aha guidelines stemi
DESCRIPTION
guideline stemiTRANSCRIPT
-
7/18/2019 Aha Guidelines Stemi
1/94
1
ACC/AHA Guidelines for the
Management of Patients withST-Elevation Myocardial nfarction
-
7/18/2019 Aha Guidelines Stemi
2/94
2
Management !efore STEMManagement !efore STEM
ACC/AHA Guidelines for the
Management of Patients withST-Elevation Myocardial nfarction
-
7/18/2019 Aha Guidelines Stemi
3/94
3
dentification of Patients at "is# of STEMdentification of Patients at "is# of STEM
The presence and status of control of majorrisk factors for CHD should be evaluated
approximately every 3 to 5 years
1!"year risk of developin# symptomatic CHD
should be calculated for all patients $ith % 2
major risk factors to assess the need forprimary prevention strate#ies
-
7/18/2019 Aha Guidelines Stemi
4/94
&
dentification of Patients at "is# of STEMdentification of Patients at "is# of STEM
'atients $ith established CHD or a CHD risk
e(uivalent )diabetes mellitus* chronic kidney
disease* + 2!, 1!"year -ramin#ham risk.
should be identified for secondary prevention
-
7/18/2019 Aha Guidelines Stemi
5/94
5
$nset of STEM$nset of STEM
ACC/AHA Guidelines for the
Management of Patients withST-Elevation Myocardial nfarction
-
7/18/2019 Aha Guidelines Stemi
6/94
/
Prehos%ital Chest Pain EvaluationPrehos%ital Chest Pain Evaluation
and Treatmentand Treatment
'rehospital 0 providers should administer 1/2 to 325 m# of
aspirin )che$ed. to chest pain patients suspected of havin# T0
unless contraindicated or already taken by the patient 4lthou#h
some trials have used enteric"coated aspirin for initial dosin#* more
rapid buccal absorption occurs $ith nonenteric"coated
formulations
-
7/18/2019 Aha Guidelines Stemi
7/946
$%tions for Trans%ort of Patients &ith$%tions for Trans%ort of Patients &ith
STEM and nitial "e%erfusion TreatmentSTEM and nitial "e%erfusion Treatment
0 Transport
$nset of
sym%toms of
STEM
EMS
'is%atch
EMS on-scene7 0ncoura#e 12"lead 0C8s7 Consider prehospital fibrinolytic if
capable and 0"to"needle $ithin3! min
G$A(S
'Ccapable
9ot 'C
capable
Hos%ital fi)rinolysis*
'oor-to-+eedle
within , min.
EMS
Triage
Plan
nter-
Hos%ital
Transfer
Golden Hour first 0 min. Total ischemic time* within 12 min.
Patient EMS Prehos%ital fi)rinolysis
0"to"needle
$ithin 3! min
EMS trans%ort
0"to"balloon $ithin :! min
Patient self-trans%ort
Hospital door"to"balloon$ithin :! min
'is%atch1 min
5
min;
min
-
7/18/2019 Aha Guidelines Stemi
8/94;
7 'atients receivin# fibrinolysis should be risk"stratified to identify needfor further revasculari
-
7/18/2019 Aha Guidelines Stemi
9/94:
nitial "ecognition andnitial "ecognition and
Management in theManagement in the
Emergency 'e%artmentEmergency 'e%artment
ACC/AHA Guidelines for theManagement of Patients with
ST-Elevation Myocardial nfarction
-
7/18/2019 Aha Guidelines Stemi
10/941!
E' Evaluation ofE' Evaluation of
Patients &ith STEMPatients &ith STEM
1 4ir$ay* =reathin#* Circulation )4=C.
2 >ital si#ns* #eneral observation
3 'resence or absence of ju#ular venous distension
& 'ulmonary auscultation for rales
5 Cardiac auscultation for murmurs and #allops
/ 'resence or absence of stroke
6 'resence or absence of pulses
; 'resence or absence of systemic hypoperfusion )cool* clammy*
pale* ashen.
!rief Physical E4amination in the E'
-
7/18/2019 Aha Guidelines Stemi
11/9411
E' Evaluation ofE' Evaluation of
Patients &ith STEMPatients &ith STEM
4ortic dissection
'ulmonary embolus
'erforatin# ulcer
Tension pneumothorax
=oerhaave syndrome
)esopha#eal rupture $ith
mediastinitis.
'ifferential 'iagnosis of STEM* Life-Threatening
-
7/18/2019 Aha Guidelines Stemi
12/9412
E' Evaluation ofE' Evaluation of
Patients &ith STEMPatients &ith STEM
'ericarditis
4typical an#ina
0arly repolariasospastic an#inaHypertrophic
cardiomyopathy
'ifferential 'iagnosis of STEM* Other Cardiovascular andNonischemic
-
7/18/2019 Aha Guidelines Stemi
13/9413
8astroesopha#eal reflux
)80AD. and spasm
Chest"$all pain
'leurisy
'eptic ulcer disease
'anic attack
Cervical disc or neuropathic
pain
=iliary or pancreatic pain
omati
-
7/18/2019 Aha Guidelines Stemi
14/941&
ElectrocardiogramElectrocardiogram
f the initial 0C8 is not dia#nostic of T0* serial
0C8s or continuous T"se#ment monitorin# should
be performed in the patient $ho remains
symptomatic or if there is hi#h clinical suspicion for
T0
-
7/18/2019 Aha Guidelines Stemi
15/9415
ElectrocardiogramElectrocardiogram
ho$ 12"lead 0C8 results to emer#ency physician
$ithin 1! minutes of 0D arrival in all patients $ith
chest discomfort )or an#inal e(uivalent. or other
symptoms of T0
n patients $ith inferior T0* 0C8 leads should
also be obtained to screen for ri#ht ventricular
infarction
-
7/18/2019 Aha Guidelines Stemi
16/941/
(a)oratory E4aminations(a)oratory E4aminations
@aboratory examinations should be performed as part of the
mana#ement of T0 patients* but should not delay the
implementation of reperfusion therapy
erum biomarkers for cardiac dama#e
Complete blood count )C=C. $ith platelets nternational normali
-
7/18/2019 Aha Guidelines Stemi
17/9416
Cardiac"specific troponins should be used as theoptimum biomarkers for the evaluation of patients
$ith T0 $ho have coexistent skeletal muscle
injury
-or patients $ith T elevation on the 12"lead 0C8
and symptoms of T0* reperfusion therapy
should be initiated as soon as possible and is notcontin#ent on a biomarker assay
!iomar#ers of Cardiac 'amage!iomar#ers of Cardiac 'amage
-
7/18/2019 Aha Guidelines Stemi
18/941;
'atients $ith T0 should have a portable chest
"ray* but this should not delay implementation of
reperfusion therapy )unless a potential
contraindication is suspected* such as aortic
dissection.
