St Elevation Mi

2
This slide set was adapted from the ACC/AHA
Guidelines for Management of Patients With ST-
Elevation Myocardial Infarction (Journal of the
American College of Cardiology 2004;44:671-
719, e1-e211 and Circulation 2004;44:671-619,
e82-e292)
The full-text guidelines and executive summary
are also available on the Web sites:
ACC (www.acc.org) and,
AHA (www.americanheart.org)

3
IntroductionIntroduction
ACC/AHA Guidelines for the
Management of Patients with
ST-Elevation Myocardial Infarction

4
Daniel T. Anbe, MD, FACC, FAHA
Paul Wayne Armstrong, MD, FACC,
FAHA
Eric R. Bates, MD, FACC, FAHA
Lee A. Green, MD, MPH
Mary Hand, MSPH, RN, FAHA
Judith S. Hochman, MD, FACC, FAHA
Harlan M. Krumholz, MD, FACC, FAHA
Elliott M. Antman, MD, FACC, FAHA, Chair
ACC/AHA Guidelines for the ManagementACC/AHA Guidelines for the Management
of Patients With ST-Elevation Myocardialof Patients With ST-Elevation Myocardial
InfarctionInfarction
Writing Committee MembersWriting Committee Members
Frederick G. Kushner, MD, FACC, FAHA
Gervasio A. Lamas, MD, FACC
Charles J. Mullany, MB, MS, FACC
Joseph P. Ornato, MD, FACC, FAHA
David L. Pearle, MD, FACC, FAHA
Michael A. Sloan, MD, FACC
Sidney C. Smith, Jr., MD, FACC, FAHA

5
Class I
Benefit >>> Risk
Procedure/ Treatment
SHOULD be
performed/
administered
Class IIa
Benefit >> Risk
Additional studies with
focused objectives
needed
IT IS REASONABLE to
perform
procedure/administer
treatment
Class IIb
Benefit ≥ Risk
Additional studies with
broad objectives needed;
Additional registry data
would be helpful
Procedure/Treatment
MAY BE CONSIDERED
Class III
Risk ≥ Benefit
No additional studies
needed
Procedure/Treatment
should NOT be
performed/administered
SINCE IT IS NOT
HELPFUL AND MAY BE
HARMFUL
should
is recommended
is indicated
is useful/effective/
beneficial
is reasonable
can be useful/effective/
beneficial
is probably recommended or
indicated
may/might be considered
may/might be reasonable
usefulness/effectiveness is
unknown /unclear/uncertain
or not well established
is not recommended
is not indicated
should not
is not
useful/effective/beneficial
may be harmful
Applying Classification ofApplying Classification of
Recommendations and Level of EvidenceRecommendations and Level of Evidence

6
Level A
Multiple (3-5)
population risk
strata evaluated
General
consistency of
direction and
magnitude of
effect
Class I
• Recommen-
dation that
procedure or
treatment is
useful/
effective
• Sufficient
evidence from
multiple
randomized
trials or meta-
analyses
Class IIa
• Recommen-
dation in favor
of treatment or
procedure
being useful/
effective
• Some
conflicting
evidence from
multiple
randomized
trials or meta-
analyses
Class IIb
• Recommen-
dation’s
usefulness/
efficacy less
well
established
• Greater
conflicting
evidence from
multiple
randomized
trials or meta-
analyses
Class III
• Recommen-
dation that
procedure or
treatment not
useful/effective
and may be
harmful
• Sufficient
evidence from
multiple
randomized
trials or meta-
analyses
Applying Classification of
Recommendations and Level of Evidence

7
Level B
Limited (2-3)
population risk
strata evaluated
Class I
• Recommen-
dation that
procedure or
treatment is
useful/effective
• Limited
evidence from
single
randomized
trial or non-
randomized
studies
Class IIa
• Recommen-
dation in favor
of treatment or
procedure
being useful/
effective
• Some
conflicting
evidence from
single
randomized
trial or non-
randomized
studies
Class IIb
• Recommen-
dation’s
usefulness/
efficacy less
well established
• Greater
conflicting
evidence from
single
randomized trial
or non-
randomized
studies
Class III
• Recommen-
dation that
procedure or
treatment not
useful/effective
and may be
harmful
• Limited
evidence from
single
randomized trial
or non-
randomized
studies

