ACC/AHA Guidelines for the Management of Patients with ST-Elevation Myocardial Infarction

Management Before STEMI

ACC/AHA Guidelines for the Management of Patients with ST-Elevation Myocardial Infarction

Identification of Patients at Risk of STEMI

The presence and status of control of major risk 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.

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.

Onset of STEMI
ACC/AHA Guidelines for the Management of Patients with ST-Elevation Myocardial Infarction

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.

Options for Transport of Patients With STEMI and Initial Reperfusion Treatment
Hospital fibrinolysis: Door-to-Needle within 30 min.

Not PCI capable

Onset of symptoms of STEMI EMS Dispatch

EMS on-scene
Encourage 12-lead ECGs. Consider prehospital fibrinolytic if capable and EMS-to-needle within 30 min.

InterHospital Transfer

PCI capable

GOALS
5 min. Patient

8 min.
EMS

EMS Transport
Prehospital fibrinolysis EMS transport EMS-to-needle EMS-to-balloon within 90 min. within 30 min. Patient self-transport Hospital door-to-balloon within 90 min.

Dispatch 1 min.

Golden Hour = first 60 min.

Total ischemic time: within 120 min.

Options for Transport of Patients With STEMI and Initial Reperfusion Treatment

Patients receiving fibrinolysis should be risk-stratified to identify need for 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 Not PCI Capable PCI Capable Noninvasive Risk Stratification Rescue Ischemia driven Late Hospital Care and Secondary Prevention

PCI or CABG
Primary PCI

Initial Recognition and Management in the Emergency Department

ACC/AHA Guidelines for the Management of Patients with ST-Elevation Myocardial Infarction

ED Evaluation of Patients With STEMI

Brief Physical Examination in the ED
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)

10

ED Evaluation of Patients With STEMI

Differential Diagnosis of STEMI: Life-Threatening
Aortic dissection Pulmonary embolus Perforating ulcer Tension pneumothorax Boerhaave syndrome (esophageal rupture with mediastinitis)

11

ED Evaluation of Patients With STEMI

Differential Diagnosis of STEMI: Other Cardiovascular and Nonischemic
Pericarditis Atypical angina Early repolarization Wolff-Parkinson-White syndrome Deeply inverted T-waves suggestive of a central nervous system lesion or apical hypertrophic cardiomyopathy LV hypertrophy with strain Brugada syndrome

Myocarditis
Hyperkalemia Bundle-branch blocks Vasospastic angina Hypertrophic cardiomyopathy

12

ED Evaluation of Patients With STEMI

Differential Diagnosis of STEMI: Other Noncardiac
Gastroesophageal reflux (GERD) and spasm Cervical disc or neuropathic pain

Chest-wall pain
Pleurisy Peptic ulcer disease Panic attack

Biliary or pancreatic pain

Somatization and psychogenic pain disorder

13

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.

14

Electrocardiogram
Show 12-lead ECG results to emergency physician within 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 ventricular

infarction.

15

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

16

Biomarkers of Cardiac Damage

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 not contingent on a biomarker assay.

17

Imaging
Patients with STEMI should have a portable chest X-ray, but this should not delay implementation of reperfusion 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 STEMI from aortic dissection in patients for whom this distinction is initially unclear.
18

Oxygen

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.

19

Nitroglycerin
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.

20

Nitroglycerin
Nitrates should not be administered to patients with:

systolic pressure < 90 mm Hg or to 30 mm Hg below baseline severe bradycardia (< 50 bpm) tachycardia (> 100 bpm) or suspected RV infarction.
Nitrates should not be administered to patients who have received a phosphodiesterase inhibitor for erectile dysfunction within the last 24 hours (48 hours for tadalafil).

21

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 choice for management of pain associated with STEMI.

22

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 with nonenteric-coated formulations.

23

Beta-Blockers
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 betablockers promptly to STEMI patients without contraindications, especially if a tachyarrhythmia or hypertension is present.

24

Reperfusion
Given the current literature, it is not possible to say

definitively 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
25

Reperfusion
The medical system goal is to facilitate rapid recognition and treatment of patients with STEMI such that door-toneedle (or medical contactto-needle) time for initiation of fibrinolytic therapy can be achieved within 30 minutes or that door-to-balloon (or medical contacttoballoon) time for PCI can be kept within 90 minutes.