ma#in# studies such as a hi#h (uality portable chest
"ray* transthoracic andor transesopha#eal
echocardio#raphy* and a contrast chest CT scan or
an A scan should be used for differentiatin# T0from aortic dissection in patients for $hom this
distinction is initially unclear
magingmaging
-
7/18/2019 Aha Guidelines Stemi
19/94
1:
upplemental oxy#en should be administered to
patients $ith arterial oxy#en desaturation )aE2
F :!,.
t is reasonable to administer supplemental
oxy#en to all patients $ith uncomplicated T0
durin# the first / hours
$4ygen$4ygen
-
7/18/2019 Aha Guidelines Stemi
20/94
2!
'atients $ith on#oin# ischemic discomfort should
receive sublin#ual 9T8 )!& m#. every 5 minutes for a
total of 3 doses* after $hich an assessment should be
made about the need for intravenous 9T8
ntravenous 9T8 is indicated for relief of on#oin#
ischemic discomfort that responds to nitrate therapy*
control of hypertension* or mana#ement of pulmonary
con#estion
+itroglycerin+itroglycerin
-
7/18/2019 Aha Guidelines Stemi
21/94
21
9itrates should not be administered to patients $ithG
9itrates should not be administered to patients $ho
have received a phosphodiesterase inhibitor for
erectile dysfunction $ithin the last 2& hours )&;hours for tadalafil.
7 systolic pressure F :! mm H# or % to 3! mm
H# belo$ baseline7 severe bradycardia )F 5! bpm.7 tachycardia )+ 1!! bpm. or
7 suspected A> infarction
+itroglycerin+itroglycerin
-
7/18/2019 Aha Guidelines Stemi
22/94
22
AnalgesiaAnalgesia
orphine sulfate )2 to & m# intravenously $ith
increments of 2 to ; m# intravenously repeated at
5 to 15 minute intervals. is the anal#esic of choicefor mana#ement of pain associated $ith T0
-
7/18/2019 Aha Guidelines Stemi
23/94
23
As%irinAs%irin
4spirin should be che$ed by patients $ho have
not taken aspirin before presentation $ith T0
The initial dose should be 1/2 m# )Level of
Evidence: A. to 325 m# )Level of Evidence: C.
Although some trials have used enteric-coated aspirin for
initial dosing, more rapid buccal absorption occurs withnonenteric-coated formulations.
-
7/18/2019 Aha Guidelines Stemi
24/94
2&
Eral beta"blocker therapy should be administered
promptly to those patients $ithout a contraindication*irrespective of concomitant fibrinolytic therapy or
performance of primary 'C
t is reasonable to administer intravenous beta"
blockers promptly to T0 patients $ithout
contraindications* especially if a tachyarrhythmia or
hypertension is present
!eta-!loc#ers!eta-!loc#ers
-
7/18/2019 Aha Guidelines Stemi
25/94
25
"e%erfusion"e%erfusion
7 8iven the current literature* it is not possible to saydefinitively that a particular reperfusion approach is
superior for all pts* in all clinical settin#s* at all times of
day
7 The main point is that some type of reperfusion therapy
should be selected for all appropriate pts $ith suspected
T0
7 The appropriate timely use of some reperfusion
therapy is likely more important than the choice of
therapy
-
7/18/2019 Aha Guidelines Stemi
26/94
2/
"e%erfusion"e%erfusion
The medical system #oal is to facilitate rapid reco#nition
and treatment of patients $ith T0 such that door-to-
needle)or medical contactto"needle. time for initiation
of fi)rinolytic thera%ycan be achieved within ,
minutesor that door-to-)alloon)or medical contactto"
balloon. time for PCcan be kept within 5 minutes
-
7/18/2019 Aha Guidelines Stemi
27/94
26
Media cam%aign
Patient education
Methods of
S%eeding
Time to
"e%erfusion
Greater use of
5-1-1
Prehos%ital "4
M %rotocol
Critical %athway
6ualityim%rovement
%rogram
!olus lytics'edicated
PC team
7min 8 , min'-! 95 min
'-+ 9, min
Goals
Prehos%ital
ECG
'atient Transport nhospital Aeperfusion
"e%erfusion"e%erfusion
-
7/18/2019 Aha Guidelines Stemi
28/94
2;
Sym%tom
"ecognition
Call to
Medical System
E' Cath (a)PreHos%ital
'elay in nitiation of "e%erfusion Thera%y
ncreasing (oss of Myocytes
Treatment 'elayed is Treatment 'eniedTreatment 'elayed is Treatment 'enied
-
7/18/2019 Aha Guidelines Stemi
29/94
2:
Contraindications and CautionsContraindications and Cautions
for 3i)rinolysis in STEMfor 3i)rinolysis in STEM
4bsolute
Contraindications
7 4ny prior intracranial hemorrha#e
7 Ino$n structural cerebral vascular lesion
)e#* arteriovenous malformation.
