ACC/AHA Guidelines STEMI DR RAJESH K F. Class I Benefit >>> Risk Procedure/ Treatment SHOULD be performed/ administered Class IIa Benefit >> Risk Additional

ACC/AHA Guidelines STEMI

DR RAJESH K F

Class I Benefit >>> Risk

Procedure/ Treatment SHOULD be performed/ administered

Class IIa Benefit >> RiskAdditional studies with focused objectives needed

IT IS REASONABLE to perform procedure/administer treatment

Class IIb Benefit ≥ RiskAdditional studies with broad objectives needed; Additional registry data would be helpful

Procedure/Treatment MAY BE CONSIDERED

Class III Risk ≥ BenefitNo additional studies needed

Procedure/Treatment should NOT be performed/administered SINCE IT IS NOT HELPFUL AND MAY BE HARMFUL

Applying Classification of Recommendations and Level of Evidence

Level A: Multiple populations evaluated; Data derived from multiple randomized clinical trials or meta-analyses

Level B: Limited populations evaluated. Data derived from a single randomized trial or non-randomized studies

Level C: Very limited populations evaluated. Only consensus opinion of experts, case studies, or standard-of-care.

shouldis recommendedis indicatedis useful/effective/

beneficial

is reasonablecan be useful/effective/

beneficialis probably recommended or

indicated

may/might be consideredmay/might be reasonableusefulness/effectiveness is

unknown /unclear/uncertain or not well established

is not recommendedis not indicatedshould notis not

useful/effective/beneficialmay be harmful

3

Class I Benefit >>> Risk

Procedure/ Treatment SHOULD be performed/ administered

Class IIa Benefit >> RiskAdditional studies with focused objectives needed

IT IS REASONABLE to perform procedure/administer treatment

Class IIb Benefit ≥ RiskAdditional studies with broad objectives needed; Additional registry data would be helpful

Procedure/Treatment MAY BE CONSIDERED

Class III Risk ≥ BenefitNo additional studies needed

Procedure/Treatment should NOT be performed/administered SINCE IT IS NOT HELPFUL AND MAY BE HARMFUL

Applying Classification of Recommendations and Level of Evidence

Evolution of Guidelines for STEMI

• 1990 ACC/AHA MI R Gunnar• 1996 ACC/AHA review MI T Ryan• 1999 ACC/AHA update MI T Ryan• 2004 ACC/AHA review STEMI E Antman• 2007 ACC/AHA update STEMI E Antman • 2009 ACC/AHA update STEMI & PCI F Kushner

• Prehospital issues• Management in ED• Management in hospital• Long term management

Prehospital issues

Prehospital Chest pain Evaluation and Treatment

• Prehospital EMS providers should administer 162-325 mg of non enteric coated aspirin (chewed) to suspected STEMI patients

• All ACLS providers perform and evaluate ECGs of suspected STEMI patients

Prehospital Fibrinolysis

• Establishment of prehospital fibrinolysis protocol is reasonable in 1) when physicians are present in ambulance or 2)well organized EMS systems(if transport time more than 60 min)

Prehospital Destination Protocols• Patients with STEMI who have

cardiogenic shock and are <75yrs should be brought immediately or secondarily transferred to facilities capable of PCI and CABG if it can be performed within 18 hrs of shock (SHOCK TRIAL)

• >75yrs and high risk of dying

III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII

• Patients with STEMI who have contraindications to fibrinolysis should be brought immediately or secondarily transferred to facilities capable of PCI and CABG

• (Door to departure time <30min)


• It is reasonable to transfer high risk patients who receive fibrinolytic therapy at non-PCI capable facility to a PCI-capable facility as soon as possible where either PCI can be performed when needed or as a pharmacoinvasive strategy.

