dr.andrianto sympo-1.pdf

8/18/2019 dr.andrianto sympo-1.pdf

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THE NEW GUIDELINES FOR MANAGEMENT OF STEMI :

Primary PCI, Lytics & Adjuvant Therapy

Andrianto

Devie Caroline

Dept. of Cardiology & Vascular Medicine

Airlangga University - Dr. Soetomo Teaching Hospital

Surabaya


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TIME IS MUSCLE

EARLY DIAGNOSIS

EMERGENCY CARE

REPERFUSION

MYOCARDIAL

SALVAGE

Iniitial aim management of STEMI :

to restore blood flow to the infarct zone


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Comparing outcomes

PPCI vs Thrombolysis vs No Reperfusion

P < 0.001s

S. Dharma., D.A Juzar I. Firdaus et al. Neth Heart J (3012) 20: 354-259

% o

f m o r t a

l i t y

In-hospital mortality of STEMI patients

6.2

13.3

5.3

PPCI Fibrinolytic No Reperfusion


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TIME & MORTALITY :

Primary PCI vs Thrombolysis

8

6

4

2

0

0 1 2 3 4 5 6

Onset of pain to treatment (hours)

3 0 - d a y m o

r t a l i t y ( %

)

7 8

12

10

Thrombolysis

Primary PCICommon

total ischaemia time

Huber K et al. Eur Heart J 2005;26:2063 –2074. Huber et al. Eur Heart J 2005; 26: 1063-1074


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FMC= first medical contact; PCI= percutaneus coronary intervention

A summary of important delays & treatmentgoals in the management of acute STEMI


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REPERFUSION


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What The New Guideline Says ?

2013 ACCF/AHA Guideline for

The Management of STEMI


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Fibrinolytic Therapy When

There Is an Anticipated Delay

to Performing Primary PCI

Within 120 Minutes of FMC

Reperfusion at a Non – PCI-CapableHospital


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Indications for Transfer for Angiography

After Fibrinolytic Therapy

*Although individual circumstances will vary, clinical stability is defined by the absence of low

output, hypotension, persistent tachycardia, apparent shock, high-grade ventricular or symptomatic

supraventricular tachyarrhythmias, and spontaneous recurrent ischemia.


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Adjunctive Antithrombotic Therapy to Support

Reperfusion With Fibrinolytic Therapy


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Reperfusion With Fibrinolytic Therapy (cont.)


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Transfer of Patients With

STEMI to a PCI Capable

Hospital for Coronary

Angiography After Fibrinolytic

Therapy

Reperfusion at a Non – PCI-CapableHospital


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Indications for Transfer for Angiography


* Although individual circumstances will vary, clinical stability is defined by the

absence of low output, hypotension, persistent tachycardia, apparent shock,

high-grade ventricular or symptomatic supraventricular tachyarrhythmias,

and spontaneous recurrent ischemia.


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PCI of an Infarct Artery in

Patients Who Initially Were

Managed With Fibrinolysis or

Who Did Not Receive

Reperfusion Therapy

Delayed Invasive Management


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Indications for PCI of an Infarct Artery in Patients

Who Were Managed With Fibrinolytic Therapy or

Who Did Not Receive Reperfusion Therapy

* Although individual circumstances will vary, clinical stability is defined by the absence of low output,

hypotension, persistent tachycardia, apparent shock, high-grade ventricular or symptomatic

supraventricular tachyarrhythmias, and spontaneous recurrent ischemia.


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PCI of a Noninfarct Artery Before Hospital

Discharge

PCI is indicated in a noninfarct artery at a time

separate from primary PCI in patients who have

spontaneous symptoms of myocardial ischemia.

PCI is reasonable in a noninfarct artery at a time

separate from primary PCI in patients with intermediate-

or high-risk findings on noninvasive testing.

I IIa IIb III

I IIa IIb III

Adj ti A tith b ti Th t S t PCI


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Adjunctive Antithrombotic Therapy to Support PCI



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Adjunctive Antithrombotic Therapy to Support PCI

After Fibrinolytic Therapy (cont.)

*Balloon angioplasty without stent placement may be used in selected

patients. It might be reasonable to provide P2Y12 inhibitor therapy to patients

with STEMI undergoing balloon angioplasty after fibrinolysis alone

according to the recommendations listed for BMS. (Level of Evidence: C )


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PCI After Fibrinolytic Therapy (cont.)


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Primary PCI in STEMI

Reperfusion at a PCI-CapableHospital


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Primary PCI in STEMI


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Adjunctive Antithrombotic Therapy to

Support Reperfusion With Primary PCI

*The recommended maintenance dose of aspirin to be

used with ticagrelor is 81 mg daily.


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Indications for Fibrinolytic Therapy When There Is

a >120-Minute Delay From FMC to Primary PCI


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Routine Medical TherapiesGuideline for STEMI


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Beta Blockers

Oral beta blockers should be initiated in the first 24 hours inpatients with STEMI who do not have any of the following: signs

of HF, evidence of a low output state, increased risk for

cardiogenic shock,* or other contraindications to use of oral beta

blockers (PR interval >0.24 seconds, second- or third-degree

heart block, active asthma, or reactive airways disease).

Beta blockers should be continued during and after

hospitalization for all patients with STEMI and with no

contraindications to their use.

Risk factors for cardiogenic shock (the greater the number of risk factors present, the higher the

risk of developing cardiogenic shock) are age >70 years, systolic BP 110 bpm or heart rate


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Renin-Angiotensin-Aldosterone System Inhibitors

An ACE inhibitor should be administered within

the first 24 hours to all patients with STEMI with

anterior location, HF, or EF ≤ 0.40, unlesscontraindicated.

An ARB should be given to patients with STEMIwho have indications for but are intolerant of

ACE inhibitors.

I IIa IIb III

I IIa IIb III


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Renin-Angiotensin-Aldosterone System Inhibitors

An aldosterone antagonist should be given to

patients with STEMI and no contraindications who

are already receiving an ACE inhibitor and beta

blocker and who have an EF ≤ 0.40 and either

symptomatic HF or diabetes mellitus.

ACE inhibitors are reasonable for all patients with

STEMI and no contraindications to their use.

I IIa IIb III

I IIa IIb III


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Lipid Management

High-intensity statin therapy should be

initiated or continued in all patients with

STEMI and no contraindications to its

use.

It is reasonable to obtain a fasting lipid

profile in patients with STEMI, preferably

within 24 hours of presentation.

I IIa IIb III

I IIa IIb III


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Summary

•The first therapeutic aim of STEMI is restore blood flow toinfarct zone in order to myocardial salvage by reperfusion

therapy.

• Primary PCI is preferred reperfusion methodes; when itcannot be perfomed in due time ( more than 120 minutes),

fibrinolysis followed by coronary angiography in the the

next few hours (3-24 hours) constitutes a valid alternative.

• Beside reperfusion therapy, management of STEMI requires

antithrombotic medications combining dual antiplatelet

therapy and anti coagulant , B-blockers, ACE-I and statin


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For Your Attention


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Media campaign

Patient education

Methods ofSpeeding

Time to

Reperfusion

Greater use of

9-1-1

Prehospital Rx

MI protocol

Critical pathway

Qualityimprovement

program

Bolus lyticsDedicated

PCI team

5 min < 30 minD-B ≤ 90 min

D-N ≤ 30 min

Goals

Prehospital

ECG

Patient Transport Inhospital Reperfusion

Reperfusion

Documents

dr.andrianto sympo-1.pdf