7 Ino$n mali#nant intracranial neoplasm)primary or metastatic.
7 schemic stroke $ithin 3 months 0C0'T
acute ischemic stroke $ithin 3 hours
9ET0G 4#e restriction for fibrinolysis has been removed
compared $ith prior #uidelines
-
7/18/2019 Aha Guidelines Stemi
30/94
3!
Contraindications and CautionsContraindications and Cautions
for 3i)rinolysis in STEMfor 3i)rinolysis in STEM
4bsoluteContraindications
7 uspected aortic dissection
7 4ctive bleedin# or bleedin# diathesis
)excludin# menses.
7 i#nificant closed"head or facial trauma$ithin 3 months
-
7/18/2019 Aha Guidelines Stemi
31/94
31
Contraindications and CautionsContraindications and Cautions
for 3i)rinolysis in STEMfor 3i)rinolysis in STEM
7 History of chronic* severe* poorly controlled
hypertension
7 evere uncontrolled hypertension on
presentation )=' + 1;! mm H# or D=' +
11! mm H#.
7 History of prior ischemic stroke #reater than
3 months* dementia* or kno$n intracranial
patholo#y not covered in contraindications
7 Traumatic or prolon#ed )+ 1! minutes. C'A
or major sur#ery )F 3 $eeks.
Aelative
Contraindications
-
7/18/2019 Aha Guidelines Stemi
32/94
32
Contraindications and CautionsContraindications and Cautions
for 3i)rinolysis in STEMfor 3i)rinolysis in STEM
AelativeContraindications
7 Aecent )F 2 to & $eeks. internal bleedin#7 9oncompressible vascular punctures
7 -or streptokinaseanistreplaseG prior
exposure )+ 5 days a#o. or prior aller#ic
reaction to these a#ents
7 're#nancy
7 4ctive peptic ulcer
7 Current use of anticoa#ulantsG the hi#her the
9A* the hi#her the risk of bleedin#
-
7/18/2019 Aha Guidelines Stemi
33/94
33
"e%erfusion $%tions for STEM Patients"e%erfusion $%tions for STEM Patients
Step OneStep One: Assess Time and is!": Assess Time and is!"
Time Since
Sym%tom
$nset
Time "e:uired
for Trans%ort to
a S#illed PC
(a)
"is# of STEM "is# of
3i)rinolysis
-
7/18/2019 Aha Guidelines Stemi
34/94
3&
3i)rinolysis generally %referred Early presentation ! " hours from symptom
onset and delay to invasive strategy#
$nvasive strategy not an option
Cath lab occupied or not available
>ascular access difficulties
9o access to skilled 'C lab
%elay to invasive strategy
'rolon#ed transport Door"to"balloon more than :! minutes
+ 1 hour vs fibrinolysis )fibrin"specific a#ent. no$
"e%erfusion $%tions for STEM Patients"e%erfusion $%tions for STEM Patients
Step #:Step #: Select eperfusion Treatment"Select eperfusion Treatment"
$f presentation is & " hours and there is no delay to an invasive
strategy, there is no preference for either strategy.
" f i $ i f STEM P i
-
7/18/2019 Aha Guidelines Stemi
35/94
35
nvasive strategy generally %referred '(illed )C$ lab available with surgical bac(up
Door"to"balloon F :! minutes
*igh +is( from 'E$
Cardio#enic shock* Iillip class % 3
Contraindications to fibrinolysis, includin#
increased risk of bleedin# and CH
Late presentation + 3 hours from symptom onset
%iagnosis of 'E$ is in doubt
"e%erfusion $%tions for STEM Patients"e%erfusion $%tions for STEM Patients
Step #:Step #: Select eperfusion Treatment"Select eperfusion Treatment"
$f presentation is & " hours and there is no delay to an invasive strategy,
there is no preference for either strategy.
-
7/18/2019 Aha Guidelines Stemi
36/94
3/
3i)rinolysis3i)rinolysis
n the absence of contraindications* fibrinolytic
therapy should be administered to T0
patients $ith symptom onset $ithin the prior 12
hours
n the absence of contraindications* fibrinolytic
therapy should be administered to T0
patients $ith symptom onset $ithin the prior 12
hours and ne$ or presumably ne$ left bundlebranch block )@===.
-
7/18/2019 Aha Guidelines Stemi
37/94
36
3i)rinolysis3i)rinolysis
n the absence of contraindications* it is
reasonable to administer fibrinolytic therapy toT0 patients $ith symptom onset $ithin the
prior 12 hours and 12"lead 0C8 findin#s
consistent $ith a true posterior
n the absence of contraindications* it is
reasonable to administer fibrinolytic therapy to
patients $ith symptoms of T0 be#innin# in
the prior 12 to 2& hours $ho have continuin#
ischemic symptoms and T elevation + !1 m>in % 2 conti#uous precordial leads or % 2 adjacent
limb leads
-
7/18/2019 Aha Guidelines Stemi
38/94
3;
3i)rinolysis3i)rinolysis
-ibrinolytic therapy should not be administered to
asymptomatic patients $hose initial symptoms of
T0 be#an more than 2& hours earlier
-ibrinolytic therapy should not be administered to
patients $hose 12"lead 0C8 sho$s only T"
se#ment depression* except if a true posterior
is suspected
Evolution of PC for STEMEvolution of PC for STEM
-
7/18/2019 Aha Guidelines Stemi
39/94
3:
Evolution of PC for STEMEvolution of PC for STEM
Primary PC for STEM*Primary PC for STEM*
-
7/18/2019 Aha Guidelines Stemi
40/94
&!
Primary PC for STEM*Primary PC for STEM*
$eneral Considerations$eneral Considerations
'atient $ith T0 )includin# posterior . or
$ith ne$ or presumably ne$ @===
'C of infarct artery $ithin 12 hours of symptom
onset
=alloon inflation $ithin :! minutes of presentation
killed personnel available )individual performs + 65
procedures per year.
4ppropriate lab environment )lab performs + 2!!