• Consideration should be given to initiating a preparatory antithrombotic (anticoagulant plus antiplatelet) regimen prior to and during patient transfer (CARESS-IN-AMI,TRANSFER-AMI)

ACC/AHA 2009 Joint STEMI/PCI Guidelines Focused Update

Pathway: Triage and Transfer for PCI (in STEMI)

STEMI patient who is acandidate for reperfusion

Initially seen at a PCIcapable facility

Initially seen at a non-PCIcapable facility

Send to Cath Lab for primary PCI(Class I, LOE:A)

Transfer for primary PCI(Class I, LOE:A)

Initial Treatmentwith fibrinolytictherapy (Class 1, LOE:A)

Prep antithrombotic (anticoagulantplus antiplatelet) regimen

Diagnostic angio

Medicaltherapy only

PCI CABG

NOT HIGH RISK

Transfer to a PCI facility may be considered (Class IIb, LOE:C especially if ischemic symptoms persist and failure to reperfuse is suspected),

HIGH RISKTransfer to a PCI facility is reasonable for early diagnostic angio & possible PCI or CABG (Class IIa, LOE:B),

High-risk patients as defined by 2007 STEMI Focused Update should undergo cath (Class 1: LOE B)

At PCI facility, evaluate for timing of diagnostic angio

13

Options for Transport of Patients With STEMI and Initial Reperfusion Treatment

EMS Transport

Onset of symptoms of

STEMI

9-1-1EMS

Dispatch

EMS on-scene• Encourage 12-lead ECGs.• Consider prehospital fibrinolytic if

capable and EMS-to-needle within 30 min.

GOALS

PCIcapable

Not PCIcapable

Hospital fibrinolysis:

Door-to-Needle

within 30 min.

EMS Triage Plan

Inter-HospitalTransfer

Golden Hour = first 60 min. Total ischemic time: within 120 min.

Patient EMS Prehospital fibrinolysisEMS-to-needlewithin 30 min.

EMS transportEMS-to-balloon within 90 min.

Patient self-transport Hospital door-to-balloon

within 90 min.Dispatch

1 min.

5 min.

8 min.

Management in Emergency Department

Initial patient evaluvation

• Targeted history• Physical examination including focused

and limited neurological examination to look for prior stroke or cognitive defects prior to thrombolysis


ECG

• A 12 lead ECG should be performed within 10 min

• If not diagnostic and patient is symptomatic, serial ECGs at 5to10min or continuous ST segment monitoring

• In patients with IWMI, Rt sided ECG leads should be obtained

Laboratory examinations

• Should be performed but should not delay implementation of reperfusion therapy

• Serial biomarker measurements useful to provide supportive noninvasive evidence of reperfusion

• Serial biomarker measurements should not be relied on to diagnose reinfarction in 18 hrs after onset of STEMI


18

0 1 2 3 4 5 6 78

Cardiac troponin-no reperfusion

Days After Onset of STEMI

Mu

ltip

les

of

the

UR

L

Upper reference limit1

2

5

10

20

50

URL = 99th %tile of Reference Control Group

100

Cardiac troponin-reperfusion

CKMB-no reperfusion

CKMB-reperfusion

Cardiac Biomarkers in STEMI

Alpert et al. J Am Coll Cardiol 2000;36:959.Wu et al. Clin Chem 1999;45:1104.

Imaging

• Should have a portable CXR but should not delay reperfusion unless AD is suspected

• Portable CXR,TTE or TEE ,contrast CT or MRI should be used to differentiate STEMI from AD if not clear initially

Portable echo in ED is reasonable to • Clarify diagnosis of STEMI• Risk stratification• Diagnosis confounded by LBBB or

pacing• Suspicion of PWMI with anterior ST

depression • Mechanical causes of failure or shock

Hospital management

Routine measures

Oxygen• Supplemental oxygen should be

administered to patients with SaO2<90%

• It reasonable in all patients in first 6hrs

Nitroglycerin

• Patients with ongoing pain should receive s/l NTG (.4mg) for a total 3 doses

• IV NTG indicated for ongoing pain control of hypertension pulmonary congestion

Nitrates should not be administered when SBP<90mmhg SBP<30mmhg below baseline Severe bradycardia (<50) Tachycardia(>100) Suspected RV infarction Those received PDE inhibitor in 24 hrs (48hrs for tadalafil)


Analgesia

• Morphine sulfate(2-4mg IV with increments 2-8mg IV 5 to 15 min intervals) is the choice

