Upload
beny-rilianto
View
231
Download
0
Embed Size (px)
Citation preview
7/28/2019 Aha Guidelines for Stemi
1/94
1
ACC/AHA Guidelines for the
Management of Patients withST-Elevation Myocardial Infarction
7/28/2019 Aha Guidelines for Stemi
2/94
2
Management Before STEMI
ACC/AHA Guidelines for the
Management of Patients withST-Elevation Myocardial Infarction
7/28/2019 Aha Guidelines for Stemi
3/94
3
Identification of Patients at Risk of STEMI
The presence and status of control of majorrisk 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.
7/28/2019 Aha Guidelines for Stemi
4/94
4
Identification of Patients at Risk of STEMI
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.
7/28/2019 Aha Guidelines for Stemi
5/94
5
Onset of STEMI
ACC/AHA Guidelines for the
Management of Patients withST-Elevation Myocardial Infarction
7/28/2019 Aha Guidelines for Stemi
6/94
6
Prehospital Chest Pain Evaluation
and Treatment
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 nonenteric-coated
formulations.
7/28/2019 Aha Guidelines for Stemi
7/947
Options for Transport of Patients With
STEMI and Initial Reperfusion Treatment
EMS Transport
Onset of
symptoms of
STEMI
EMS
Dispatch
EMS on-scene Encourage 12-lead ECGs.
Consider prehospital fibrinolytic if
capable and EMS-to-needle within30 min.
GOALS
PCIcapable
Not PCI
capable
Hospital fibrinolysis:
Door-to-Needle
within 30 min.
Inter-
Hospital
Transfer
Golden Hour = first 60 min. Total ischemic time: within 120 min.
Patient EMS Prehospital fibrinolysis
EMS-to-needle
within 30 min.
EMS transport
EMS-to-balloon within 90 min.
Patient self-transport
Hospital door-to-balloonwithin 90 min.
Dispatch1 min.
5
min.8
min.
7/28/2019 Aha Guidelines for Stemi
8/948
Patients receiving fibrinolysis should be risk-stratified to identify needfor 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
Primary PCI
Noninvasive Risk
Stratification
Late
Hospital Care
and Secondary
Prevention
PCI or CABG
Not
PCI Capable
PCI Capable
Rescue Ischemia
driven
Options for Transport of Patients With STEMI and
Initial Reperfusion Treatment
7/28/2019 Aha Guidelines for Stemi
9/949
Initial Recognition and
Management in the
Emergency Department
ACC/AHA Guidelines for theManagement of Patients with
ST-Elevation Myocardial Infarction
7/28/2019 Aha Guidelines for Stemi
10/9410
ED Evaluation of
Patients With STEMI
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)
Brief Physical Examination in the ED
7/28/2019 Aha Guidelines for Stemi
11/9411
ED Evaluation of
Patients With STEMI
Aortic dissection
Pulmonary embolus
Perforating ulcer
Tension pneumothorax
Boerhaave syndrome
(esophageal rupture withmediastinitis)
Differential Diagnosis of STEMI: Life-Threatening
7/28/2019 Aha Guidelines for Stemi
12/9412
ED Evaluation of
Patients With STEMI
Pericarditis
Atypical angina
Early repolarizationWolff-Parkinson-White
syndrome
Deeply inverted T-waves
suggestive of a central
nervous system lesionor apical hypertrophic
cardiomyopathy
LV hypertrophy with strain
Brugada syndrome
Myocarditis
Hyperkalemia
Bundle-branch blocks
Vasospastic anginaHypertrophic
cardiomyopathy
Differential Diagnosis of STEMI: Other Cardio vascular andNonischemic
7/28/2019 Aha Guidelines for Stemi
13/9413
Gastroesophageal reflux
(GERD) and spasm
Chest-wall pain
Pleurisy
Peptic ulcer disease
Panic attack
Cervical disc or neuropathic
pain
Biliary or pancreatic pain
Somatization and
psychogenic pain disorder
ED Evaluation of
Patients With STEMI
Differential Diagnosis of STEMI: Other Noncardiac
7/28/2019 Aha Guidelines for Stemi
14/9414
Electrocardiogram
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.
7/28/2019 Aha Guidelines for Stemi
15/9415
Electrocardiogram
Show 12-lead ECG results to emergency physicianwithin 10 minutes of ED arrival in all patients with
chest discomfort (or anginal equivalent) or other
symptoms of STEMI.