'Csyear of $hich at least 3/ are primary 'C forT0.
Cardiac sur#ical backup available
P i PC f STEMP i PC f STEM
-
7/18/2019 Aha Guidelines Stemi
41/94
&1
Primary PC for STEM*Primary PC for STEM*
Specific ConsiderationsSpecific Considerations
edical contactto"balloon or door"to"balloonshould be $ithin :! minutes
'C preferred if + 3 hours from symptom onset
'rimary 'C should be performed in patients $ith
severe con#estive heart failure )CH-. andorpulmonary edema )Iillip class 3. and onset of
symptoms $ithin 12 hours
P i PC f STEMP i PC f STEM
-
7/18/2019 Aha Guidelines Stemi
42/94
&2
Primary PC for STEM*Primary PC for STEM*
Specific ConsiderationsSpecific Considerations
'rimary 'C should be performed in patients less
than 65 years old $ith T elevation or @=== $ho
develop shock $ithin 3/ hours of and are
suitable for revasculari
-
7/18/2019 Aha Guidelines Stemi
43/94
&3
Primary PC for STEM*Primary PC for STEM*
Specific ConsiderationsSpecific Considerations
'rimary 'C is reasonable in selected patients 65
years or older $ith T elevation or @=== $ho develop
shock $ithin 3/ hours of and are suitable for
revasculari
-
7/18/2019 Aha Guidelines Stemi
44/94
&&
t is reasonable to perform primary 'C forpatients $ith onset of symptoms $ithin the prior
12 to 2& hours and 1 or more of the follo$in#G
a evere CH-
b Hemodynamic or electrical instability
c 'ersistent ischemic symptoms
Primary PC for STEM*Primary PC for STEM*
Specific ConsiderationsSpecific Considerations
-
7/18/2019 Aha Guidelines Stemi
45/94
&5
"escue PC"escue PC
Aescue 'C should be performed in patients lessthan 65 years old $ith T elevation or @=== $ho
develop shock $ithin 3/ hours of and are
suitable for revasculari
-
7/18/2019 Aha Guidelines Stemi
46/94
&/
"escue PC"escue PC
Aescue 'C is reasonable for selected patients 65
years or older $ith T elevation or @=== or $hodevelop shock $ithin 3/ hours of and are suitable
for revasculari
-
7/18/2019 Aha Guidelines Stemi
47/94
&6
PC for Cardiogenic Shoc#PC for Cardiogenic Shoc#
'rimary 'C is recommended for patients less than
65 years $ith T elevation or @=== or $ho develop
shock $ithin 3/ hours of and are suitable for
revasculari
-
7/18/2019 Aha Guidelines Stemi
48/94
&;
Cardiogenic Shoc#
1-2 vessel CA' Moderate ,-vessel CA' Severe ,-vessel CA' (eft main CA'
PC "A PC "A mmediate CA!G
Staged Multivessel
PC
Staged CA!GCannot )e
%erformed
Early Shoc#; 'iagnosed onHos%ital Presentation
'elayed $nset Shoc#Echocardiogram to "ule $ut
Mechanical 'efects
Cardiac Catheteri
-
7/18/2019 Aha Guidelines Stemi
49/94
&:
PC After 3i)rinolysisPC After 3i)rinolysis
n patients $hose anatomy is suitable* 'C should be
performed for the follo$in#G
Ebjective evidence of recurrent
oderate or severe spontaneousprovocable
myocardial ischemia durin# recovery from T0
Cardio#enic shock or hemodynamic instability
PC After 3i)rinolysisPC After 3i)rinolysis
-
7/18/2019 Aha Guidelines Stemi
50/94
5!
PC After 3i)rinolysisPC After 3i)rinolysis
t is reasonable to perform routine 'C in patients
$ith left ventricular ejection fraction )@>0-. J !&!*CH-* or serious ventricular arrhythmias
Aoutine 'C mi#ht be considered as part of
an invasive strate#y after fibrinolytic therapy
t is reasonable to perform 'C $hen there is
documented clinical heart failure durin# the acuteepisode* even thou#h subse(uent evaluation
sho$s preserved @> function )@>0- + !&!.
Assessment of "e%erfusionAssessment of "e%erfusion
-
7/18/2019 Aha Guidelines Stemi
51/94
51
Assessment of "e%erfusionAssessment of "e%erfusion
t is reasonable to monitor the pattern of T elevation*
cardiac rhythm and clinical symptoms over the /! to 1;!minutes after initiation of fibrinolytic therapy
9oninvasive findin#s su##estive of reperfusion includeG
Aelief of symptoms
aintenance and restoration of hemodynamic andor
electrical instability
Aeduction of % 5!, of the initial T"se#ment elevationpattern on follo$"up 0C8 /! to :! minutes after
initiation of therapy
Ancillary Thera%y to "e%erfusionAncillary Thera%y to "e%erfusion
-
7/18/2019 Aha Guidelines Stemi
52/94
52
Ancillary Thera%y to "e%erfusionAncillary Thera%y to "e%erfusion
Bnfractionated heparin )B-H. should be #iven
intravenously inG
'atients under#oin# 'C or sur#ical
revasculari
-
7/18/2019 Aha Guidelines Stemi
53/94
53
Ancillary Thera%y to "e%erfusionAncillary Thera%y to "e%erfusion
@o$ molecular"$ei#ht heparin )@?H. mi#ht be considered an
acceptable alternative to B-H in patients less than 65 years
$ho are receivin# fibrinolytic therapy in the absence of
si#nificant renal dysfunction
0noxaparin used $ith tenecteplase is the most
comprehensively studied
'latelet counts should be monitored daily in patients
takin# B-H
As%irinAs%irin
-