• Patients taking NSAIDS should be discontinued due to increased risk of mortality ,reinfarction , HTN,HF and myocardial rupture

• (ExTRACT TIMI25)

Aspirin

• Aspirin should be chewed by patients who have not taken ,initial dose

• 162

• 325

• maintenance dose of 75 to 162 mg should be given indefinitely after STEMI to all patients without a true aspirin allergy

• For all post PCI STEMI patients stented without aspirin resistance ,allergy or increased risk of bleeding

• 162.5 to 325 mg od for 1month after BMS• 3months after SES• 6months after PES• After which 75 to 162 mg/d and continue

indefinitely.• if concerned about risk of bleeding 75 to

162 mg is reasonable in initial period


Beta blocker

• Oral beta blocker therapy should be initiated in 24hrs to those who not have

Signs of HF E/O low out put state Increased risk for cardiogenic shock >70yrs,SBP< 120,HR>110 or< 60 or Increased time since onset of symptoms•Other relative CI PR>.24sec 2nd or 3rd degree HB Active asthma Reactive airway diseases

• It is reasonable to administer IV BB at the time of presentation to patients who are hypertensive without any above contraindications

• Continue indefinitely • (COMMIT/CCS 2)

Reperfusion

• STEMI patients presenting to a facility without PCI or capability to transfer for PCI in 90 min should undergo fibrinolysis in 30 min

• ( compared with fibrin specific agent PCI may not reduce mortality if delay>60min)

Pharmacological reperfusion

• In the absence of contraindications fibrinolytic therapy should be administered if symptom onset within prior 12hrs and ST elevation >1mm in 2adjuscent limb leads or 2 contiguous chest leads

• New or presumably new LBBB

• It is reasonable if STEMI beginning within prior 12 to 24 hrs who have continuing chest discomfort and ST elevation

• It is reasonable if findings consistent with true PWMI

• The occurrence of a change in neurological status during or after reperfusion therapy particularly within 24hrs is considered to be ICH unless proved otherwise . Fibrinolytic, antiplatelet and anticoagulants should be discontinued until brain imaging disproves ICH

Primary PCI

• Patients with STEMI or MI with new or presumably new LBBB

• PCI of infarct related artery within 12hr of symptom onset

• Door to balloon time <90min• Person skilled in procedure(>75PCI/yr)• Supporting lab (>200PCI/yr of which 36

primary)• Cardiac surgical backup available

• STEMI patients presenting to hospital with PCI capability should be treated with primary PCI in 90 min

• If symptom duration is within 3hrs and expected DB-DN is

<1hr primary PCI >1hr fibrinolysis• >3hrs-primary PCI is generally preferred

with a goal of DB time <90 min

• <75yrs who develop shock within 36hrs of MI and suitable for revascularization that can be performed within 18hrs of shock

• Severe CHF and/or pulmonary edema(killip3) and onset of symptoms within 12hrs (DB<90 min)

• Primary PCI is reasonable for selected patients >75yrs who develop shock …..

• It is reasonable if onset of symptoms within prior 12 to 24hrs and

severe CHF or hemodynamic or electrical instability or persistent ischemic symptoms


• Should not be performed in non infarcted artery

• Should not be performed in asymptomatic patients >12hr after onset if they are hemodynamically and electrically stable


In fibrinolytic ineligible patients

• It should be performed who present in12hrs

• It is reasonable who present in12 to 24hrs and one of the following

severe CHF hemodynamic or electrical instability persistent ischemic symptoms


Facilitated PCI

• Regimens other than full dose fibrinolytic therapy might be considered when all of the following are present

high risk patient PCI not available in 90 min bleeding risk is low• Facilitated PCI with full dose fibrinolysis

is harmful• (ASSENT-4PCI,FINESSE )


Rescue PCI

• A strategy of CAG with intent to perform PCI (or emergency CABG) is recommended for patients after fibrinolysis, have any one of following

<75yrs who develop cardiogenic shock within 36hrs of MI and suitable for revascularization severe CHF or and /pulmonary edema (killip3) hemodynamically compromising ventricular arrhythmia