In patients with inferior STEMI, ECG leads should
also be obtained to screen for right ventricularinfarction.
7/28/2019 Aha Guidelines for Stemi
16/9416
Laboratory Examinations
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
7/28/2019 Aha Guidelines for Stemi
17/9417
Cardiac-specific troponins should be used as the
optimum biomarkers for the evaluation of patients
with STEMI who have coexistent skeletal muscle
injury.
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 notcontingent on a biomarker assay.
Biomarkers of Cardiac Damage
7/28/2019 Aha Guidelines for Stemi
18/94
18
Patients with STEMI should have a portable chest
X-ray, but this should not delay implementation ofreperfusion 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 STEMIfrom aortic dissection in patients for whom this
distinction is initially unclear.
Imaging
7/28/2019 Aha Guidelines for Stemi
19/94
19
Supplemental oxygen should be administered to
patients with arterial oxygen desaturation (SaO2
< 90%).
It is reasonable to administer supplemental
oxygen to all patients with uncomplicated STEMI
during the first 6 hours.
Oxygen
7/28/2019 Aha Guidelines for Stemi
20/94
20
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.
Intravenous NTG is indicated for relief of ongoing
ischemic discomfort that responds to nitrate therapy,
control of hypertension, or management of pulmonary
congestion.
Nitroglycerin
7/28/2019 Aha Guidelines for Stemi
21/94
21
Nitrates should not be administered to patients with:
Nitrates should not be administered to patients who
have received a phosphodiesterase inhibitor for
erectile dysfunction within the last 24 hours (48hours for tadalafil).
systolic pressure < 90 mm Hg or to 30 mm Hgbelow baseline
severe bradycardia (< 50 bpm)
tachycardia (> 100 bpm) or
suspected RV infarction.
Nitroglycerin
7/28/2019 Aha Guidelines for Stemi
22/94
22
Analgesia
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 choicefor management of pain associated with STEMI.
7/28/2019 Aha Guidelines for Stemi
23/94
23
Aspirin
Aspirin should be chewed by patients who have
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 withnonenteric-coated formulations.
7/28/2019 Aha Guidelines for Stemi
24/94
24
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 beta-
blockers promptly to STEMI patients without
contraindications, especially if a tachyarrhythmia orhypertension is present.
Beta-Blockers
7/28/2019 Aha Guidelines for Stemi
25/94
25
Reperfusion
Given the current literature, it is not possible to saydefinitively 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
7/28/2019 Aha Guidelines for Stemi
26/94
26
Reperfusion
The medical system goal is to facilitate rapid recognition
and treatment of patients with STEMI such that door-to-
needle (or medical contactto-needle) time for initiation
offibrinolytic therapy can be achieved within 30
minutes or that door-to-balloon (or medical contactto-
balloon) time forPCI can be kept within 90 minutes.
7/28/2019 Aha Guidelines for Stemi
27/94
27
Media campaign
Patient education
Methods of
Speeding
Time to
Reperfusion
Greater use of
9-1-1
Prehospital Rx
MI protocol
Critical pathway
Qualityimprovement
program
Bolus lyticsDedicated
PCI team
5min < 30 minD-B 90 min
D-N 30 min
Goals
Prehospital
ECG
Patient Transport Inhospital Reperfusion
Reperfusion
7/28/2019 Aha Guidelines for Stemi
28/94
28
Symptom
Recognition Call toMedical System EDCath LabPreHospital
Delay in Initiation of Reperfusion TherapyIncreasing Loss of Myocytes
Treatment Delayed is Treatment Denied
7/28/2019 Aha Guidelines for Stemi
29/94
29
Contraindications and Cautions
for Fibrinolysis in STEMI
Absolute
Contraindications
Any prior intracranial hemorrhage
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.
7/28/2019 Aha Guidelines for Stemi
30/94
30
Contraindications and Cautions
for Fibrinolysis in STEMI
AbsoluteContraindications
Suspected aortic dissection
Active bleeding or bleeding diathesis
(excluding menses)
Significant closed-head or facial traumawithin 3 months
7/28/2019 Aha Guidelines for Stemi
31/94
31
Contraindications and Cautions
for Fibrinolysis in STEMI
History of chronic, severe, poorly controlled
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)
Relative
Contraindications
C i di i d C i
7/28/2019 Aha Guidelines for Stemi
32/94
32
Contraindications and Cautions
for Fibrinolysis in STEMI
RelativeContraindications
Recent (< 2 to 4 weeks) internal bleeding
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
7/28/2019 Aha Guidelines for Stemi
33/94
33
Reperfusion Options for STEMI Patients
Step One: Assess Time and Risk .