7/18/2019 Aha Guidelines Stemi
54/94
5&
As%irinAs%irin
4 daily dose of aspirin )initial dose of 1/2 to
325 m# orallyK maintenance dose of 65 to 1/2
m#. should be #iven indefinitely after T0 to
all patients $ithout a true aspirin aller#y
Thieno%yridinesThieno%yridines
-
7/18/2019 Aha Guidelines Stemi
55/94
55
Thieno%yridinesThieno%yridines
n patients for $hom 'C is planned* clopido#rel
should be started and continuedG
7% 1 month after bare"metal stent
7% 3 months after sirolimus"elutin# stent
7% / months after paclitaxel"elutin# stent
7Bp to 12 months in absence of hi#h risk for
bleedin#
Thieno%yridinesThieno%yridines
-
7/18/2019 Aha Guidelines Stemi
56/94
5/
Thieno%yridinesThieno%yridines
n patients takin# clopido#rel in $hom C4=8 is
planned* the dru# should be $ithheld for at
least 5 days* and preferably for 6 days* unless
the ur#ency for revasculari
-
7/18/2019 Aha Guidelines Stemi
57/94
56
Thieno%yridinesThieno%yridines
Clopido#rel is probably indicated in patientsreceivin# fibrinolytic therapy $ho are unable
to take aspirin because of hypersensitivity or
#astrointestinal intolerance
Gl t i )/ hi)it
-
7/18/2019 Aha Guidelines Stemi
58/94
5;
Glyco%rotein )/a nhi)itorsGlyco%rotein )/a nhi)itors
t is reasonable to start treatment $ith
abciximab as early as possible before primary
'C )$ith or $ithout stentin#. in patients $ith
T0
Treatment $ith tirofiban or eptifibatide may be
considered before primary 'C )$ith or
$ithout stentin#. in patients $ith T0
$th Ph l i l M$th Ph l i l M
-
7/18/2019 Aha Guidelines Stemi
59/94
5:
$ther Pharmacological Measures$ther Pharmacological Measures
Angiotensin converting en
inhi)itors
Angiotensin rece%tor )loc#ers =A"!>
Aldosterone )loc#ers
Glucose control
Magnesium
Calcium channel )loc#ers
nhi)ition ofthe renin
-angiotensin
-aldosterone
system
ACE/A"!* &ithin 2? HoursACE/A"!* &ithin 2? Hours
-
7/18/2019 Aha Guidelines Stemi
60/94
/!
ACE/A"!* &ithin 2? HoursACE/A"!* &ithin 2? Hours
4n 4C0 inhibitor should be administered orally
$ithin the first 2& hours of T0 to the follo$in#patients $ithout hypotension or kno$n class of
contraindicationsG
7 4nterior infarction
'ulmonary con#estion @>0- F !&!
4n 4A= should be #iven to 4C0"intolerant patients
$ith either clinical or radiolo#ical si#ns of H- or @>0-F !&!
ACE/A"!* &ithin 2? HoursACE/A"!* &ithin 2? Hours
-
7/18/2019 Aha Guidelines Stemi
61/94
/1
ACE/A"!* &ithin 2? HoursACE/A"!* &ithin 2? Hours
4n 4C0 inhibitor administered orally can be useful
$ithin the first 2& hours of T0 to the follo$in#patients $ithout hypotension or kno$n class
contraindicationsG
4nterior infarction
'ulmonary con#estion@>0- F !&!
4n intravenous 4C0 inhibitor should not be #iven to
patients $ithin the first 2& hours of T0 becauseof the risk of hypotension )possible exceptionG
refractory hypotension.
Strict Glucose Control 'uring STEMStrict Glucose Control 'uring STEM
-
7/18/2019 Aha Guidelines Stemi
62/94
/2
Strict Glucose Control 'uring STEMStrict Glucose Control 'uring STEM
4n insulin infusion to normali
-
7/18/2019 Aha Guidelines Stemi
63/94
/3
Hos%ital ManagementHos%ital Management
ACC/AHA Guidelines for the
Management of Patients with
ST-Elevation Myocardial nfarction
Sam%le Admitting $rders for theSam%le Admitting $rders for the
-
7/18/2019 Aha Guidelines Stemi
64/94
/&
Sam%le Admitting $rders for theSam%le Admitting $rders for the
Patient &ith STEMPatient &ith STEM
1 Condition*erious2 +ormal Saline or '7&intravenous to keep vein open
3 @ital signs* Heart rate* blood pressure* respiratory rate
& Monitor*Continuous 0C8 monitorin# for arrhythmiaT"
se#ment deviation
5 'iet* 9C0' 4T' Therapeutic @ifestyle Chan#es* lo$
sodium diet
Sam%le Admitting $rders for theSam%le Admitting $rders for the
-
7/18/2019 Aha Guidelines Stemi
65/94
/5
Sam%le Admitting $rders for theSam%le Admitting $rders for the
Patient &ith STEMPatient &ith STEM
/ Activity* =ed rest $ith bedside commode* li#htactivity $hen stable
6 $4ygen* 2 @min $hen stable for / hrs* reassess
need )ie* E2sat F :!,. Consider discontinuin# if
E2saturation is + :!,
; Medications*9T8* 44* beta"blocker* 4C0* 4A=*
pain meds* anxiolytics* daily stool softener
: (a)oratory tests* cardiac biomarkers* C=C$platelets* 9A* a'TT* electrolytes* #2L* =B9*
creatinine* #lucose* serum lipids
Emergency Management of Com%licated STEMEmergency Management of Com%licated STEM
-
7/18/2019 Aha Guidelines Stemi
66/94
//
Administer7-luids7=lood transfusions7Cause"specific
interventions
Considervasopressors
Arrhythmia
=radycardia Tachycardia
Systolic !P
8reater than 1!! mm H#
Systolic !P
6! to 1!! mm H#
+$ si#nssymptoms
of shock
Systolic !P
6! to 1!! mm H#
i#nssymptoms
of shock
Systolic !P
less than 6! mm H#
i#nssymptoms of shock
'o)utamine
2 to 2!