8
Level C
Very limited (1-
2) population
risk strata
evaluated
Class I
• Recommen-
dation that
procedure or
treatment is
useful/
effective
• Only expert
opinion, case
studies, or
standard-of-
care
Class IIa
• Recommen-
dation in favor
of treatment or
procedure
being
useful/effective
• Only diverging
expert opinion,
case studies, or
standard-of-
care
Class IIb
• Recommen-
dation’s
usefulness/
efficacy less
well established
• Only diverging
expert opinion,
case studies, or
standard-of-
care
Class III
• Recommend-
ation that
procedure or
treatment not
useful/effective
and may be
harmful
• Only expert
opinion, case
studies, or
standard-of-
care

9
PathologyPathology

10
Chronology of the
interface between the
patient and the
clinician through the
progression of plaque
formation and the
onset of complications
of STEMI.
Management
Before STEMI
4
1 2 3 4 5 6
Onset of STEMI
- Prehospital issues
- Initial recognition and management
in the Emergency Department (ED)
- Reperfusion
Hospital Management
- Medications
- Arrhythmias
- Complications
- Preparation for discharge
Secondary Prevention/
Long-Term Management
Presentation
Working Dx
ECG
Cardiac
Biomarker
Final Dx
UA
NQMI QwMI
No ST Elevation
NSTEMI
Ischemic Discomfort
Acute Coronary Syndrome
Unstable
Angina
Myocardial Infarction
ST Elevation
Modified from Libby. Circulation 2001;104:365,
Hamm et al. The Lancet 2001;358:1533 and
Davies. Heart 2000;83:361.

11
Prevention of Coronary Heart Disease (CHD)Prevention of Coronary Heart Disease (CHD)
Campaigns and StatementsCampaigns and Statements
• National Cholesterol Education Program (NCEP) Adult Treatment
Panel (ATP) III
• LDL goals, CHD risk equivalent, metabolic syndrome
• Joint National Committee (JNC)-7
• Hypertension management
• World Heart Federation (WHF), World Health Organization (WHO)
• Cigarette smoking
• National Heart, Lung, and Blood Institute (NHLBI), Food and
Drug Administration (FDA), Centers for Disease Control (CDC)
• Obesity
• AHA/NHLBI Go Red for Women, AHA Guidelines on Prevention
of Cardiovascular Disease (CVD) in Women
• Women and CVD

12
Management Before STEMIManagement Before STEMI

13
Identification of Patients at Risk of STEMIIdentification 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.
III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII

14
Identification of Patients at Risk of STEMIIdentification 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.

15
Onset of STEMIOnset of STEMI

16
Patient Education for Early Recognition andPatient Education for Early Recognition and
Response to STEMIResponse to STEMI
Patients should understand the advisability
of calling 9-1-1 if symptoms are unimproved
or worsening after 5 minutes.
Patients should understand their risk of
STEMI and how to recognize symptoms of
STEMI.

17
If you have any heart
attack symptoms,
CALL 9-1-1
immediately.
Don’t wait for more than
a few minutes – 5 at
most – to call 9-1-1.
ACT in TIMEACT in TIME
http://www.nhlbi.nih.gov/actintime/index.htm.
Accessed December 20, 2004.

18
Patient Education for Early Recognition andPatient Education for Early Recognition and
Response to STEMIResponse to STEMI
Healthcare providers should instruct patients
previously prescribed nitroglycerin (NTG) on use
for chest discomfort or pain and to call 9-1-1 if
symptoms do not improve or worsen 5 minutes
after ONE sublingual NTG dose*.
(* Nitroglycerin Dose: 0.4 mg sublingually)

19
Prehospital Chest Pain EvaluationPrehospital Chest Pain Evaluation
and Treatmentand 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 non–enteric-coated
formulations.
It is reasonable for all 9-1-1 dispatchers to advise patients without a
history of aspirin allergy who have symptoms of STEMI to chew
aspirin (162 to 325 mg) while awaiting arrival of prehospital EMS
providers. Although some trials have used enteric-coated aspirin for
initial dosing, more rapid buccal absorption occurs with non–enteric-
coated formulations.