Time Since
Symptom
OnsetTime Required
for Transport to
a Skilled PCI
Lab
Risk of STEMI Risk ofFibrinolysis
R f i O i f STEMI P i
7/28/2019 Aha Guidelines for Stemi
34/94
34
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
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.
R f i O ti f STEMI P ti t
7/28/2019 Aha Guidelines for Stemi
35/94
35
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
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.
7/28/2019 Aha Guidelines for Stemi
36/94
36
Fibrinolysis
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 bundlebranch block (LBBB).
7/28/2019 Aha Guidelines for Stemi
37/94
37
Fibrinolysis
In the absence of contraindications, it is
reasonable to administer fibrinolytic therapy toSTEMI 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 mVin 2 contiguous precordial leads or 2 adjacent
limb leads.
7/28/2019 Aha Guidelines for Stemi
38/94
38
Fibrinolysis
Fibrinolytic therapy should not be administered to
asymptomatic patients whose initial symptoms of
STEMI began more than 24 hours earlier.
Fibrinolytic therapy should not be administered to
patients whose 12-lead ECG shows only ST-
segment depression, except if a true posterior MIis suspected.
Evolution of PCI for STEMI
7/28/2019 Aha Guidelines for Stemi
39/94
39
Evolution of PCI for STEMI
Primary PCI for STEMI:
7/28/2019 Aha Guidelines for Stemi
40/94
40
Primary PCI for STEMI:
General Considerat ion s
Patient with STEMI (including posterior MI) or MI
with new or presumably new LBBB
PCI of infarct artery within 12 hours of symptom
onset
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 forSTEMI)
Cardiac surgical backup available
P i PCI f STEMI
7/28/2019 Aha Guidelines for Stemi
41/94
41
Primary PCI for STEMI:
Speci f ic Considerat ions
Medical contactto-balloon or door-to-balloonshould be within 90 minutes.
PCI preferred if > 3 hours from symptom onset.
Primary PCI should be performed in patients with
severe congestive heart failure (CHF) and/orpulmonary edema (Killip class 3) and onset of
symptoms within 12 hours.
P i PCI f STEMI
7/28/2019 Aha Guidelines for Stemi
42/94
42
Primary PCI for STEMI:
Speci f ic Considerat ions
Primary 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 aresuitable for revascularization that can be
performed within 18 hours of shock.
P i PCI f STEMI
7/28/2019 Aha Guidelines for Stemi
43/94
43
Primary PCI for STEMI:
Speci f ic Considerat ions
Primary PCI is reasonable in selected patients 75
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.
P i PCI f STEMI
7/28/2019 Aha Guidelines for Stemi
44/94
44
It is reasonable to perform primary PCI forpatients 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.
Primary PCI for STEMI:
Speci f ic Considerat ions
7/28/2019 Aha Guidelines for Stemi
45/94
45
Rescue PCI
Rescue PCI should be performed in patients lessthan 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.
Rescue PCI should be performed in patients with
severe CHF and/or pulmonary edema (Killip class
3) and onset of symptoms within 12 hours.
Rescue PCI
7/28/2019 Aha Guidelines for Stemi
46/94
46
Rescue PCI
Rescue PCI is reasonable for selected patients 75
years or older with ST elevation or LBBB or whodevelop 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:
a. Hemodynamic or electrical instability
b. Persistent ischemic symptoms.
PCI for Cardiogenic Shock
7/28/2019 Aha Guidelines for Stemi
47/94
47
PCI for Cardiogenic Shock
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.
PCI for Cardiogenic Shock
7/28/2019 Aha Guidelines for Stemi
48/94
48
Cardiogenic Shock
1-2 vessel CAD Moderate 3-vessel CAD Severe 3-vessel CAD Left main CAD
PCI IRA PCI IRA Immediate CABG
Staged Multivessel
PCI
Staged CABGCannot be
performed
Early Shock, Diagnosed onHospital Presentation
Delayed Onset ShockEchocardiogram to Rule Out
Mechanical Defects
Cardiac Catheterization and Coronary
Angiography
IABP
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
Arrange prompt transfer to invasiveprocedure-capable center
Arrange rapid transfer to invasive
procedure-capable center
PCI for Cardiogenic Shock
PCI After Fibrinolysis
7/28/2019 Aha Guidelines for Stemi
49/94
49
PCI After Fibrinolysis
In patients whose anatomy is suitable, PCI should be
performed for the following:
Objective evidence of recurrent MI
Moderate or severe spontaneous/provocable
myocardial ischemia during recovery from STEMI
Cardiogenic shock or hemodynamic instability.