• Is reasonable for patients after fibrinolysis in patients >75yrs who develop cardiogenic shock and suitable for revascularization

• It is reasonable for patients with one of the following

hemodynamic or electrical instability or persistent ischemic symptoms


• It is reasonable in failed fibrinolytic therapy(<50% ST resolution in lead with worst initial elevation) and moderate to large area of myocardium at risk

(AWMI,IWMI +RVMI , precordial ST depression)

• (REACT)

PCI after successful fibrinolysis or no reperfusion

• PCI of totally occluded IRA >24hrs after STEMI not recommended in asymptomatic with SVD or DVD if hemodynamically and electrically stable and do not have E/O ischemia

Ancillary therapy

• Patients undergoing reperfusion with fibrinolytics should receive anticoagulant therapy for minimum 48hrs

• And preferably for duration of index hospitalization ,up to 8days (UFH is not recommended after 48hrs due to risk of HIT)

• UFH should be given intravenously in(dose 60U/kg max 4000U bolus, 12U/kg/hr max 1000/hr)(APTT 1.5 to 2 x control)

Enoxaparin( SCr <2.5 in male and 2 in female)(ExTRACT TIMI 25)• <75yrs dose 30mg IV bolus ,1mg/kg sc bd • >750.75mg/kg sc bd• Cr cl<301mg/kg odFondaparinux (SCr<3mg)2.5mgIV then 2.5mg sc od (OASIS 6)

• It is reasonable for patients do not undergo reperfusion therapy to be treated with anticoagulant therapy (non UFH regimen),dose time similar

• (CREATE,OASIS-6)

For patients proceeding to primary PCI • For prior treatment with UFH, additional

boluses should be administered as needed to maintain therapeutic APTT(200/250) taking into account whether GP IIb/IIIa receptor antagonists have been administered

• Bivalirudin is useful as support for primary PCI with or without prior treatment with heparin.

(HORIZONS-AMI)


• Prior enoxaparin If last sc dose in 8hrs no additional dose If last sc dose in 8to 12hrs IV 0.3 mg/kg

• Prior fondaparinux • additional IV anticoagulant

possessing anti IIa activity taking into account, whether GPIIb/IIIa RA given

• Because of the risk of catheter thrombosis fondaparinux should not be used as sole anticoagulant


• In patients with HIT it is reasonable to consider bivalirudin

Dose 0.25mg/kg bolus,0.5mg/kg/hr for 12hrs0.25mg/kg/hr for 36hrsreduce rate if PTT>75sec in 12hrs

Thienopyridines

• Clopidogrel 75mg should be added to aspirin regardless of whether they undergo fibrinolysis or no reperfusion therapy

(COMMIT-CCS2,CLARITY-TIMY 28)

• In patients <75yrs it reasonable to administer loading dose of 300mg

• For patients with medical therapy alone or PTCA without stenting –at least 14 days

• It is reasonable up to 1yr in all STEMI pts

• It is probably indicated in aspirin hypersensitivity or GI intolerance



If PCI is planned, one of the following • Clopidogrel at least 300 mg to 600mg

should be given as early as possible before or at the time of primary or non-primary PCI

• Prasugrel 60 mg should be given as soon as possible for primary PCI

• (TRITON TIMI 38)

For STEMI patients undergoing non-primary PCI

If the patient has received fibrinolytic therapya. ……and has been given clopidogrel, it

should be continued as the thienopyridine of choice.

b. …without a thienopyridine, a loading dose of 300-600 mg of clopidogrel should be given

• If the patient did not receive fibrinolytic therapy

• Either a loading dose of 300-600 mg of clopidogrel should be given or, once the coronary anatomy is known and PCI is planned, a loading dose of 60 mg of prasugrel should be given promptly and no later than 1 hour after the PCI

• In STEMI patients with a prior history of stroke and transient ischemic attack for whom primary PCI is planned, prasugrel is not recommended as part of a dual antiplatelet therapy regimen

The duration of therapy should bea. In patients receiving a stent (BMS or

DES)during PCI for ACS, clopidogrel 75 mg daily or prasugrel 10 mg daily should be given for at least 12 months

b. If the risk of morbidity from bleeding outweighs the anticipated benefit earlier discontinuation should be considered

• Continuation of clopidogrel or prasugrel beyond 15 months may be considered in patients undergoing drug-eluting stent placement


In patients taking a thienopyridine in whom CABG is planned and can be delayed, it is recommended that the drug be discontinued

• at least 5 days-clopidogrel • at least 7 days -prasugrel• … unless the need for revascularization

and/or the net benefit of the thienopyridine outweighs the potential risks of excess bleeding.