20
Has the patient been previously
prescribed nitroglycerin?
No
Is Chest Discomfort/Pain Unimproved or Worsening
5 Minutes After It Starts?
5 Minutes After It Starts?
Yes No
CALL 9-1-1
IMMEDIATELY.
CALL 9-1-1
IMMEDIATELY.
Follow 9-1-1 instructions.
[Patients may receive instructions to chew aspirin
(162-325 mg) if not contraindicated or may receive
aspirin en route to the hospital.]
Follow 9-1-1 instructions.
[Patients may receive instructions to chew aspirin
(162-325 mg) if not contraindicated or may receive
aspirin en route to the hospital.]
Notify Physician.Notify Physician.
Instructions for NitroglycerinInstructions for Nitroglycerin
Use and EMS ContactUse and EMS Contact
Patient experiences
chest pain/discomfort

21
Take ONE Nitroglycerin
Dose Sublingually.
Take ONE Nitroglycerin
Dose Sublingually.
5 Minutes After Taking ONE Nitroglycerin Dose*
Sublingually?
5 Minutes After Taking ONE Nitroglycerin Dose*
Sublingually?
Yes
YesNo
See ACC/AHA Guidelines for
the Management of Patients
with Chronic Stable Angina.
See ACC/AHA Guidelines for
the Management of Patients
with Chronic Stable Angina.
Instructions for NitroglycerinInstructions for Nitroglycerin
Use and EMS ContactUse and EMS Contact
CALL 9-1-1
IMMEDIATELY.
CALL 9-1-1
IMMEDIATELY.
Patient experiences
chest pain/discomfort
* Nitroglycerin Dose: 0.4 mg sublingually

22
Prehospital IssuesPrehospital Issues

23
All public safety first responders trained and
equipped to provide early defibrillation with
AEDs.
Prehospital aspirin 162 to 325 mg (chewed)
administration:
By prehospital providers
Advice by dispatchers

24
Prehospital 12-lead ECG by ACLS
Prehospital fibrinolysis
Reperfusion “checklist” by ACLS providers that
is relayed with the ECG to a predetermined
medical control facility and/or receiving
hospital

25
Prehospital destination protocols
Patients with STEMI who have cardiogenic
shock and are <75 yrs old should be brought
immediately or secondarily transferred to
facilities capable of cardiac catheterization and
rapid revascularization with 18 hrs of shock

26
Prehospital destination protocols:
Patients with STEMI who have contraindications
to fibrinolytic therapy should be brought
immediately or secondarily transferred promptly
(primary-receiving hospital door-to-departure time
less than 30 min.) to facilities capable of cardiac
catheterization and rapid revascularization

27
Options for Transport of Patients WithOptions for Transport of Patients With
STEMI and Initial Reperfusion TreatmentSTEMI and Initial Reperfusion Treatment
EMS Transport
Onset of
symptoms of
STEMI
9-1-1
EMS
Dispatch
EMS on-scene
• Encourage 12-lead ECGs.
• Consider prehospital fibrinolytic if
capable and EMS-to-needle within
30 min.
GOALS
PCI
capable
Not PCI
capable
Hospital fibrinolysis:
Door-to-Needle
within 30 min.
EMS
Triage
Plan
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-balloon
within 90 min.
Dispatch
1 min.
5
min.
8
min.

28
• 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
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 andOptions for Transport of Patients With STEMI and
Initial Reperfusion TreatmentInitial Reperfusion Treatment

29
Initial Recognition andInitial Recognition and
Management in theManagement in the
Emergency DepartmentEmergency Department

30
ED Evaluation ofED Evaluation of
Patients With STEMIPatients 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

31
Aortic dissection
Pulmonary embolus
Perforating ulcer
Tension pneumothorax
Boerhaave syndrome
(esophageal rupture with
mediastinitis)
Differential Diagnosis of STEMI: Life-Threatening

32
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
Differential Diagnosis of STEMI: Other Cardiovascular and
Nonischemic

33
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
Differential Diagnosis of STEMI: Other Noncardiac

34
ElectrocardiogramElectrocardiogram
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.

35
ElectrocardiogramElectrocardiogram
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.

36
Laboratory ExaminationsLaboratory 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

37
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.
Biomarkers of Cardiac DamageBiomarkers of Cardiac Damage

38
00 11 22 33 44 55 66 77
88
Cardiac troponin-no reperfusionCardiac troponin-no reperfusion
Days After Onset of STEMIDays After Onset of STEMI
MultiplesoftheURLMultiplesoftheURL
Upper reference limitUpper reference limit
11
22
55
1010
2020
5050
URL = 99th %tile ofURL = 99th %tile of
Reference Control GroupReference Control Group
100100
Cardiac troponin-Cardiac troponin-reperfusionreperfusion
CKMB-no reperfusionCKMB-no reperfusion
CKMB-CKMB-reperfusionreperfusion
Cardiac Biomarkers in STEMICardiac Biomarkers in STEMI
Alpert et al. J Am Coll Cardiol 2000;36:959.
Wu et al. Clin Chem 1999;45:1104.