26

Reperfusion
Patient Transport Inhospital Reperfusion

Goals
D-N 30 min 5 min < 30 min D-B 90 min

Media campaign Patient education

Prehospital ECG MI protocol Critical pathway Bolus lytics Quality Greater use of improvement Dedicated 9-1-1 PCI team program Prehospital Rx

Methods of Speeding Time to Reperfusion

27

Treatment Delayed is Treatment Denied

Symptom Recognition

Call to Medical System

PreHospital

ED

Cath Lab

Increasing Loss of Myocytes

Delay in Initiation of Reperfusion Therapy

28

Contraindications and Cautions for Fibrinolysis in STEMI

Any prior intracranial hemorrhage Absolute Contraindications 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.

29

Contraindications and Cautions for Fibrinolysis in STEMI

Absolute Suspected aortic dissection Contraindications Active bleeding or bleeding diathesis (excluding menses) Significant closed-head or facial trauma within 3 months

30

Contraindications and Cautions for Fibrinolysis in STEMI

Relative History of chronic, severe, poorly controlled Contraindications 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)

31

Contraindications and Cautions for Fibrinolysis in STEMI

Relative Recent (< 2 to 4 weeks) internal bleeding Contraindications 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

32

Reperfusion Options for STEMI Patients Step One: Assess Time and Risk.

Time Since Symptom Onset

Risk of STEMI

Risk of Fibrinolysis

Time Required for Transport to a Skilled PCI Lab

33

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.
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

34

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. 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
35

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 bundle branch block (LBBB).

36

Fibrinolysis
In the absence of contraindications, it is reasonable to administer fibrinolytic therapy to STEMI 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 mV in 2 contiguous precordial leads or 2 adjacent limb leads.

37

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 MI

is suspected.

38

Evolution of PCI for STEMI

39

Primary PCI for STEMI: General Considerations

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 for STEMI) Cardiac surgical backup available
40

Primary PCI for STEMI: Specific Considerations

Medical contactto-balloon or door-to-balloon should 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/or pulmonary edema (Killip class 3) and onset of symptoms within 12 hours.

41

Primary PCI for STEMI: Specific Considerations

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 are

suitable for revascularization that can be

performed within 18 hours of shock.

42

Primary PCI for STEMI: Specific Considerations

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.

43

Primary PCI for STEMI: Specific Considerations

It is reasonable to perform primary PCI for patients 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.

44

Rescue PCI

Rescue 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 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.

45

Rescue PCI
Rescue 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. 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.

46

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.

47

PCI for Cardiogenic Shock

Cardiogenic Shock
Early Shock, Diagnosed on Hospital Presentation
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 invasive procedure-capable center

Delayed Onset Shock Echocardiogram to Rule Out Mechanical Defects

Arrange rapid transfer to invasive procedure-capable center

IABP

Cardiac Catheterization and Coronary Angiography

1-2 vessel CAD

Moderate 3-vessel CAD

Severe 3-vessel CAD

Left main CAD

PCI IRA

PCI IRA

Immediate CABG Cannot be performed

Staged Multivessel PCI

Staged CABG

48

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.

49

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. It is reasonable to perform PCI when there is documented clinical heart failure during the acute episode, even though subsequent evaluation shows preserved LV function (LVEF > 0.40). Routine PCI might be considered as part of an invasive strategy after fibrinolytic therapy.

50

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 elevation pattern on follow-up ECG 60 to 90 minutes after initiation of therapy.

51

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.

52

Ancillary Therapy to Reperfusion

Platelet counts should be monitored daily in patients taking UFH.

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.

53

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.

54

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.

55

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.

56

Thienopyridines

Clopidogrel is probably indicated in patients

receiving fibrinolytic therapy who are unable

to take aspirin because of hypersensitivity or gastrointestinal intolerance.

57

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.

58

Other Pharmacological Measures

Inhibition of the renin angiotensin aldosterone system Angiotensin converting enzyme (ACE) inhibitors

Angiotensin receptor blockers (ARB)

Aldosterone blockers Glucose control Magnesium Calcium channel blockers

59

ACE/ARB: Within 24 Hours

An ACE inhibitor should be administered orally within the first 24 hours of STEMI to the following patients 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.

60

ACE/ARB: Within 24 Hours

An ACE inhibitor administered orally can be useful within the first 24 hours of STEMI to the following patients 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 because of the risk of hypotension (possible exception: refractory hypotension).