PCI After Fibrinolysis
7/28/2019 Aha Guidelines for Stemi
50/94
50
PCI After Fibrinolysis
It is reasonable to perform routine PCI in patients
with left ventricular ejection fraction (LVEF) 0.40,CHF, or serious ventricular arrhythmias.
Routine PCI might be considered as part of
an invasive strategy after fibrinolytic therapy.
It is reasonable to perform PCI when there is
documented clinical heart failure during the acuteepisode, even though subsequent evaluation
shows preserved LV function (LVEF > 0.40).
Assessment of Reperfusion
7/28/2019 Aha Guidelines for Stemi
51/94
51
Assessment of Reperfusion
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 elevationpattern on follow-up ECG 60 to 90 minutes after
initiation of therapy.
Ancillary Therapy to Reperfusion
7/28/2019 Aha Guidelines for Stemi
52/94
52
Ancillary Therapy to Reperfusion
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.
Ancillary Therapy to Reperfusion
7/28/2019 Aha Guidelines for Stemi
53/94
53
Ancillary Therapy to Reperfusion
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.
Platelet counts should be monitored daily in patients
taking UFH.
Aspirin
7/28/2019 Aha Guidelines for Stemi
54/94
54
Aspirin
A daily dose of aspirin (initial dose of 162 to
325 mg orally; maintenance dose of 75 to 162
mg) should be given indefinitely after STEMI to
all patients without a true aspirin allergy.
Thienopyridines
7/28/2019 Aha Guidelines for Stemi
55/94
55
Thienopyridines
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.
Thienopyridines
7/28/2019 Aha Guidelines for Stemi
56/94
56
Thienopyridines
In patients taking clopidogrel in whom CABG is
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.
Thienopyridines
7/28/2019 Aha Guidelines for Stemi
57/94
57
Thienopyridines
Clopidogrel is probably indicated in patients
receiving fibrinolytic therapy who are unable
to take aspirin because of hypersensitivity or
gastrointestinal intolerance.
Gl t i IIb/III I hibit
7/28/2019 Aha Guidelines for Stemi
58/94
58
Glycoprotein IIb/IIIa Inhibitors
It is reasonable to start treatment with
abciximab as early as possible before primary
PCI (with or without stenting) in patients with
STEMI.
Treatment with tirofiban or eptifibatide may be
considered before primary PCI (with or
without stenting) in patients with STEMI.
Oth Ph l i l M
7/28/2019 Aha Guidelines for Stemi
59/94
59
Other Pharmacological Measures
Angiotensin converting enzyme (ACE)
inhibitors
Angiotensin receptor blockers (ARB)
Aldosterone blockersGlucose control
Magnesium
Calcium channel blockers
Inhibition ofthe renin -
angiotensin -
aldosterone
system
ACE/ARB: Within 24 Hours
7/28/2019 Aha Guidelines for Stemi
60/94
60
ACE/ARB: Within 24 Hours
An ACE inhibitor should be administered orally
within the first 24 hours of STEMI to the followingpatients without hypotension or known class of
contraindications:
Anterior infarction
Pulmonary congestion LVEF < 0.40
An ARB should be given to ACE-intolerant patients
with either clinical or radiological signs of HF or LVEF< 0.40.
ACE/ARB: Within 24 Hours
7/28/2019 Aha Guidelines for Stemi
61/94
61
ACE/ARB: Within 24 Hours
An ACE inhibitor administered orally can be useful
within the first 24 hours of STEMI to the followingpatients without hypotension or known class
contraindications:
Anterior infarction
Pulmonary congestion LVEF < 0.40.
An intravenous ACE inhibitor should not be given to
patients within the first 24 hours of STEMI becauseof the risk of hypotension (possible exception:
refractory hypotension).
Strict Glucose Control During STEMI
7/28/2019 Aha Guidelines for Stemi
62/94
62
Strict Glucose Control During STEMI
An insulin infusion to normalize blood glucose
is recommended for patients and complicated
courses.
It is reasonable to administer an insulin
infusion to normalize blood glucose even in
patients with an uncomplicated course.