39
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.
ImagingImaging

40
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.
OxygenOxygen

41
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.
NitroglycerinNitroglycerin

42
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 (48
hours for tadalafil).
• systolic pressure < 90 mm Hg or ≥ to 30 mm
Hg below baseline
• severe bradycardia (< 50 bpm)
• tachycardia (> 100 bpm) or
• suspected RV infarction.
NitroglycerinNitroglycerin

43
AnalgesiaAnalgesia
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.

44
AspirinAspirin
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
non–enteric-coated formulations.

45
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 or
hypertension is present.
Beta-BlockersBeta-Blockers

46
Phase of
Treatment
Acute
treatment
Secondary
prevention
Overall
Total No.
Patients
28,970
24,298
53,268
0.5 1 2
Relative risk (RR) of death
Beta blocker
better
RR (95% CI)
Placebo
better
0.87 (0.77-0.98)
0.77 (0.70-0.84)
0.81 (0.75-0.87)
Summary of Trials of Beta-Blocker TherapySummary of Trials of Beta-Blocker Therapy
Antman E, Braunwald E. Acute Myocardial Infarction. In:
Braunwald E, Zipes DP, Libby P, eds. Heart Disease: A
textbook of Cardiovascular Medicine, 6th ed.,
Philadelphia, PA: W.B. Sanders, 2001, 1168.

47
ReperfusionReperfusion
• 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

48
The medical system goal is to facilitate rapid recognition
and treatment of patients with STEMI such that door-to-
needle (or medical contact–to-needle) time for initiation
of fibrinolytic therapy can be achieved within 30
minutes or that door-to-balloon (or medical contact–to-
balloon) time for PCI can be kept within 90 minutes.

49
Media campaign
Patient education
Methods of
Speeding
Time to
Reperfusion
Greater use of
9-1-1
Prehospital Rx
MI protocol
Critical pathway
Quality
improvement
program
Bolus lytics
Dedicated
PCI team
5 min < 30 min
D-B ≤ 90 min
D-N ≤ 30 min
Goals
Prehospital
ECG
Patient Transport Inhospital Reperfusion

50
Symptom
Recognition
Call to
Medical System
ED Cath LabPreHospital
Delay in Initiation of Reperfusion Therapy
Increasing Loss of Myocytes
Treatment Delayed is Treatment DeniedTreatment Delayed is Treatment Denied

51
PCI vs Fibrinolysis for STEMI:PCI vs Fibrinolysis for STEMI:
Short Term Clinical OutcomesShort Term Clinical Outcomes
7
4.5
2.2
6
1
0
7
89
7 7
21
2 1
5
13
0
5
10
15
20
25
30
35
PCI
Frequency(%)
P=0.0002
P=0.0003 P < 0.0001
P < 0.0001
P < 0.0001
P=0.0004
P=0.032
P < 0.0001
Death Death,
no
SHOCK
data
Recurr.
MI
Recurr.
Ischemia
Total
Stroke
Hemorrh.
Stroke
Major
Bleed
Death
MI
CVA
Fibrinolysis
N = 7739
Keeley et al. The Lancet 2003;361:13.

52
Overview of PCI vs Lysis:Overview of PCI vs Lysis: Issues to ConsiderIssues to Consider
• Sample Size = 7739
• Data span 10–15 years
• Selection bias of pts enrolled
• 2% mortality benefit with PCI depends on lytic –
(not significant vs tPA if SHOCK is excluded)
• Composite endpoint is driven by reMI –
potential biases against lytic arms:
Hard to diagnose peri-PCI MI
UFH used in lytic arms--? Better antithrombins
Dependent on use of PCI post-lysis
JACC 2004;44: 671.
Circulation 2004;110: 588.

53
Contraindications and CautionsContraindications and Cautions
for Fibrinolysis in STEMIfor 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.

54
Absolute
Contraindications
• Suspected aortic dissection
• Active bleeding or bleeding diathesis
(excluding menses)
• Significant closed-head or facial trauma
within 3 months

55
• 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

56
Relative
Contraindications
• 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

57
PCI versus Fibrinolysis with Fibrin-SpecificPCI versus Fibrinolysis with Fibrin-Specific
Agents: Is Timing (Almost) Everything?Agents: Is Timing (Almost) Everything?
Favors PCI
Favors fibrinolysis with
a fibrin-specific agent
13 RCTs
N = 5494
P = 0.04
AbsoluteRiskDifferenceinDeath(%)
30 40 50 60 70 80
PCI-Related Time Delay (minutes)
10 −
5 −
0 −
-5 − ┬ ┬ ┬ ┬ ┬ ┬
Nallamothu and Bates. Am J Cardiol 2003;92:824.