61

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.

62

Hospital Management

ACC/AHA Guidelines for the Management of Patients with ST-Elevation Myocardial Infarction

63

Sample Admitting Orders for the Patient With STEMI

1. 2. 3. 4. Condition: Serious Normal Saline or D5W intravenous to keep vein open Vital signs: Heart rate, blood pressure, respiratory rate Monitor: Continuous ECG monitoring for arrhythmia/STsegment deviation 5. Diet: NCEP ATP III Therapeutic Lifestyle Changes, low sodium diet

64

Sample Admitting Orders for the Patient With STEMI

6. Activity: Bed rest with bedside commode, light activity 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

65

Emergency Management of Complicated STEMI

Clinical signs: Shock, hypoperfusion, congestive heart failure, acute pulmonary edema Most likely major underlying disturbance? Acute Pulmonary Edema
Hypovolemia

Low Output Cardiogenic Shock

Arrhythmia

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

First line of action

Administer Fluids Blood transfusions Cause-specific interventions Consider vasopressors

Bradycardia

Tachycardia

Check Blood Pressure See Section 7.7 in the ACC/AHA Guidelines for Patients With ST-Elevation Myocardial Infarction

Second line of action

Check Blood Pressure Systolic BP Greater than 100 mm Hg and not less than 30 mm Hg below baseline

Systolic BP Greater than 100 mm Hg

Systolic BP 70 to 100 mm Hg NO signs/symptoms of shock Dobutamine 2 to 20 mcg/kg per minute IV

Systolic BP 70 to 100 mm Hg Signs/symptoms of shock Dopamine 5 to 15 mcg/kg per minute IV

Systolic BP less than 70 mm Hg Signs/symptoms of shock

Nitroglycerin 10 to 20 mcg/min IV

Norepinephrine 0.5 to 30 mcg/min IV

ACE Inhibitors Short-acting agent such as captopril (1 to 6.25 mg) 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

Third line of action

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

66

Arrhythmias During Acute Phase of STEMI: Electrical Instability

Arrhythmia VPBs VT AIVR Treatment K+ , Mg++, beta blocker Antiarrhythmics, DC shock Observe unless hemodynamic compromise Search for cause (e.g., dig toxicity)

NPJT

67

Arrhythmias During Acute Phase of STEMI: Pump Failure / Excess Sympathetic Tone
Arrhythmia Sinus Tach Afib / Flutter PSVT Treatment Treat cause; beta blocker Treat cause; slow ventricular rate; DC shock Vagal maneuvers; beta blocker, verapamil / diltiazem; DC shock

68

Arrhythmias During Acute Phase of STEMI: Bradyarrhythmias

Arrhythmia Sinus Brady Treatment Treat if hemodynamic compromise; atropine / pacing Treat if hemodynamic compromise; atropine / pacing

Junctional

69

Arrhythmias During Acute Phase of STEMI: AV Conduction Disturbances

Proximal His Bundle < 120 ms 45 - 60 Distal Distal > 120 ms Often < 30

Escape Rhythm

Duration of AVB
Mortality Rx

2 - 3 days
Low Observe

Transient
High (CHF, VT) PM (ICD)

70

Recommendations for Treatment of Atrioventricular and Intraventricular Conduction Disturbances During STEMI
Atrioventricular Conduction INTRAVENTRICULAR First degree AV block Mobitz I second degree AV block CONDUCTION Normal ANTERIOR MI NON-ANTERIOR ANTERIOR MI NON-ANTERIOR ACTION CLASS ACTION CLASS ACTION CLASS ACTION CLASS ACTION CLASS Normal Observe I Observe I Observe I Observe IIb Observe IIa A III A III A III A* III A III TC III TC IIb TC IIb TC I TC I TV III TV III TV III TV III TV III Observe I Observe IIb Observe IIb Observe IIb Observe IIb Old or New III A III A III A* III A III Fascicular block A IIb TC I TC IIa TC I TC I (LAFB or LPFB) TC TV III TV III TV III TV III TV III Observe I Observe III Observe III Observe III Observe III Old bundle A III A III A III A* III A III branch block TC IIb TC I TC I TC I TC I TV III TV IIb TV IIb TV IIb TV IIb Observe III Observe III Observe III Observe III Observe III New bundle A III A III A III A* III A III branch block TC I TC I TC I TC I TC I TV IIb TV IIa TV IIa TV IIa TV IIa Observe III Observe III Observe III Observe III Observe III Fascicular A III A III A III A* III A III block + RBBB TC I TC I TC I TC I TC I TV IIb TV IIa TV IIa TV IIa TV IIa Observe III Observe III Observe III Observe III Observe III Alternating A III A III A III A* III A III left and right TC IIb TC IIb TC IIb TC IIb TC IIb bundle branch TV I TV I TV I TV I TV I block Mobitz II second degree AV block ANTERIOR MI NON-ANTERIOR ACTION CLASS ACTION CLASS Observe III Observe III A III A III TC I TC I TV IIa TV IIa Observe III Observe III A III A III TC I TC I TV IIa TV IIb Observe III Observe III A III A III TC I TC I TV IIa TV IIa Observe III Observe III A III A III TC IIb TC IIb TV I TV I Observe III Observe III A III A III TC IIb TC IIb TV I TV I Observe III Observe III A III A III TC IIb TC IIb TV I TV I