7/28/2019 Aha Guidelines for Stemi
63/94
63
Hospital Management
ACC/AHA Guidelines for the
Management of Patients with
ST-Elevation Myocardial Infarction
Sample Admitting Orders for the
7/28/2019 Aha Guidelines for Stemi
64/94
64
Sample Admitting Orders for the
Patient With STEMI
1. Condition: Serious2. Normal Saline or D5W intravenous to keep vein open
3. Vital signs: Heart rate, blood pressure, respiratory rate
4. Monitor: Continuous ECG monitoring for arrhythmia/ST-
segment deviation
5. Diet: NCEP ATP III Therapeutic Lifestyle Changes, low
sodium diet
Sample Admitting Orders for the
7/28/2019 Aha Guidelines for Stemi
65/94
65
Sample Admitting Orders for the
Patient With STEMI
6. Activity: Bed rest with bedside commode, lightactivity 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
Emergency Management of Complicated STEMI
7/28/2019 Aha Guidelines for Stemi
66/94
66
Administer
Fluids
Blood transfusions
Cause-specific
interventions
Considervasopressors
Arrhythmia
Bradycardia Tachycardia
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
Dobutamine
2 to 20
mcg/kg per
minute IV
Low Output -
Cardiogenic Shock
Nitroglycerin
10 to 20 mcg/min IV
Dopamine
5 to 15
mcg/kg per
minute IV
Norepinephrine
0.5 to 30 mcg/min IV
Hypovolemia
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 presentDobutamine 2 to 20 mcg/kg per minute IV if SBP 70
to 100 mm Hg and no signs/symptoms of shockFirstline
ofaction
Second
line
ofaction
Third
line
ofaction
See Section 7.7
in the ACC/AHA Guidelines for
Patients With ST-Elevation
Myocardial Infarction
Check Blood Pressure
Clinical signs: Shock, hypoperfusion, congestive heart failure, acute pulmonary edema
Most likely major underlying disturbance?
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
AcutePulmonary Edema
Check Blood Pressure
Systolic BP
Greater than 100 mm Hg
and not less than 30 mm Hg
below baseline
ACE Inhibitors
Short-acting agent such ascaptopril (1 to 6.25 mg)
Circulation 2000;102(suppl I):I-172-I-216.
Arrhythmias During Acute Phase of STEMI:
7/28/2019 Aha Guidelines for Stemi
67/94
67
y g
Electr ical Instab i l i ty
VPBs K+ , Mg++, beta blocker
VT Antiarrhythmics, DC shock
AIVR Observe unless hemodynamic
compromise
NPJT Search for cause (e.g., dig toxicity)
Arrhythmia Treatment
Arrhythmias During Acute Phase of STEMI:
7/28/2019 Aha Guidelines for Stemi
68/94
68
Sinus Tach Treat cause; beta blocker
Afib / Flutter Treat cause; slow ventricular rate; DC shock
PSVT Vagal maneuvers; beta blocker,
verapamil / diltiazem; DC shock
y g
Pump Fai lure / Excess Sympathet ic Tone
Arrhythmia Treatment
Arrhythmias During Acute Phase of STEMI:
7/28/2019 Aha Guidelines for Stemi
69/94
69
Sinus Brady Treat if hemodynamic compromise;
atropine / pacing
Junctional Treat if hemodynamic compromise;
atropine / pacing
Arrhythmias During Acute Phase of STEMI:
Bradyarrhythmias
Arrhythmia Treatment
Arrhythmias During Acute Phase of STEMI:
7/28/2019 Aha Guidelines for Stemi
70/94
70
Arrhythmias During Acute Phase of STEMI:
AV Conduct ion Disturbances
Escape Rhythm His Bundle Distal
< 120 ms > 120 ms
45 - 60 Often < 30
Duration of AVB 2 - 3 days Transient
Mortality Low High (CHF, VT)
Rx Observe PM (ICD)
Proximal Distal
Recommendations for Treatment ofAtrioventricular and Intraventricular Conduction
7/28/2019 Aha Guidelines for Stemi
71/94
71
Atrioventricular and Intraventricular Conduction
Disturbances During STEMI
INTRAVENTRICULAR
CONDUCTION Normal
ACTION CLASS ACTION CLASS ACTION CLASS ACTION CLASS ACTION CLASS ACTION CLASS ACTION CLASS
Observe I Observe I Observe I Observe IIb Observe IIa Observe III Observe III
A III A III A III A* III A III A III A III