58
SymptomsSymptoms toto balloon inflation (minutes)balloon inflation (minutes)
One-yearmortality,%One-yearmortality,%
6 RCTs of Primary PCI by Zwolle Group 19946 RCTs of Primary PCI by Zwolle Group 1994 –– 20012001
N = 1791N = 1791
RR = 1.08 [1.01RR = 1.08 [1.01 –– 1.16] for each 30 min delay1.16] for each 30 min delay
((PP = 0.04)= 0.04)
PP < 0.0001< 0.0001
1212
1010
88
66
44
22
00
00 6060 120120 180180 240240 300300
360360
Symptom Onset to Balloon Time andSymptom Onset to Balloon Time and
Mortality in Primary PCI for STEMIMortality in Primary PCI for STEMI
DeLuca et al. Circulation 2004;109:1223.

59
Reperfusion Options for STEMI PatientsReperfusion Options for STEMI Patients
Step OneStep One: Assess Time and Risk.: Assess Time and Risk.
Time Since
Symptom
Onset
Time Required
for Transport to
a Skilled PCI
Lab
Risk of STEMI Risk of
Fibrinolysis

60
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:Step 2: Select Reperfusion Treatment.Select Reperfusion Treatment.
If presentation is < 3 hours and there is no delay to an invasive
strategy, there is no preference for either strategy.

61
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:Step 2: Select Reperfusion Treatment.Select Reperfusion Treatment.
If presentation is < 3 hours and there is no delay to an invasive strategy,
there is no preference for either strategy.

62
PCI vs Lysis:PCI vs Lysis: Additional DataAdditional Data
• Mortality advantage of PCI diminishes:
As risk with lytic decreases: PCI = Lysis at 3%
With increasing delay:
PCI = Fibrin spec lytic with 60 min delay
RR = 1.08 for every 30 min from onset of sx
The earlier patient is seen: PCI = Lysis in < 3 h from sx
• Outcomes with PCI are influenced by time of day and
operator/institution volume and experience
• Trials of transfer for PCI:
Had very short transport and D-B times
PCI mortality higher than prehospital lysis in pts
treated early (2h)
JACC 2004;44: 671
Circ 2004;110: 588

63
FibrinolysisFibrinolysis
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).
III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII

64
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.

65
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.

66
Evolution of PCI for STEMIEvolution of PCI for STEMI
Antman. Circulation 2001;103:2310.
Balloon Antiplatelet
Rx
Stent DES
GP IIb/IIIa inhibitor
ASA
Clopidogrel
AngioJet
Thrombus
Removal and
Distal
Embolization
Protection
Devices
Embolization
Protection Device
Platelet

67
Primary PCI for STEMI:Primary PCI for STEMI:
General ConsiderationsGeneral 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

68
Specific ConsiderationsSpecific Considerations
Medical contact–to-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.

69
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.

70
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.

71
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.

72
Rescue PCIRescue 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
Rescue PCI should be performed in patients with
severe CHF and/or pulmonary edema (Killip class
3) and onset of symptoms within 12 hours.

73
Rescue PCIRescue 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.

74
PCI for Cardiogenic ShockPCI 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

75
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
IABP

76
Cardiogenic Shock
Delayed Onset Shock
Echocardiogram to Rule Out
Mechanical Defects
IABP
onset
Arrange rapid transfer to invasive

77
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 CABG
Cannot be
performed
Delayed Onset Shock
Echocardiogram to Rule Out
Mechanical Defects
Cardiac Catheterization and Coronary
Angiography
IABP
onset
Arrange rapid transfer to invasive

78
PCI After FibrinolysisPCI 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.

79
PCI After FibrinolysisPCI After Fibrinolysis
It is reasonable to perform routine PCI in patients
with left ventricular ejection fraction (LVEF) ≤ 0.40,
CHF, or serious ventricular arrhythmias.
Routine PCI might be considered as part of
an invasive strategy after fibrinolytic therapy.
It is reasonable to perform PCI when there is
documented clinical heart failure during the acute
episode, even though subsequent evaluation
shows preserved LV function (LVEF > 0.40).