mc#k# per
minute >
(ow $ut%ut -
Cardiogenic Shoc#
+itroglycerin
1! to 2! mc#min >
'o%amine
5 to 15
mc#k# per
minute >
+ore%ine%hrine
!5 to 3! mc#min >
Hy%ovolemia
Administer73urosemide> !5 to 1! m#k#7Mor%hine> 2 to & m#7$4ygenintubation as needed7+itroglycerin @* then 1! to 2! mc#min > if ='
#reater than 1!! mm H#7'o%amine5 to 15 mc#k# per minute > if =' 6! to
1!! mm H# and si#nssymptoms of shock present7'o)utamine2 to 2! mc#k# per minute > if =' 6!
to 1!! mm H# and no si#nssymptoms of shock-irstline
ofaction
2econd
line
ofaction
Third
line
ofaction
ee ection 66
in the 4CC4H4 8uidelines for
'atients ?ith T"0levation
yocardial nfarction
Chec# !lood Pressure
Clinical signs*hock* hypoperfusion* con#estive heart failure* acute pulmonary edema
Most li#ely maor underlying distur)anceB
-urther dia#nostictherapeutic considerations )should be considered in
nonhypovolemic shock.
'iagnostic Thera%eutic
M 'ulmonary artery catheter M ntra"aortic balloon pump
M 0chocardio#raphy M Aeperfusionrevasculari
-
7/18/2019 Aha Guidelines Stemi
67/94
/6
y gy g
Electrical %nsta&ilit'Electrical %nsta&ilit'
>'=s IL* #LL* beta blocker
>T 4ntiarrhythmics* DC shock
4>A Ebserve unless hemodynamic
compromise
9'NT earch for cause )e#* di# toxicity.
Arrhythmia Treatment
Arrhythmias 'uring Acute Phase of STEM*Arrhythmias 'uring Acute Phase of STEM*
-
7/18/2019 Aha Guidelines Stemi
68/94
/;
inus Tach Treat causeK beta blocker
4fib -lutter Treat causeK slo$ ventricular rateK DC shock
'>T >a#al maneuversK beta blocker*
verapamil diltia
-
7/18/2019 Aha Guidelines Stemi
69/94
/:
inus =rady Treat if hemodynamic compromiseK
atropine pacin#
Nunctional Treat if hemodynamic compromiseK
atropine pacin#
Arrhythmias 'uring Acute Phase of STEM*Arrhythmias 'uring Acute Phase of STEM*
+rad'arrh'thmias+rad'arrh'thmias
Arrhythmia Treatment
Arrhythmias 'uring Acute Phase of STEM*Arrhythmias 'uring Acute Phase of STEM*
-
7/18/2019 Aha Guidelines Stemi
70/94
6!
Arrhythmias 'uring Acute Phase of STEM*Arrhythmias 'uring Acute Phase of STEM*
A, Conduction istur&ancesA, Conduction istur&ances
0scape Ahythm His =undle Distal
F 12! ms + 12! ms
&5 " /! Eften F 3!
Duration of 4>= 2 " 3 days Transient
ortality @o$ Hi#h )CH-* >T.
Ax Ebserve ' )CD.
Pro4imal 'istal
"ecommendations for Treatment ofAtrioventricular and ntraventricular Conduction
-
7/18/2019 Aha Guidelines Stemi
71/94
61
Atrioventricular and ntraventricular Conduction
'istur)ances 'uring STEM
+T"A@E+T"C(A"
C$+'CT$+ +ormal
ACT$+ C(ASS ACT$+ C(ASS ACT$+ C(ASS ACT$+ C(ASS ACT$+ C(ASS ACT$+ C(ASS ACT$+ C(ASS
Ebserve Ebserve Ebserve Ebserve b Ebserve a Ebserve Ebserve
4 4 4 4O 4 4 4
TC TC b TC b TC TC TC TC
T> T> T> T> T> T> a T> a
$ld or +ew Ebserve Ebserve b Ebserve b Ebserve b Ebserve b Ebserve Ebserve
3ascicular )loc# 4 4 4 4O 4 4 4
=(A3! or (P3!> TC b TC TC a TC TC TC TC
T> T> T> T> T> T> a T> b
Ebserve Ebserve Ebserve Ebserve Ebserve Ebserve Ebserve
4 4 4 4O 4 4 4
TC b TC TC TC TC TC TC
T> T> b T> b T> b T> b T> a T> a
Ebserve Ebserve Ebserve Ebserve Ebserve Ebserve Ebserve
4 4 4 4O 4 4 4
TC TC TC TC TC TC b TC b
T> b T> a T> a T> a T> a T> T>
3ascicular Ebserve Ebserve Ebserve Ebserve Ebserve Ebserve Ebserve
)loc# D "!!! 4 4 4 4O 4 4 4
TC TC TC TC TC TC b TC bT> b T> a T> a T> a T> a T> T>
Alternating Ebserve Ebserve Ebserve Ebserve Ebserve Ebserve Ebserve
left and right 4 4 4 4O 4 4 4
)undle )ranch TC b TC b TC b TC b TC b TC b TC b
)loc# T> T> T> T> T> T> T>
+ormal
$ld )undle
)ranch )loc#
+ew )undle
)ranch )loc#
Mo)it< second degree A@ )loc#Mo)it< second degree A@ )loc#3irst degree A@ )loc#
A+TE"$" M +$+-A+TE"$" A+TE"$" M +$+-A+TE"$" A+TE"$" M +$+-A+TE"$"
Atrioventricular Conduction
C' m%lantation After STEM th Aft 'E$
-
7/18/2019 Aha Guidelines Stemi
72/94
62
ne onth After 'E$/
0o 'pontaneous 1 or 12 34 hours post-'E$
E3 8 .,
EPS
es
D
+EFM ,?5*
1,0;2,
E3 .,1 - .?
+o
+o C'.
Medical "4
E3 .?