TC III TC IIb TC IIb TC I TC I TC I TC I
TV III TV III TV III TV III TV III TV IIa TV IIa
Old or New Observe I Observe IIb Observe IIb Observe IIb Observe IIb Observe III Observe III
Fascicular block A III A III A III A* III A III A III A III
(LAFB or LPFB) TC IIb TC I TC IIa TC I TC I TC I TC I
TV III TV III TV III TV III TV III TV IIa TV IIb
Observe I Observe III Observe III Observe III Observe III Observe III Observe III
A III A III A III A* III A III A III A III
TC IIb TC I TC I TC I TC I TC I TC I
TV III TV IIb TV IIb TV IIb TV IIb TV IIa TV IIa
Observe III Observe III Observe III Observe III Observe III Observe III Observe III
A III A III A III A* III A III A III A III
TC I TC I TC I TC I TC I TC IIb TC IIb
TV IIb TV IIa TV IIa TV IIa TV IIa TV I TV I
Fascicular Observe III Observe III Observe III Observe III Observe III Observe III Observe III
block + RBBB A III A III A III A* III A III A III A III
TC I TC I TC I TC I TC I TC IIb TC IIbTV IIb TV IIa TV IIa TV IIa TV IIa TV I TV I
Alternating Observe III Observe III Observe III Observe III Observe III Observe III Observe III
left and right A III A III A III A* III A III A III A III
bundle branch TC IIb TC IIb TC IIb TC IIb TC IIb TC IIb TC IIb
block TV I TV I TV I TV I TV I TV I TV I
Normal
Old bundle
branch block
New bundle
branch block
Mobitz II second degree AV blockMobitz I second degree AV blockFirst degree AV block
ANTERIOR MI NON-ANTERIOR ANTERIOR MI NON-ANTERIOR ANTERIOR MI NON-ANTERIOR
Atrioventricular Conduction
ICD Implantation After STEMIO M th Aft STEMI
7/28/2019 Aha Guidelines for Stemi
72/94
72
One Month After STEMI;
No Spontaneous VT or VF 48 hours post-STEMI
EF < 0.30
EPS
Yes
+
NEJM 349:
1836,2003
EF 0.31 - 0.40
No
No ICD.
Medical Rx
EF > 0.40
-
Additional Marker of
Electrical Instability?
Algorithm for Management of RecurrentIschemia/Infarction After STEMI
7/28/2019 Aha Guidelines for Stemi
73/94
73
Ischemia/Infarction After STEMI
Obtain 12-lead ECG
YES NO
Consider (re)
administration of
YES NO
Is patient
a candidate for
revascularization?
ST-segment elevation?
Escalation of medical therapy (nitrates, beta-
blockers)
Anticoagulation if not already given
Consider IABP for hemodynamic instability,
poor LV function, or a large area ofmyocardium at risk
Correct secondary causes of ischemia
Recurrent ischemic-type discomfort at rest after STEMI
YES NO
Refer for
nonurgent
catheterization
Refer for urgent
catheterization (consider
IABP)
Is ischemia
controlled by escalation
of medical therapy?
YES
Coronary
angiography
Revascularization with PCI
and/or CABG as dictated by
anatomy
NO
Can
catheterization
be performed promptly?*
Obtain 12-lead ECG
YES NO
Consider (re) administration
of fibrinolytic therapy
YES NO
Is patient
a candidate for
revascularization?
Is patient
a candidate for
revascularization?
ST-segment elevation?ST-segment elevation?
Escalation of medical therapy (nitrates, beta-
blockers)
Anticoagulation if not already given
Consider IABP for hemodynamic instability,
poor LV function, or a large area ofmyocardium at risk
Correct secondary causes of ischemia
Recurrent ischemic-type discomfort at rest after STEMI
YES NO
Refer for
nonurgent
catheterization
Refer for urgent
catheterization (consider
IABP)
YES NO
Refer for
nonurgent
catheterization
Refer for urgent
catheterization (consider
IABP)
Is ischemia
controlled by escalation
of medical therapy?
Is ischemia
controlled by escalation
of medical therapy?
YES
Coronary
angiography
Revascularization with PCI
and/or CABG as dictated by
anatomy
NO
Can
catheterization
be performed promptly?*
Can
catheterization
be performed promptly?