80
Assessment of ReperfusionAssessment 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.

81
Ancillary Therapy to ReperfusionAncillary 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.

82
Ancillary Therapy to ReperfusionAncillary Therapy to Reperfusion
Low molecular-weight heparin (LMWH) might be considered an
acceptable alternative to UFH in patients less than 75 years
who are receiving fibrinolytic therapy in the absence of
significant renal dysfunction.
Enoxaparin used with tenecteplase is the most
comprehensively studied.
Platelet counts should be monitored daily in patients
taking UFH.

83
AspirinAspirin
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.

84
ThienopyridinesThienopyridines
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.

85
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.

86
Clopidogrel is probably indicated in patients
receiving fibrinolytic therapy who are unable
to take aspirin because of hypersensitivity or
gastrointestinal intolerance.

87
Glycoprotein IIb/IIIa InhibitorsGlycoprotein 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.

88
Other Pharmacological MeasuresOther Pharmacological Measures
Angiotensin converting enzyme (ACE)
inhibitors
Angiotensin receptor blockers (ARB)
Aldosterone blockers
Glucose control
Magnesium
Calcium channel blockers
Inhibition of
the renin
-angiotensin
-aldosterone
system

89
All-Cause Mortality
Years
ProbabilityofEvent
0
0.05
0.
1
0.15
0.2
0.25
0.3
0 1 2 3
0.35
0.4
4
ACE-I
Placebo
ACE-I 2995 2250 1617 892 223
Placebo 2971 2184 1521 853 138
Flather MD, et al. Lancet. 2000;355:1575–1581
OR: 0.74 (0.66–0.83)
ACE-I: 702/2995 (23.4%)
Placebo: 866/2971 (29.1%)
TRACE
Echocardiographic
EF ≤ 35%
AIRE
Clinical and/or
radiographic
signs of HF
SAVE
Radionuclide
EF ≤ 40%

90
Captopril
0
0.05
0.1
0.15
0.2
0.25
0.3
0 6 12 18 24 30 36
ProbabilityofEvent
Mortality by Treatment
Pfeffer, McMurray, Velazquez, et al. N Engl J Med 2003;349
Valsartan 4909 4464 4272 4007 2648 1437 357
Months
Valsartan vs. Captopril: HR = 1.00; P = 0.982
Valsartan + Captopril vs. Captopril: HR = 0.98; P = 0.726
Captopril 4909 4428 4241 4018 2635 1432 364
Valsartan + Cap 4885 4414 4265 3994 2648 1435 382
Valsartan
Valsartan + Captopril

91
P = 0.008
RR = 0.85 (95% CI, 0.75–0.96)
EPHESUS: All-Cause Mortality
Eplerenone 3319 3044 2463 1260 336 0 0
Placebo 3313 2983 2418 1213 323 2 0
Month 6 12 18 24 30 36
0
5
10
15
20
25
CumulativeIncidence(%)
0
Eplerenone
Placebo
Pitt et al. N Engl J Med 2003;348:1309-1321

92
ACE/ARB: Within 24 HoursACE/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.

93
ACE/ARB: Within 24 HoursACE/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).

94
Strict Glucose Control During STEMIStrict 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.

95
Hospital ManagementHospital Management

96
Sample Admitting Orders for theSample Admitting Orders for the
Patient With STEMIPatient With STEMI
1. Condition: Serious
2. 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

97
Sample Admitting Orders for theSample Admitting Orders for the
Patient With STEMIPatient 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

98
Emergency Management of Complicated STEMIEmergency Management of Complicated STEMI
Administer
• Fluids
• Blood transfusions
• Cause-specific
interventions
Consider vasopressors
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 present
• Dobutamine 2 to 20 mcg/kg per minute IV if SBP 70
to 100 mm Hg and no signs/symptoms of shock
FirstlineofactionSecondlineofactionThirdlineofaction
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
Acute Pulmonary 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 as
captopril (1 to 6.25 mg)
Circulation 2000;102(suppl I):I-172-I-216.

99
Right Ventricular InfarctionRight Ventricular Infarction
Clinical findings:
Shock with clear lungs, elevated JVP
Kussmaul sign
Hemodynamics:
Increased RA pressure (y descent)
Square root sign in RV tracing
ECG:
ST elevation in R sided leads
Echo:
Depressed RV function
Rx:
Maintain RV preload
Lower RV afterload (PA---PCW)
Inotropic support
ReperfusionV4R
Modified from Wellens. N Engl J Med
1999;340:381.

