6.6.07 fibrinolytic therapy in stemi falk

7/28/2019 6.6.07 Fibrinolytic Therapy in STEMI FALK

1/24

A 63-yo non-English-speaking woman comes to the ED b/cof severe, steady precordial discomfort that began 14hours ago. She thought that the CP may have beenindigestion, but she had no relief with an antacid. She

has a h/o HTN. She is taking no medication. Her HR is92/min, and her BP is 150/90. Her chest and cardiacexam is normal. Her EKG shows 3-mm STE in V2-V6.She is given a chewable ASA, morphine 4mg IV,metoprolol 5mg IV, and NTG 20mcg/min IV w/ a

decrease in her CP intensity from severe to moderate. Ahospital in the next county (1.5h away by ambulance)recently established a program that provides 24hangioplasty services.


2/24

Which of the following should be considered

in the decision of whether to refer this

patient for treatment?A) Angioplasty (with or without stenting) has a

better outcome than thrombolysis in thispatient

B) Thrombolysis has a better outcome than

angioplasty (with or without stenting) in thispatient

C) Thrombolysis and angioplasty (with or withoutstenting) are equivalent in outcome for this

patientD) Neither thrombolysis nor angioplasty (with orwithout stenting) should be performed in thispatient


3/24

74yo female is admitted w/ 3h of crushing substernal CP.She has a h/o L carotid occlusion w/ hemiparesisoccurring 3 months ago. She also has a h/o mild HTN,hyperlipidemia, and DM complicated by neuropathy and

retinopathy. Her meds include coumadin, atenolol, andpravastatin. In the ED, she has a Vfib arrest and issuccessfully converted to NSR after receiving 2 min ofCPR. Her EKG shows SR w/ 3-mm STE in V2-V6. Theresults of initial laboratory tests are within normal limits,

except for an elevated PT w/ and INR of 1.8.


4/24

Which of the following represent an absolute

contraindication to the use of a thrombolytic agent

in this patient?

A) L carotid occlusion w/ hemiparesis 3

months ago

B) CPR for 2 minutes

C) Patient age>70 years

D) Patient on coumadin with an INR of 1.8

E) Diabetic retinopathy


5/24

Fibrinolytic Therapy in STEMI

June 6, 2007


6/24

90% of patients w/ acute STEMI have complete

occlusion of culprit artery

PCI preferred if performed w/in 90 minutes of

presentation or if transfer to neighboringinstitution for PCI can occur w/in 30-60 min.

Thombolytic therapy is the alternative treatment

Not as effective in non-STEMI as the infarct-related artery is not totally occluded in 60-85% of

cases


7/24

EFFICACY

Benefit first demonstrated w/ streptokinase(GISSI-2 and ISIS-2 trials). ISIS-2 showedcombination of ASA and streptokinase reducedmortality from 10.2% (placebo) to 7.2%.

GUSTO-I: alteplase superior to streptokinase(although more expensive)

ASSENT-2 and GUSTO-III: newer agents like

tenecteplase, reteplase, lanoteplase aseffective as alteplase but have significantly lowerincidence of noncerebral bleeding complicationsand need for transfusion.


8/24

Time to presentation

Survival benefit greatest when lytics administeredwithin first 4 hours after onset of symptoms,particularly within the first 70 minutes.

Mortality benefit less likely at 13-18 hours.

There MAY be benefit in patients presenting>12hours if patient has on-going stuttering chestpain.

AHA recommendations (2004): administer

lytics if no contraindications w/in 12 hr ofsymptom onset; reasonable to administer at12-24 hr if continuing symptoms orpersistent ST elevation on EKG.


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Long-term survival

Long-term benefit primarily seen in

patients who achieved TIMI 3 flow w/ lytic

administration. Vessel opening (TIMI 2 or

3) reported in 60-87% of patients receivinglytics, but normalization (TIMI 3) in only

50-60% of arteries. Only TIMI 3 flow

associated w/ improved LV function andsurvival.

***Note: TIMI 3 flow is achieved in ~90% of patients treated with primary PCI.


10/24

Other prognostic indicatorspositive

predictors of one-year mortality

Demographics: older age (>55), lowerweight (115), longerQRS (>125), lower EF/heart failure,cardiogenic shock

Presence of cardiac risk factors such assmoking, HTN, prior CVA


11/24

CONTRAINDICATIONS

It is estimated that 20-30% of

patients ineligible for

thrombolytic therapy

This is what we missed on the in-service!!


