCI of an anatomically significant stenosis in the infarct artery

should be performed in patients with suitable anatomy and any of the following:

a. Cardiogenic shock or acute severe HF (Level of Evidence: B); b. Intermediate- or high-risk findings on predischarge noninvasive

ischemia testing (Level of Evidence: C); or c. Myocardial ischemia that is spontaneous or provoked by

minimal exertion during hospitalization. (Level of Evidence: C)

What do the guidelines say? Class IIb Delayed PCI of a significant stenosis in a patent infarct

artery greater than 24 hours after STEMI may be considered as part of an invasive strategy in stable patients. (Level of Evidence: B)

Class III: No Benefit Delayed PCI of a totally occluded infarct artery greater

than 24 hours after STEMI should not be performed in asymptomatic patients with 1- or 2-vessel disease if they are hemodynamically and electrically stable and do not have evidence of severe ischemia. (Level of Evidence: B)

No specifically designed studies have addressed the role of primary percutaneous coronary intervention in patients with acute ST-segment elevation myocardial infarction (STEMI) presenting more than 12 hours after symptom onset. Current guidelines do not recommend reperfusion treatment in these patients.

To assess whether an immediate invasive treatment strategy is associated with a reduction of infarct size in patients with acute STEMI, presenting between 12 and 48 hours after symptom onset, vs a conventional conservative strategy.

International, multicenter, open-label, randomized controlled trial conducted from May 23, 2001, to December 15, 2004, of 365 patients aged 18 to 80 years without persistent symptoms admitted with the diagnosis of acute STEMI between 12 and 48 hours after symptom onset.

Random assignment to either an invasive strategy (n=182) based predominantly on coronary stenting with abciximab or a conventional conservative treatment strategy (n=183).

The primary end point was final left ventricular infarct size (SPECT) 5 and 10 days after randomization in 347patients (95.1%). Secondary end points included composite of death, recurrent MI, or stroke at 30 days.

The final left ventricular infarct size was significantly smaller in patients assigned to the invasive group (median, 8.0%; interquartile range [IQR], 2.0%-15.8%) vs those assigned to the conservative group (median, 13.0%; IQR, 3.0%-27.0%; P.001). The mean difference in final left ventricular infarct size between the invasive and conservative groups was −6.8% (95% confidence interval [CI], −10.2% to −3.5%). The secondary end points of death, recurrent MI, or stroke at 30 days occurred in 8 patients in the invasive group (4.4%) and 12 patients in the conservative group (6.6%) (relative risk, 0.67; 95% CI, 0.27-1.62; P=.37).

References