-
Additional Mar#er of
Electrical nsta)ilityB
Algorithm for Management of "ecurrentschemia/nfarction After STEM
-
7/18/2019 Aha Guidelines Stemi
73/94
63
schemia/nfarction After STEM
$)tain 12-lead ECG
ES +$
Consider =re>
administration of
ES +$
s %atient
a candidate for
revasculari
I Anticoagulation if not already given
I Consider A!P for hemodynamic insta)ility;
%oor (@ function; or a large area ofmyocardium at ris#
I Correct secondary causes of ischemia
"ecurrent ischemic-ty%e discomfort at rest after STEM
ES +$
"efer for
nonurgent
catheteri
-
7/18/2019 Aha Guidelines Stemi
74/94
(ong-Term Antithrom)otic Thera%y atHos%ital 'ischarge After STEM
-
7/18/2019 Aha Guidelines Stemi
75/94
65
Hos%ital 'ischarge After STEM
+o Stent m%lanted
9o 44 aller#y 44 4ller#y
Preferred*
44 65 to 1/2 m#
Class $/ LE: A
Preferred*
Clopido#rel 65 m#
Class $/ LE: C
Alternative*
?arfarin9A )25 to 35.
Class $/ LE: 5
Alternative*
44 65 to 1/2 m#
?arfarin
)9A 2! to 3!.
Class: $$a/ LE: 5
$"
?arfarin
)9A 25 to 35.Class $$a/ LE: 5
ndicationsfor 4nticoa#ulation
9o ndicationsfor 4nticoa#ulation
9o ndicationsfor 4nticoa#ulation
ndicationsfor 4nticoa#ulation
44 65 to 1/2 m#
?arfarin
)9A 2! to 3!.
Class $/ LE 5
$"
?arfarin
)9A 25 to 35.
Class $/ LE: 5
?arfarin
9A )25 to 35.
Class $/ LE: 5
STEM Patient at 'ischarge
(ong-Term Antithrom)otic Thera%y atHos%ital 'ischarge After STEM
-
7/18/2019 Aha Guidelines Stemi
76/94
6/
Hos%ital 'ischarge After STEM
Stent m%lanted
9o 44 4ller#y 44 4ller#y
44 65 to 1/2 m#
Clopido#rel 65 m#
Class: $/ LE: 5
44 65 to 1/2 m#
Clopido#rel 65 m#
?arfarin)9A 2! to 3!.
Class: $$b/ LE: C
Clopido#rel 65 m#
Class $/ LE: 5
Clopido#rel 65 m#
?arfarin
)9A 2! to 3!.Class $/ LE: C
STEM Patient at 'ischarge
9o ndications
for
4nticoa#ulation
ndications
for 4nticoa#ulation
ndications
for
4nticoa#ulation
9o ndications
for
4nticoa#ulation
-
7/18/2019 Aha Guidelines Stemi
77/94
66
(ong-Term Management(ong-Term Management
ACC/AHA Guidelines for the
Management of Patients withST-Elevation Myocardial nfarction
Secondary Prevention and (ong Term Management
-
7/18/2019 Aha Guidelines Stemi
78/94
6;
74ssess tobacco use
7tron#ly encoura#e patient and family to
stop smokin# and to avoid secondhand
smoke
7'rovide counselin#* pharmacolo#ical
therapy )includin# nicotine replacement and
bupropion.* and formal smokin# cessation
pro#rams as appropriate
Smo#ing6oal:
Complete
Cessation
Goals "ecommendations
Secondary Prevention and (ong Term Management
-
7/18/2019 Aha Guidelines Stemi
79/94
6:
f )lood %ressure is 12/ mm Hg or greater*
7 nitiate lifestyle modification )$ei#ht control* physical
activity* alcohol moderation* moderate sodium restriction* and
emphasis on fruits* ve#etables* and lo$"fat dairy products. in
all patients
f )lood %ressure is 1?/5 mm Hg or greater or 1,/
mm Hg or greater for individuals with chronic #idney
disease or dia)etes*
7 4dd blood pressure"reducin# medications* emphasi
-
7/18/2019 Aha Guidelines Stemi
80/94
;!
74ssess risk* preferably $ith exercise test* to #uide
prescription
70ncoura#e minimum of 3! to /! minutes of activity*
preferably daily but at least 3 or & times $eekly )$alkin#*
jo##in#* cyclin#* or other aerobic activity. supplemented by
an increase in daily lifestyle activities )e#* $alkin# breaks
at $ork* #ardenin#* household $ork.
7Cardiac rehabilitation pro#rams are recommended for
patients $ith T0
Physical activity*
inimum goal:
"8 minutes " to 3
days per wee(/
ptimal daily
Goals "ecommendations
Secondary Prevention and (ong Term Management
-
7/18/2019 Aha Guidelines Stemi
81/94
;1
7tart dietary therapy in all patients )F 6, of total calories as
saturated fat and F 2!! m#d cholesterol. 'romote physicalactivity and $ei#ht mana#ement 0ncoura#e increased
consumption of ome#a"3 fatty acids
74ssess fastin# lipid profile in all patients* preferably $ithin
2& hours of T0 4dd dru# therapy accordin# to the
follo$in# #uideG
(i%id
management*=TG less than
2 mg/d(>
)rimary goal:
L%L-C && than
788 mg9dL
Goals "ecommendations
('(-C 8 1 mg/d( =)aseline or on treatment>*
tatins should be used to lo$er @D@"C
('(-C K 1 mg/d( =)aseline or on
treatment>*ntensify @D@"Clo$erin# therapy $ith dru# treatment*
#ivin# preference to statins
Secondary Prevention and (ong Term Management
-
7/18/2019 Aha Guidelines Stemi
82/94
;2
f TGs are K 17 mg/d( or H'(-C is 8 ? mg/d(*0mphasi
-
7/18/2019 Aha Guidelines Stemi
83/94
;3
Goals "ecommendations
Calculate = and measure $aist circumference
as part of evaluation onitor response of =
and $aist circumference to therapy
tart $ei#ht mana#ement and physical activity as
appropriate Desirable = ran#e is 1;5 to 2&:k#m2
f $aist circumference is % 35 inches in $omen or
% &! inches in men* initiate lifestyle chan#es and
treatment strate#ies for metabolic syndrome
&eightmanagement*
6oal:
5$ 74.; to
-
7/18/2019 Aha Guidelines Stemi
84/94
;&
y g g
Goals "ecommendations
4ppropriate hypo#lycemic therapy to
achieve near"normal fastin# plasma
#lucose* as indicated by Hb41c
Treatment of other risk factors )e#*physical activity* $ei#ht mana#ement*
blood pressure* and cholesterol
mana#ement.