GP IIb/IIIa inhibitors

• It is reasonable to start treatment with abciximab at the time of primary PCI (with or without stenting) in selected patients with STEMI

• Tirofiban or eptifibatide before primary PCI

ACE inhibitors(SAVE,AIRE AND TRACE)

• ACE inhibitors should be started within 24hrs and continued indefinitely in all patients recovering from STEMI with LVEF <40% and HTN,CKD or diabetes unless CI

• who are not at low risk (normal LVEF, controlled RF and revascularization done)

• low risk patients is reasonable

Angiotensin receptor blockers

• ARB in patients who are intolerant of ACE inhibitors and with either heart failure or LVEF < 0.40.

• it is beneficial in ACE intolerant and have HTN

• (CHARM,VALIANT)

Aldosterone blockade

• Aldosterone blockade in patients without significant renal dysfunction or hyperkalemia who are already receiving therapeutic doses of an ACE inhibitor and BB have LVEF ≤ 0.40, and have either diabetes or heart failure.

• (EPHESUS,RALES)

Magnesium

• Documented magnesium deficits to be

corrected especially in patients receiving diuretics before STEMI

• TDP type VT associated with a prolonged QT interval to be treated with 1-2 gm of magnesium IV bolus over 5 min


CCB

• Diltiazem or verapamil to patients in whom beta blockers are ineffective or contraindicated for relief of ongoing ischemia or control of rapid ventricular rate in AF or AFL

• Nifedipine is contraindicated in treatment of STEMI


Blood sugar control

• It is reasonable to use an insulin based regimen to achieve and maintain glucose levels less than 180 mg/dl while avoiding hypoglycemia for patients with STEMI with either a complicated or uncomplicated course

• NICE SUGAR

68

Emergency Management of Complicated STEMI

Administer• Fluids• Blood transfusions• Cause-specific interventionsConsider vasopressors

Arrhythmia

Bradycardia Tachycardia

Systolic BPGreater than 100 mm Hg

Systolic BP 70 to 100 mm Hg

NO signs/symptomsof shock

Systolic BP70 to 100 mm HgSigns/symptoms

of shock

Systolic BP less than 70 mm Hg

Signs/symptoms of shock

Dobutamine2 to 20

mcg/kg per minute IV

Low Output -Cardiogenic Shock

Nitroglycerin10 to 20 mcg/min IV

Dopamine5 to 15

mcg/kg per minute IV

Norepinephrine0.5 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 present• Dobutamine 2 to 20 mcg/kg per minute IV if SBP 70 to 100 mm Hg and no signs/symptoms of shock

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See Section 7.7in the ACC/AHA Guidelines for

Patients With ST-Elevation Myocardial Infarction

Check Blood Pressure

Clinical signs: Shock, hypoperfusion, congestive heart failure, acute pulmonary edemaMost 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

Acute Pulmonary Edema

Check Blood Pressure

Systolic BP Greater than 100 mm Hg

and not less than 30 mm Hg below baseline

ACE InhibitorsShort-acting agent such as

captopril (1 to 6.25 mg)

Circulation 2000;102(suppl I):I-172-I-216.