71

ICD Implantation After STEMI

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

EF < 0.30

EF 0.31 - 0.40

EF > 0.40

Additional Marker of Electrical Instability? No No ICD. Medical Rx

Yes

+
NEJM 349: 1836,2003

EPS

72

Algorithm for Management of Recurrent Ischemia/Infarction After STEMI

Recurrent ischemic-type discomfort at rest after STEMI
Escalation of medical therapy (nitrates, beta blockers) Anticoagulation if not already given Consider IABP for hemodynamic instability, poor LV function, or a large area of myocardium at risk Correct secondary causes of ischemia

Obtain 12-lead ECG

YES

ST-segment elevation?

NO

Is patient a candidate for revascularization ?? YES YES YES NO

Is Is ischemia ischemia controlled controlled by by escalation escalation of of medical medical therapy? therapy? NO NO

Can Can catheterization catheterization be be performed performed promptly? promptly?* promptly?*

Consider Consider (re) administration (re) of administration fibrinolytic therapy of

Refer Refer for for nonurgent nonurgent catheterization catheterization

Refer Refer for for urgent urgent catheterization catheterization (consider (consider IABP) IABP)

YES YES

NO NO

Coronary Coronary angiography angiography

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

Revascularization Revascularization with with PCI PCI and/or and/or CABG CABG as as dictated dictated by by anatomy anatomy

73

Evidence-Based Approach to Need for Catheterization and Revascularization After STEMI

STEMI
Primary Invasive Strategy Fibrinolytic Therapy Cath Performed EF greater than 0.40 No High -Risk Features No Cath Performed EF less than 0.40 No Reperfusion Therapy EF less than 0.40 EF greater than 0.40 High -Risk Features No High -Risk Features

Revascularization as Indicated

High -Risk Features

Catheterization and Revascularization as Indicated Functional Evaluation

ECG Interpretable Able to Exercise

ECG Uninterpretable Unable to Exercise Able to Exercise

Pharmacological Stress
Submaximal Symptom Symptom-Limited Adenosine Exercise Test Exercise Test or Dipyridamole Before Discharge Before or After Discharge Nuclear Scan

Dobutamine Echo

Exercise Echo

Exercise Nuclear

Catheterization and Revascularization as Indicated

Clinically Significant Ischemia* Ischemia

No Clinically Significant Ischemia* Ischemia

Medical Therapy

74

Long-Term Antithrombotic Therapy at Hospital Discharge After STEMI

STEMI Patient at Discharge

No Stent Implanted

No ASA allergy
No Indications for Anticoagulation Preferred: ASA 75 to 162 mg Class I; LOE: A 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 Indications for 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 No Indications for Anticoagulation Preferred: Clopidogrel 75 mg Class I; LOE: C Alternative: Warfarin INR (2.5 to 3.5) Class I; LOE: B

ASA Allergy
Indications for Anticoagulation

Warfarin INR (2.5 to 3.5) Class I; LOE: B

75

Long-Term Antithrombotic Therapy at Hospital Discharge After STEMI

STEMI Patient at Discharge
Stent Implanted

No ASA Allergy

ASA Allergy

No Indications for Anticoagulation

Indications for Anticoagulation

No Indications for Anticoagulation

Indications for Anticoagulation

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

76

Long-Term Management
ACC/AHA Guidelines for the Management of Patients with ST-Elevation Myocardial Infarction

77

Secondary Prevention and Long Term Management

Goals Smoking Goal: Complete Cessation Recommendations 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.

