guideline stemi aha 2013

8/13/2019 Guideline STEMI AHA 2013

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Definition

STEMI is a clinical syndrome defined by characteristicsymptoms of myocardial ischemia in association withpersistent electrocardiographic (ECG) ST elevation

and subsequent release of biomarkers of myocardialnecrosis


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Diagnosis

Diagnostic ST elevation in the absence of leftventricular (LV) hypertrophy or left bundle-branchblock (LBBB) is defined by the European Society of

Cardiology/ACCF/AHA/World Heart Federation TaskForce for the Universal Definition of MyocardialInfarction

new ST elevation at the J point in at least 2 contiguous

leads of 2 mm (0.2 mV) in men or 1.5 mm (0.15 mV) inwomen in leads V2 V3 and/or of 1 mm (0.1 mV) in other contiguous chest leads or the limb leads.The majority of patients will evolve ECG evidence of Q-

wave infarction.


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Atypical ECG Presentation

LBBBBaseline ECG abnormalities other than LBBB (eg,paced rhythm, LV hypertrophy, Brugada syndrome)

ST depression in 2 precordial leads (V1 V4) mayindicate transmural posterior injuryMultilead ST depression with coexistent STelevation in lead aVR left main or proximal leftanterior descending artery occlusionHyperacute T-waves


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Diagnosis

Transthoracic echocardiographyevidence of focal wall motion abnormalitiesfacilitate triage in patients with ECG findings that are difficultto interpret.

If doubt persists invasive angiographyCardiac troponin is the preferred biomarker for

diagnosis of MI.


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Epidemiology


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Early Risk Assessment

Some of the independent predictors of early death fromSTEMI

AgeKillip class

Time to reperfusionCardiac arrestTachycardiaHypotension

Anterior infarct location

Prior infarctionDiabetes mellitusSmoking statusRenal functionBiomarker findings


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Early Risk Assessment

Thrombolysis In Myocardial Infarction (TIMI) riskscore was developed specifically in patients with

STEMIThe GRACE model predicts in-hospital and 6-monthmortality rate across the spectrum of patientspresenting with ACS, including those with STelevation or ST depression.Risk assessment is a continuous process that shouldbe repeated throughout hospitalization and at time ofdischarge.


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Reperfusion at a Non PCI-Capable Hospital

Class IIn the absence of contraindications, fibrinolytic therapy should begiven to patients with STEMI and onset of ischemic symptoms withinthe previous 12 hours when it is anticipated that primary PCI cannotbe performed within 120 minutes of FMC ( Level of Evidence: A)

Class IIaIn the absence of contraindications and when PCI is not available,fibrinolytic therapy is reasonable for patients with STEMI if there isclinical and/or ECG evidence of ongoing ischemia within 12 to 24hours of symptom onset and a large area of myocardium at risk orhemodynamic instability. ( Level of Evidence: C)

Class III: HarmFibrinolytic therapy should not be administered to patients with STdepression except when a true posterior (inferobasal) MI issuspected or when associated with ST elevation in lead aVR ( Levelof Evidence: B)


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Timing of Fibrinolytic Therapy

The benefits of fibrinolytic therapy in patients with STelevation or bundle-branch block MI are wellestablished, with a time-dependent reduction in bothmortality and morbidity rates during the initial 12hours after symptom onsetBenefit from fibrinolytic therapy in patients whopresent >12 hours after symptom onset has notbeen established although there remains consensus

that consideration should be given to administering afibrinolytic agent in symptomatic patients presenting>12 hours after symptom onset with STEMI and alarge area of myocardium at risk or hemodynamic

instability if PCI is unavailable


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Choice of Fibrinolytic Agent


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The decision to use fibrinolytic therapy for patientswith STEMI is predicated on a risk benefit analysisthat integrates

time from onset of symptomsthe clinical and hemodynamic features at presentationpatient comorbiditiesrisk of bleedingpresence of contraindicationstime delay to PCI


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Contraindications and Cautions for FibrinolyticTherapy in STEMI


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Adjunctive Antithrombotic Therapy With Fibrinolysis

Class I Aspirin (162- to 325-mg loading dose) and clopidogrel (300-mg loading dose for patients 75 years of age, 75-mg dose forpatients >75 years of age) should be administered to patients

with STEMI who receive fibrinolytic therapy ( Level ofEvidence: A)

Aspirin should be continued indefinitely ( Level of Evidence: A)and clopidogrel (75 mg daily) should be continued for at least14 days ( Level of Evidence: A) and up to 1 year (Level ofEvidence: C) in patients with STEMI who receive fibrinolytictherapy.

Class IIaIt is reasonable to use aspirin 81 mg per day in preference tohigher maintenance doses after fibrinolytic therapy ( Level of


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Adjunctive Anticoagulant Therapy With Fibrinolysis

Class IPatients with STEMI undergoing reperfusion with fibrinolytictherapy should receive anticoagulant therapy for a minimumof 48 hours, and preferably for the duration of the indexhospitalization, up to 8 days or until revascularization if

performed ( Level of Evidence: A) Recommended regimensincludeUFH administered as a weight-adjusted intravenous bolus and infusionto obtain an activated partial thromboplastin time of 1.5 to 2.0 timescontrol, for 48 hours or until revascularization. ( Level of Evidence: C);Enoxaparin administered according to age, weight, and creatinine

clearance, given as an intravenous bolus, followed in 15 minutes bysubcutaneous injection for the duration of the index hospitalization, up to8 days or until revascularization( Level of Evidence: A); orFondaparinux administered with initial intravenous dose, followed in 24hours by daily subcutaneous injections if the estimated creatinineclearance is greater than 30 mL/min, for the duration of the indexhospitalization, up to 8 days or until revascularization ( Level ofEvidence: B)


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Assessment of Reperfusion After Fibrinolysis

TIMI 3 flow after fibrinolytic therapy predicts subsequent shortand long-term survival.

an improvement in or relief of chest painresolution of ST elevationthe presence of reperfusion arrhythmias (eg, accelerated idioventricularrhythm)

The relatively sudden and complete relief of chest paincoupled with >70% ST resolution is highly suggestive ofrestoration of normal myocardial blood flowThe combination of


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Transfer to a PCI-Capable Hospital After Fibrinolytic Therapy


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TIMI Risk Score For STEMI

Acute Coronary Syndrome. A Companion To Braunwalds Heart Disease, 2011.

guideline stemi aha 2013

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