RV infarction

• AV synchrony should be achieved and bradycardia should be corrected

• RV preload should be optimized with volume challenge in patients with hemodynamic instability if JVP is normal or low

• Inotropic support if no response• Delay CABG for 4wks to allow

recovery III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII

Mechanical complications

• Should be considered for urgent cardiac surgical repair unless further support is considered futile

• CABG should be undertaken at same time

IABP indications

• Refractory Hypotension ,Cardiogenic shock

• Low output state

• Refractory polymorphic VT

• Refractory pulmonary congestionIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII

ICD Implantation After STEMI

One Month After STEMI; No Spontaneous VT or VF 48 hours post-STEMI

EF < 0.30

EPS

Yes

+

EF 0.31 - 0.40

No

No ICD.Medical Rx

EF > 0.40

-

Additional Marker of Electrical Instability?

Spontaneous VT or VF 48 hours post-STEMI

Class I B Class IIb B

Class IIa B

Class III B

Class IA

73

Recommendations for Treatment of Atrioventricular and Intraventricular Conduction

Disturbances During STEMIINTRAVENTRICULAR 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 IIIA III A III A III A* III A III A III A IIITC III TC IIb TC IIb TC I TC I TC I TC ITV 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 IIIFascicular 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 IIbObserve I Observe III Observe III Observe III Observe III Observe III Observe IIIA III A III A III A* III A III A III A IIITC IIb TC I TC I TC I TC I TC I TC ITV III TV IIb TV IIb TV IIb TV IIb TV IIa TV IIaObserve III Observe III Observe III Observe III Observe III Observe III Observe IIIA III A III A III A* III A III A III A IIITC 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

Fascicular Observe III Observe III Observe III Observe III Observe III Observe III Observe IIIblock + 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 IIIleft and right A III A III A III A* III A III A III A IIIbundle branch TC IIb TC IIb TC IIb TC IIb TC IIb TC IIb TC IIbblock 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

Permanent pacemaker

• Persistent second degree AV block in His purkinje system with bil BBB

• Third degree AV block with in or below His purkinje system

• Transient or advanced 2nd or 3rd degree infranodal AV block and BBB

• Persistent and symptomatic 2nd or 3rd degree AV block

• Persistent second degree AV block in His purkinje system with bil BBB

Pericarditis

• Aspirin 650mg orally every 4to 6hrs

• Anticoagulants immediately discontinued if effusion develops

• Colchicine 0.6mg every 12hrs

• Acetaminophen 500 every 6hrs

• Corticosteroids

• NSAIDS

• ibuprofen


Long term management

• Smoking -Complete cessation• Blood pressure-< 140/90 mm Hg or <130/80 mm Hg if

chronic kidney disease or diabetes• Physical activity-Minimum goal is 30 minutes 3 to 4 days

per week, optimally daily• Weight management- Goal BMI 18.5 to 24.9 kg/m2, Waist

circumference-Women: < 35 in,Men: < 40 in. • Diabetes management-Appropriate hypoglycemic therapy

to achieve near-normal HbA1c.

Lipid management

• Start dietary therapy in all patients (< 7% of total calories as saturated fat and < 200 mg/d cholesterol, trans fatty acids)

• Adding plant stanol/sterol(2gm/day)and /or viscous fiber (>10gm/d).

• Promote physical activity and weight management.

• Encourage increased consumption of omega-3 fatty acids in form of fish or capsules 1gm/d.

• Assess fasting lipid profile in all patients, preferably within 24 hours of STEMI.

• Add drug therapy according to the following guide

• LDL-C should be < 100 mg/Dl • Further reduction to <70mg/dl is

reasonable • LDL-C ≥ 100 mg/dL• LDL-C–lowering therapy

• 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-C–lowering therapy, consider adding fibrate or niacin.• If TG is ≥ 500 mg/dL Consider fibrate or niacin before LDL-C–lowering therapy

warfarin

• Managing warfarin to INR 2 to 3 in patients when clinically indicated(AF or LV thrombus)

• when used in conjunction with antiplatelets should be monitored closely

• INR of 2 to 2.5 is recommended in such patients

• HRT with estrogen plus progestin should not be given

• Antioxidant vitamins should not be prescribed for sec preveventoin

Documents

ACC/AHA Guidelines STEMI DR RAJESH K F. Class I Benefit >>> Risk Procedure/ Treatment SHOULD be performed/ administered Class IIa Benefit >> Risk Additional