Aha Guidelines for Stemi

7/28/2019 Aha Guidelines for Stemi

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ACC/AHA Guidelines for the

Management of Patients withST-Elevation Myocardial Infarction


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Management Before STEMI




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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.


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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.


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Onset of STEMI




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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.


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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.


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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


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Initial Recognition and

Management in the

Emergency Department

ACC/AHA Guidelines for theManagement of Patients with

ST-Elevation Myocardial Infarction


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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


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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


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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


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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


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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.


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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.


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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


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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


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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


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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


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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


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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


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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.


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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.


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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


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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


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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.


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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


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Symptom

Recognition Call toMedical System EDCath LabPreHospital

Delay in Initiation of Reperfusion TherapyIncreasing Loss of Myocytes

Treatment Delayed is Treatment Denied


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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.


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AbsoluteContraindications

Suspected aortic dissection

Active bleeding or bleeding diathesis

(excluding menses)

Significant closed-head or facial traumawithin 3 months


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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


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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


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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


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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


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


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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


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.


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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).


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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.


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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


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Evolution of PCI for STEMI

Primary PCI for STEMI:


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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


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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


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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


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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


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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.




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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


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


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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


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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




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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 After Fibrinolysis


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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.



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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


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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


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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.



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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


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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


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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


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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


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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


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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


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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


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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.



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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


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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.


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Hospital Management


Management of Patients with

ST-Elevation Myocardial Infarction

Sample Admitting Orders for the


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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



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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


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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:


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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



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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




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Sinus Brady Treat if hemodynamic compromise;

atropine / pacing

Junctional Treat if hemodynamic compromise;

atropine / pacing


Bradyarrhythmias




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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


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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


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


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


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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


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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


IABP)

YES NO

Refer for

nonurgent

catheterization

Refer for urgent


IABP)

Is ischemia


of medical therapy?

Is ischemia


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


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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


Indicated

Catheterization and


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


Indicated

Catheterization and


Indicated

Catheterization and


Indicated

Able to Exercise

ExerciseEcho

ExerciseNuclear

Long-Term Antithrombotic Therapy atHospital Discharge After STEMI


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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


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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


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Long-Term Management



Secondary Prevention and Long Term Management


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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



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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


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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




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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


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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


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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.



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84

y g g


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%



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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



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86



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



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87



Start in all patients. Continue indefinitely.

Observe usual contraindications.

Beta-

Blockers

Summary of Pharmacologic Rx: Ischemia


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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.,


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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


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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


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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


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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


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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


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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.

Documents

Aha Guidelines for Stemi