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
Evidence-Based Approach to Need forCatheterization and Revascularization After STEMI
7/28/2019 Aha Guidelines for Stemi
74/94
74
Catheterization and Revascularization After STEMISTEMI
Primary Invasive Strategy Fibrinolytic Therapy No Reperfusion Therapy
Cath
Performed
No Cath
Performed
EF greater
than 0.40
EF less
than 0.40
EF less
than 0.40
EF greater
than 0.40
High-Risk
Features
No High-Risk
Features
No High-Risk
Features
High-Risk
Features
Functional
Evaluation
ECG Interpretable ECG Uninterpretable
Able to Exercise Unable to Exercise
SubmaximalExercise Test
Before Discharge
Symptom-LimitedExercise Test
Before or After Discharge
Pharmacological Stress
Nuclear Scan
DobutamineEcho
Clinically Significant
Ischemia*
No Clinically Significant
Ischemia*
Medical
Therapy
Revascularization as
Indicated
Catheterization and
Revascularization as
Indicated
Catheterization and
Revascularization as
Indicated
Able to Exercise
ExerciseEcho
ExerciseNuclear
STEMI
Primary Invasive Strategy Fibrinolytic Therapy No Reperfusion Therapy
Cath
Performed
No Cath
Performed
EF greater
than 0.40
EF less
than 0.40
EF less
than 0.40
EF greater
than 0.40
High-Risk
Features
No High-Risk
Features
No High-Risk
Features
High-Risk
Features
Functional
Evaluation
ECG Interpretable ECG Uninterpretable
Able to Exercise Unable to Exercise
SubmaximalExercise Test
Before Discharge
Symptom-LimitedExercise Test
Before or After Discharge
Pharmacological Stress
Adenosineor Dipyridamole DobutamineEcho
Clinically Significant
Ischemia
No Clinically Significant
Ischemia
Medical
Therapy
Revascularization as
Indicated
Catheterization and
Revascularization as
Indicated
Catheterization and
Revascularization as
Indicated
Able to Exercise
ExerciseEcho
ExerciseNuclear
Long-Term Antithrombotic Therapy atHospital Discharge After STEMI
7/28/2019 Aha Guidelines for Stemi
75/94
75
Hospital Discharge After STEMI
No Stent Implanted
No ASA allergy ASA Allergy
Preferred:
ASA 75 to 162 mg
Class I; LOE: A
Preferred:
Clopidogrel 75 mg
Class I; LOE: C
Alternative:
WarfarinINR (2.5 to 3.5)
Class I; LOE: B
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 IIa; LOE: B
Indicationsfor Anticoagulation
No Indicationsfor Anticoagulation
No Indicationsfor Anticoagulation
Indicationsfor Anticoagulation
ASA 75 to 162 mg
Warfarin
(INR 2.0 to 3.0)
Class I; LOE B
OR
Warfarin
(INR 2.5 to 3.5)
Class I; LOE: B
Warfarin
INR (2.5 to 3.5)
Class I; LOE: B
STEMI Patient at Discharge
Long-Term Antithrombotic Therapy atHospital Discharge After STEMI
7/28/2019 Aha Guidelines for Stemi
76/94
76
Hospital Discharge After STEMI
Stent Implanted
No ASA Allergy ASA Allergy
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
Clopidogrel 75 mg
Class I; LOE: B
Clopidogrel 75 mg
Warfarin
(INR 2.0 to 3.0)Class I; LOE: C
STEMI Patient at Discharge
No Indications
for
Anticoagulation
Indications
for Anticoagulation
Indications
for
Anticoagulation
No Indications
for
Anticoagulation
7/28/2019 Aha Guidelines for Stemi
77/94
77
Long-Term Management
ACC/AHA Guidelines for the
Management of Patients withST-Elevation Myocardial Infarction
Secondary Prevention and Long Term Management
7/28/2019 Aha Guidelines for Stemi
78/94
78
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.
SmokingGoal:
Complete
Cessation
Goals Recommendations
Secondary Prevention and Long Term Management
7/28/2019 Aha Guidelines for Stemi
79/94
79
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-angiotensin-aldosterone system.
Blood pressurecontrol:
Goal: < 140/90
mm Hg or
7/28/2019 Aha Guidelines for Stemi
80/94
80
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.
Physical activity:
Minimum goal:
30 minutes 3 to 4
days per week;
Optimal daily
Goals Recommendations
Secondary Prevention and Long Term Management
7/28/2019 Aha Guidelines for Stemi
81/94
81
Start dietary therapy in all patients (< 7% of total calories as
saturated fat and < 200 mg/d cholesterol). Promote physicalactivity 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:
Lipid
management:(TG less than
200 mg/dL)
Primary goal:
LDL-C
7/28/2019 Aha Guidelines for Stemi
82/94
82
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-Clowering therapy, consider adding
fibrate or niacin.