100
VentricularVentricular
Septal RuptureSeptal Rupture
Mitral RegurgitationMitral Regurgitation
(Pap. M. dysfunction)(Pap. M. dysfunction)
Incidence 1-2% 1-6% 1-2%
Timing 3-5 d p MI 3-6 d p MI 3-5 d p MI
Phy Exam murmur 90% JVD, EMD murmur 50%
Thrill Common No Rare
Echo Shunt Peric. Effusion Regurg. Jet
PA cath O2 step up Diast Press Equal. c-v wave in PCW
Images:Courtesy of W D Edwards (Mayo Foundation)
Data: Lavocitz. CV Rev Rpt 1984;5:948; Birnbaum. NEJM 2002;347:1426.
Free WallFree Wall
RuptureRupture

101
““Warning Arrhythmias”Warning Arrhythmias”
Antman and Rutherford. Coronary Care Medicine.
Boston, MA: Martinus Nijhoff Publishing;1986:81.

102
Arrhythmias During Acute Phase of STEMI:Arrhythmias During Acute Phase of STEMI:
Electrical InstabilityElectrical Instability
VPBs K+
, Mg++
, beta blocker
VT Antiarrhythmics, DC shock
AIVR Observe unless hemodynamic
compromise
NPJT Search for cause (e.g., dig toxicity)
Arrhythmia Treatment

103
Sinus Tach Treat cause; beta blocker
Afib / Flutter Treat cause; slow ventricular rate; DC shock
PSVT Vagal maneuvers; beta blocker,
verapamil / diltiazem; DC shock
Pump Failure / Excess Sympathetic TonePump Failure / Excess Sympathetic Tone

104
Sinus Brady Treat if hemodynamic compromise;
atropine / pacing
Junctional Treat if hemodynamic compromise;
atropine / pacing
BradyarrhythmiasBradyarrhythmias

105
AV Conduction DisturbancesAV Conduction 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

106
Recommendations for Treatment of
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 IIb
TV 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

107
ICD Trials in Post-MI Patients
NEJM 1996;335:1933-40.
NEJM 1999;341;1882-90.
NEJM 2002;346:877-93.
EF
Upper limit,
mean
3-30 VPBs
rate greater
than 120
Greater than 2
VPS
rate greater
than 100
MADIT 2 2002 1232 Greater
than 29
None
necessary
30%, 23% No 0.69 (0.51-0.93)
35%, 26% Yes 0.46 (0.26-0.82)
MUSTT 1999 704 Greater
than 3
40%, 30% Yes 0.42 (0.28-0.62)
MADIT 1996 196 Greater
than 20
Qualifying
arrhythmia
EPS Mortality hazard
ICD versus no
ICD (95%CI)
Study
Name
Year Number
of
patients
Days
post-MI

108
ICD Implantation After STEMI
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?

109
Algorithm for Management of Recurrent
Ischemia/Infarction After STEMI
Obtain 12-lead ECG
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 of
myocardium at risk
• Correct secondary causes of ischemia
Recurrent ischemic-type discomfort at rest after STEMI
Obtain 12-lead ECG
ST-segment elevation?ST-segment elevation?
blockers)
myocardium at risk

110
Obtain 12-lead ECG
YES NO
Consider (re)
administration of
YES
Is patient
a candidate for
revascularization?
blockers)
myocardium at risk
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
Is patient
a candidate for
revascularization?
Is patient
a candidate for
revascularization?
blockers)
myocardium at risk
YES
Coronary
angiography
anatomy
NO
Can
catheterization
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.

111
Obtain 12-lead ECG
YES NO
Consider (re)
administration of
YES NO
Is patient
a candidate for
revascularization?
blockers)
myocardium at risk
YES NO
Refer for
nonurgent
catheterization
Refer for urgent
catheterization (consider
IABP)
Is ischemia
controlled by escalation
of medical therapy?
YES
Coronary
angiography
anatomy
NO
Can
catheterization
Obtain 12-lead ECG
YES NO
YES NO
Is patient
a candidate for
revascularization?
Is patient
a candidate for
revascularization?
blockers)
myocardium at risk
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
anatomy
NO
Can
catheterization
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.