78

Secondary Prevention and Long Term Management

Goals
Blood pressure control: Goal: < 140/90 mm Hg or <130/80 mm Hg if chronic kidney disease or diabetes

Recommendations
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-angiotensinaldosterone system.

79

Secondary Prevention and Long Term Management

Goals
Physical activity: Minimum goal: 30 minutes 3 to 4 days per week; Optimal daily

Recommendations
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.

80

Secondary Prevention and Long Term Management

Goals
Lipid management: (TG less than 200 mg/dL) Primary goal: LDL-C << than 100 mg/dL

Recommendations
Start dietary therapy in all patients (< 7% of total calories as saturated fat and < 200 mg/d cholesterol). Promote physical activity 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: LDL-C < 100 mg/dL (baseline or on treatment): Statins should be used to lower LDL-C. LDL-C 100 mg/dL (baseline or on treatment): Intensify LDL-Clowering therapy with drug treatment, giving preference to statins.

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Secondary Prevention and Long Term Management

Goals
Lipid management: (TG 200 mg/dL or greater) Primary goal: NonHDL-C << 130 mg/dL

Recommendations
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 high TG.

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Secondary Prevention and Long Term Management

Goals Weight management: Goal: BMI 18.5 to 24.9 kg/m2 Waist circumference: Women: < 35 in. Men: < 40 in. 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 24.9 kg/m2. If waist circumference is 35 inches in women or 40 inches in men, initiate lifestyle changes and treatment strategies for metabolic syndrome.

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Secondary Prevention and Long Term Management

Goals
Diabetes management: Goal: HbA1c < 7%

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).

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Secondary Prevention and Long Term Management

Goals Recommendations

Antiplatelet In the absence of contraindications, start aspirin agents/ 75 to 162 mg/d and continue indefinitely. anticoagulants
75 mg/day or warfarin.
Manage warfarin to INR 2.5 to 3.5 in postSTEMI patients when clinically indicated or for

If aspirin is contraindicated, consider clopidogrel

those not able to take aspirin or clopidogrel.

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Secondary Prevention and Long Term Management

Goals
ReninAngiotensinAldosterone System Blockers

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 are intolerant 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 receiving therapeutic doses of an ACE inhibitor, have LVEF 0.40, and have either diabetes or heart failure.

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Secondary Prevention and Long Term Management

Goals BetaBlockers Recommendations Start in all patients. Continue indefinitely. Observe usual contraindications.

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Summary of Pharmacologic Rx: Ischemia

1st 24 h During Hosp Hosp DC + Long Term

Aspirin
Fibrinolytic

162-325 mg chewed
tPA,TNK, rPA, SK 60U/kg (4000) 12 U/kg/h (1000) aPTT 1.5 - 2 x C Oral daily

75-162 mg/d p.o.

75-162 mg/d p.o.

UFH Beta-blocker

aPTT 1.5 - 2 x C Oral daily Oral daily

JACC 2004;44: 671 Circulation 2004;110: 588

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Summary of Pharmacologic Rx: LVD, Sec. Prev.,

1st 24 h Anterior MI, Pulm Cong., EF < 40 During Hosp Hosp DC + Long Term Oral Daily Indefinitely

ACEI

ARB
Aldo Blocker

ACEI intol., HF, EF < 40

Oral Daily

Statin

No renal dysf, Same as K+ < 5.0 mEq/L during On ACEI, Hosp. HF or DM Start w/o lipid Indefinitely, profile LDL << 100

JACC 2004;44:671 Circ 2004;110:588

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Hormone Therapy

Hormone therapy with estrogen plus progestin

should not be given de novo to postmenopausal women after STEMI for secondary prevention of coronary events.

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Hormone Therapy
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 indication should weigh the risks and benefits.

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Antioxidants

Antioxidant vitamins such as vitamin E and/or

vitamin C supplements should not be prescribed to patients recovering from STEMI to prevent cardiovascular disease.

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Psychosocial Impact of STEMI

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.

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Cardiac Rehabilitation

Cardiac rehabilitation/secondary prevention

programs, when available, are recommended

for patients with STEMI, particularly those with multiple modifiable risk factors and/or those moderate- to high-risk patients in whom supervised exercise training is warranted.

94