'ia)etes
management*
6oal:
*bA7c & >?
Secondary Prevention and (ong Term Management
-
7/18/2019 Aha Guidelines Stemi
85/94
;5
Secondary Prevention and (ong Term Management
Goals "ecommendations
7n the absence of contraindications* start aspirin
65 to 1/2 m#d and continue indefinitely
7f aspirin is contraindicated* consider clopido#rel65 m#day or $arfarin
7ana#e $arfarin to 9A 25 to 35 in post"
T0 patients $hen clinically indicated or for
those not able to take aspirin or clopido#rel
Anti%latelet
agents/
anticoagulants
Secondary Prevention and (ong Term Management
-
7/18/2019 Aha Guidelines Stemi
86/94
;/
Secondary Prevention and (ong Term Management
Goals "ecommendations
4C0 inhibitors in all patients indefinitelyK start early in
stable* hi#h"risk patients )ant * previous * Iillip
class % 2 Q3 #allop* rales* radio#raphic CH-R* @>0- F
!&!.
4n#iotensin receptor blockers in patients $ho are
intolerant of 4C0 inhibitors and $ith either clinical or
radiolo#ical si#ns of heart failure or @>0- F !&!
4ldosterone blockade in patients $ithout si#nificant renal
dysfunction or hyperkalemia $ho are already receivin#therapeutic doses of an 4C0 inhibitor* have @>0- J !&!*
and have either diabetes or heart failure
"enin-
Angiotensin-
Aldosterone
System
!loc#ers
Secondary Prevention and (ong Term Management
-
7/18/2019 Aha Guidelines Stemi
87/94
;6
Secondary Prevention and (ong Term Management
Goals "ecommendations
tart in all patients Continue indefinitely
Ebserve usual contraindications
!eta-
!loc#ers
Summary of Pharmacologic "4*Summary of Pharmacologic "4*%schemia%schemia
-
7/18/2019 Aha Guidelines Stemi
88/94
;;
1st1st2? h2? h
'uring'uringHos%Hos%
Hos% 'C DHos% 'C D(ong Term(ong Term
Aspirin 102-,27 mg
chewed
L7-102
mg/d %.o.
L7-102
mg/d %.o.
(i&rinol'tic tPA;T+;
rPA; S
.(/
0/#g =?>
12 /#g/h =1>
aPTT 1.7 - 2 4 C
aPTT
1.7 - 2 4 C
+eta-&loc!er $ral daily $ral daily $ral daily
FACC 2?N??* 0L1
Circulation 2?N11* 7
Summary of Pharmacologic "4*Summary of Pharmacologic "4* L,0 Sec" Prev"0L,0 Sec" Prev"0
-
7/18/2019 Aha Guidelines Stemi
89/94
;:
1st1st2? h2? h
'uring Hos%'uring Hos% Hos% 'C DHos% 'C D(ong Term(ong Term
ACE% Anterior M;Pulm Cong.; E3 8 ? $ral
'aily
$ral
'aily
ndefinitelyA+ ACE intol.;H3; E3 8 ?
Aldo+loc!er
+o renal dysf;D 8 7. mE:/(
$n ACE;H3 or 'M
Same asduringHos%.
Statin Start w/o li%id%rofile
ndefinitely;('( 88 1
FACC 2?N??*0L1FACC 2?N??*0L1
Circ 2?N11*7Circ 2?N11*7
Hormone Thera%yHormone Thera%y
-
7/18/2019 Aha Guidelines Stemi
90/94
:!
Hormone therapy $ith estro#en plus pro#estinshould not be #iven de novo to postmenopausal
$omen after T0 for secondary prevention ofcoronary events
Hormone Thera%yHormone Thera%y
-
7/18/2019 Aha Guidelines Stemi
91/94
:1
'ostmenopausal $omen $ho are already takin#
estro#en plus pro#estin at the time of T0 should
not continue hormone therapy
Ho$ever* $omen $ho are beyond 1 to 2 years after
initiation of hormone therapy $ho $ish to continue
such therapy for another compellin# indication
should $ei#h the risks and benefits
Antio4idantsAntio4idants
-
7/18/2019 Aha Guidelines Stemi
92/94
:2
4ntioxidant vitamins such as vitamin 0 andorvitamin C supplements should not be prescribed to
patients recoverin# from T0 to preventcardiovascular disease
Psychosocial m%act of STEMPsychosocial m%act of STEM
-
7/18/2019 Aha Guidelines Stemi
93/94
:3
The psychosocial status of the patient should be evaluated*includin# in(uiries re#ardin# symptoms of depression* anxiety*
or sleep disorders and the social support environment
Treatment $ith co#nitive"behavioral therapy and selective
serotonin reuptake inhibitors can be useful for T0 patients
$ith depression that occurs in the year after hospital dischar#e
Cardiac "eha)ilitationCardiac "eha)ilitation
-
7/18/2019 Aha Guidelines Stemi
94/94
Cardiac rehabilitationsecondary prevention
pro#rams* $hen available* are recommended
for patients $ith T0* particularly those
$ith multiple modifiable risk factors andor
those moderate" to hi#h"risk patients in $hom
supervised exercise trainin# is $arranted