112
Evidence-Based Approach to Need for
Catheterization and Revascularization After STEMI
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
Submaximal
Exercise Test
Before Discharge
Symptom-Limited
Exercise Test
Before or After Discharge
Pharmacological Stress
Nuclear Scan
Dobutamine
Echo
Clinically Significant
Ischemia*
No Clinically Significant
Ischemia*
Medical
Therapy
Revascularization as
Indicated
Catheterization and
Indicated
Catheterization and
Indicated
Able to Exercise
Exercise
Echo
Exercise
Nuclear
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
Submaximal
Exercise Test
Before Discharge
Symptom-Limited
Exercise Test
Before or After Discharge
Pharmacological Stress
Adenosine
or Dipyridamole Dobutamine
Echo
Clinically Significant
Ischemia
No Clinically Significant
Ischemia
Medical
Therapy
Indicated
Catheterization and
Indicated
Catheterization and
Indicated
Able to Exercise
Exercise
Echo
Exercise
Nuclear

113
Long-Term Antithrombotic Therapy at
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:
Warfarin
INR (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
Indications
for Anticoagulation
No Indications
for Anticoagulation
No Indications
for Anticoagulation
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
Warfarin
INR (2.5 to 3.5)
Class I; LOE: B
STEMI Patient at Discharge

114
Long-Term Antithrombotic Therapy at
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

115
Long-Term ManagementLong-Term Management

116
Secondary Prevention and Long Term Management
• 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.
Smoking
Goal:
Complete
Cessation
Goals Recommendations

117
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 pressure
control:
Goal: < 140/90
mm Hg or
<130/80 mm Hg
if chronic kidney
disease or
diabetes

118
• 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

119
• 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:
Lipid
management:
(TG less than
200 mg/dL)
Primary goal:
LDL-C << than
100 mg/dL
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-C–lowering therapy with drug treatment,
giving preference to statins.

120
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.
Consider omega-3 fatty acids as adjunct for high
TG.
Lipid
management:
(TG 200 mg/dL
or greater)
Primary goal:
Non–HDL-C <<
130 mg/dL

121
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.
Weight
management:
Goal:
BMI 18.5 to 24.9
kg/m2
Waist
circumference:
Women: < 35 in.
Men: < 40 in.

122
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%

123
• In the absence of contraindications, start aspirin
75 to 162 mg/d and continue indefinitely.
• If aspirin is contraindicated, consider clopidogrel
75 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

124
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.
Renin-
Angiotensin-
Aldosterone
System
Blockers

125
Start in all patients. Continue indefinitely.
Observe usual contraindications.
Beta-
Blockers

126
1st1st
24 h24 h
DuringDuring
HospHosp
Hosp DC +Hosp DC +
Long TermLong Term
Aspirin 162-325 mg
chewed
75-162
mg/d p.o.
75-162
mg/d p.o.
Fibrinolytic 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
Summary of Pharmacologic Rx:Summary of Pharmacologic Rx: IschemiaIschemia
JACC 2004;44: 671
Circulation 2004;110: 588

127
1st1st
24 h24 h
During HospDuring Hosp Hosp DC +Hosp DC +
Long TermLong 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 << 100
Summary of Pharmacologic Rx:Summary of Pharmacologic Rx: LVD, Sec. Prev.,LVD, Sec. Prev.,
JACC 2004;44:671JACC 2004;44:671
Circ 2004;110:588Circ 2004;110:588

128
Hormone TherapyHormone Therapy
Hormone therapy with estrogen plus progestin
should not be given de novo to postmenopausal
women after STEMI for secondary prevention of
coronary events.

129
Hormone TherapyHormone 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.

130
AntioxidantsAntioxidants
Antioxidant vitamins such as vitamin E and/or
vitamin C supplements should not be prescribed to
patients recovering from STEMI to prevent
cardiovascular disease.

131
Psychosocial Impact of STEMIPsychosocial 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.

132
Cardiac RehabilitationCardiac 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.

133
• Review and continue predischarge risk
assessment.
• Delineate cardiovascular symptoms and
functional class.
• Evaluate current medications and titrate if needed.
• Review secondary prevention principles.
• Check psychosocial status.
• Discuss resumption of daily activities.
• Address plan for recognizing and responding to
potential cardiac event.
• Refer to a cardiac rehabilitation program.
Follow-Up Visit With Medical ProviderFollow-Up Visit With Medical Provider

St Elevation Mi

Recomendados

Recomendados

Mais conteúdo relacionado

Mais procurados

Mais procurados (20)

Destaque

Destaque (20)

Semelhante a St Elevation Mi

Semelhante a St Elevation Mi (20)

St Elevation Mi

Notas do Editor