If TG is 500 mg/dL:
Consider fibrate or niacin before LDL-Clowering
therapy.
Consider omega-3 fatty acids as adjunct for highTG.
Lipidmanagement:
(TG 200 mg/dL
or greater)
Primary goal:
Non
HDL-C
7/28/2019 Aha Guidelines for Stemi
83/94
83
Goals 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 24.9kg/m2.
If waist circumference is 35 inches in women or
40 inches in men, initiate lifestyle changes and
treatment strategies for metabolic syndrome.
Weightmanagement:
Goal:
BMI 18.5 to 24.9
kg/m2
Waist
circumference:
Women: < 35 in.
Men: < 40 in.
Secondary Prevention and Long Term Management
7/28/2019 Aha Guidelines for Stemi
84/94
84
y g g
Goals 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).
Diabetes
management:
Goal:
HbA1c < 7%
Secondary Prevention and Long Term Management
7/28/2019 Aha Guidelines for Stemi
85/94
85
Secondary Prevention and Long Term Management
Goals Recommendations
In the absence of contraindications, start aspirin
75 to 162 mg/d and continue indefinitely.
If aspirin is contraindicated, consider clopidogrel75 mg/day or warfarin.
Manage warfarin to INR 2.5 to 3.5 in post-
STEMI patients when clinically indicated or for
those not able to take aspirin or clopidogrel.
Antiplatelet
agents/
anticoagulants
Secondary Prevention and Long Term Management
7/28/2019 Aha Guidelines for Stemi
86/94
86
Secondary Prevention and Long Term Management
Goals 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 areintolerant 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 receivingtherapeutic doses of an ACE inhibitor, have LVEF 0.40,
and have either diabetes or heart failure.
Renin-
Angiotensin-
Aldosterone
System
Blockers
Secondary Prevention and Long Term Management
7/28/2019 Aha Guidelines for Stemi
87/94
87
Secondary Prevention and Long Term Management
Goals Recommendations
Start in all patients. Continue indefinitely.
Observe usual contraindications.
Beta-
Blockers
Summary of Pharmacologic Rx: Ischemia
7/28/2019 Aha Guidelines for Stemi
88/94
88
1st
24 h
During
Hosp
Hosp DC +
Long TermAspi r in 162-325 mg
chewed
75-162
mg/d p.o.
75-162
mg/d p.o.
Fibr inolyt ic 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 Oral daily
JACC 2004;44: 671
Circulation 2004;110: 588
Summary of Pharmacologic Rx: LVD, Sec. Prev.,
7/28/2019 Aha Guidelines for Stemi
89/94
89
1st
24 h
During Hosp Hosp DC +
Long Term
ACEI Anterior MI,Pulm Cong., EF < 40 Oral
Daily
Oral
Daily
IndefinitelyARB ACEI intol.,
HF, EF < 40
Aldo
Blocker
No renal dysf,
K+ < 5.0 mEq/L
On ACEI,
HF or DM
Same as
during
Hosp.
Statin Start w/o lipid
profile
Indefinitely,
LDL
7/28/2019 Aha Guidelines for Stemi
90/94
90
Hormone therapy with estrogen plus progestin
should not be given de novo to postmenopausal
women after STEMI for secondary prevention of
coronary events.
Hormone Therapy
7/28/2019 Aha Guidelines for Stemi
91/94
91
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 indicationshould weigh the risks and benefits.
Antioxidants
7/28/2019 Aha Guidelines for Stemi
92/94
92
Antioxidant vitamins such as vitamin E and/or
vitamin C supplements should not be prescribed to
patients recovering from STEMI to prevent
cardiovascular disease.
Psychosocial Impact of STEMI
7/28/2019 Aha Guidelines for Stemi
93/94
93
The psychosocial status of the patient should be evaluated,
including inquiries regarding symptoms of depression, anxiety,
or sleep disorders and the social support environment.
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.
Cardiac Rehabilitation
7/28/2019 Aha Guidelines for Stemi
94/94
Cardiac rehabilitation/secondary preventionprograms, when available, are recommended
for patients with STEMI, particularly those
with multiple modifiable risk factors and/orthose moderate- to high-risk patients in whom
supervised exercise training is warranted.