12/24

ABSOLUTE contraindications

Previous ICH

Known structural cerebral vascular lesion

Known malignant intracranial neoplasm

Ischemic CVA within 3 months prior

Suspected aortic dissection Active bleeding or bleeding diathesis

Significant closed-head or facial trauma within 3 monthsprior

ADVANCED AGE IS NOT A MAJOR CONTRAINDICATION FORTHROMBOLYTICS!

although pts >75y/o may get less overall benefit.


13/24

RELATIVE contraindications

Poorly controlled or chronic sustained HTN

Ischemic CVA >3 months prior

Dementia

Traumatic or prolonged CPR or major surgery within


14/24

Adjunctive anti-coagulation

Thrombin inhibition enhances coronarythrombolysis and limits reocclusion; thereforeanti-coagulation is administered to most patientsreceiving lytics.

Alteplase, reteplase, tenecteplase: UFH at60units/kg bolus followed by 12u/kg/hr gtt;maintain PTT b/w 50-70 sec for 48hr.

LMWH also effective w/ tenecteplase, although

dont use it in pts>75 y/o (increased risk of ICH)or those w/ Cr>2.5 in men or Cr>2.0 in women.

? benefit of UFH or LMWH in streptokinase,anistreplase, urokinase.


15/24

Plavix

CLARITY-TIMI 28 and COMMIT/CCS-2

demonstrated improved outcomes when

plavix given before thrombolytic therapy.

300mg loading dose followed by 75mg

daily

In patients>75, risk of ICH not clear with

300mg loading dose vs 75mg loading

dose


16/24

GP IIb/IIIa inhibitors

Two large trials failed to shows survival

benefit with combination therapy (GP

IIb/IIIa with thrombolytics) compared to

conventional thrombolytic therapy, andbleeding was increased.

DO NOT administer concurrent GP IIb/IIIa

inhibitors with thrombolytics!


17/24

Assessment of response

Relief of symptoms

Maintenance or restoration of

hemodynamic and/or electrical stability

Reduction of at least 50% of initial ST

segment injury pattern on a follow-up EKG

60-90 min after initiation of therapy

Serial measurements of cardiac

biomarkers


18/24

PCI after thrombolytics???

This issue remains unresolved

3 possible scenarios

*Facilitated PCIlytic drug given prior to planned

PCI in attempt to achieve an open infarct-relatedartery before arrival of cath lab

*Adjunctive PCIPCI performed within hours after

thrombolysis*Early elective PCIPCI performed within a few

days after thrombolysis


19/24

A 63-yo non-English-speaking woman comes to the ED b/cof severe, steady precordial discomfort that began 14hours ago. She thought that the CP may have beenindigestion, but she had no relief with an antacid. She

has a h/o HTN. She is taking no medication. Her HR is92/min, and her BP is 150/90. Her chest and cardiacexam is normal. Her EKG shows 3-mm STE in V2-V6.She is given a chewable ASA, morphine 4mg IV,metoprolol 5mg IV, and NTG 20mcg/min IV w/ a

decrease in her CP intensity from severe to moderate. Ahospital in the next county (1.5h away by ambulance)recently established a program that provides 24hangioplasty services.


20/24



patient for treatment?A) Angioplasty (with or without stenting) has a

better outcome than thrombolysis in thispatient

B) Thrombolysis has a better outcome than

angioplasty (with or without stenting) in thispatient

C) Thrombolysis and angioplasty (with or withoutstenting) are equivalent in outcome for this

patientD) Neither thrombolysis nor angioplasty (with orwithout stenting) should be performed in thispatient


21/24



patient for treatment?

A) Angioplasty (with or without stenting)

has a better outcome than

thrombolysis in this patient


22/24

74yo female is admitted w/ 3h of crushing substernal CP.She has a h/o L carotid occlusion w/ hemiparesisoccurring 3 months ago. She also has a h/o mild HTN,hyperlipidemia, and DM complicated by neuropathy and

retinopathy. Her meds include coumadin, atenolol, andpravastatin. In the ED, she has a Vfib arrest and issuccessfully converted to NSR after receiving 2 min ofCPR. Her EKG shows SR w/ 3-mm STE in V2-V6. Theresults of initial laboratory tests are within normal limits,

except for an elevated PT w/ and INR of 1.8.


23/24



in this patient?


months ago

B) CPR for 2 minutes

C) Patient age>70 years

D) Patient on coumadin with an INR of 1.8

E) Diabetic retinopathy


24/24



in this patient?


months ago

6.6.07 fibrinolytic therapy in stemi falk

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