Documente Academic
Documente Profesional
Documente Cultură
Ahmad Aslam, M.D. Prasantha Bathini, M.D. Robert Smith, M.D. Cardiac Cath Conference July 20, 2004
Step I: Assess time and risk - Time since onset of symptoms - Risk from STEMI - Risk of fibrinolysis - Time required for transport to a skilled PCI lab Step II: Determine whether fibrinolysis or invasive strategy is preferred
Fibrinolysis is generally preferred if - Early presentation (3 hours or less and delay to invasive strategy) - Invasive strategy is not an option - Cath lab not available - Vascular access difficulties - Lack of access to a skilled lab - Delay to invasive strategy Invasive strategy is generally preferred if - Skilled PCI lab available with surgical backup - High risk from STEMI - Cardiogenic shock - Killip class > or = to 3 - Contraindications to fibrinolysis including increased risk of bleeding and ICH - Late presentation - Symptom onset more than 3 hours - Diagnosis of STEMI is in doubt
Points
3 2 1
Examination
Weight < 67 kg (150#) HR > 100 Systolic BP < 100mmHg Killip Class II IV 1 2 3 2
Presentation
Anterior ST Elevation or LBBB Time to Treatment > 4 hours
1 1
Fibrinolytic Therapy
Class I
STEMI patients presenting to a facility without the capacity for expert, prompt intervention (primary PCI with 90 minutes of first medical contact) should undergo fibrinolytic therapy. (Level of Evidence: A) In the absence of contraindications, fibrinolytic therapy should be administered to STEMI patients with symptom onset within the prior 12 hours and ST elevation greater than 0.1mV in at least 2 contiguous precordial leads or at least 2 adjacent limb leads. (Level of Evidence: A) In the absence of contraindications, fibrinolytic therapy should be administered to patients with symptom onset within the prior 12 hours and new or presumably new LBBB. (Level of Evidence: A)
Fibrinolytic Therapy
Class IIa
In the absence of contraindications, it is reasonable to administer fibrinolytic therapy to STEMI patients with symptom onset within the prior 12 hours and ECG findings consistent with true posterior MI. (Level of Evidence: C) In the absence of contraindications, it is reasonable to administer fibrinolytic therapy to patients with symptoms of STEMI beginning within the prior 12-24 hours who have continuing ischemic symptoms and ST elevation greater than 0.1mV in at least 2 contiguous precordial leads or at least 2 adjacent limb leads. (Level of Evidence: B)
Fibrinolytic Therapy
Class III Fibrinolytic therapy should not be administered to asymptomatic patients whose initial symptoms of STEMI began more than 24 hours earlier. (Level of Evidence: C)
Fibrinolytic therapy should not be administered to patients whose ECG shows only ST segment depression unless true posterior MI is suspected. (Level of Evidence: A)
PCI must be performed in a timely fashion (door balloon time 90 minutes) by persons skilled in the procedure (greater than 75/year). (Level of Evidence: A)
Class IIB
It may be reasonable to administer UFH to patients undergoing reperfusion therapy with streptokinase
Class III
Should not be used for patients >75yrs who are receiving fibrinolytic therapy. (Level of Evidence: B) Should not be used in patients with significant renal dysfunction (SCr <2.5 for men, 2.0 for women). (Level of Evidence: B)
In patients taking clopidogrel in whom CABG is planned, the drug should be withheld for at least 5 days (and preferably 7), unless the urgency of CABG outweighs the risk of bleeding. (Level of Evidence: B)
General Statements:
Clopidogrel combined with ASA is recommended for patients undergoing stent implantation
There are no safety data comparing 300mg vs. 600mg loading doses
Routine administration of clopidogrel is not recommended in patients who have not undergone LHC and in whom CABG might be performed if necessary
Class III
An IV ACE-I should not be given to patients within 24 hours of STEMI because of the risk of hypotension. (Level of Evidence: B)
Class IIa
During the acute phase (first 24-48 hrs) of the management of STEMI in patients with hyperglycemia, it is reasonable to administer an insulin infusion, even in patients with an uncomplicated course. (Level of Evidence: B) After the acute phase of STEMI, it is reasonable to individualize treatment, selecting from insulin, insulin analogs, and oral hypoglycemics. (Level of Evidence: C)
Magnesium
Class IIa
It is reasonable that documented Mg deficits be corrected, especially in patients receiving diuretics before the onset of STEMI. (Level of Evidence: C)
It is reasonable that episodes of torsades de pointes associated with a prolonged QT interval be treated with 1-2 grams of IV Mg administered as an IV bolus over 5 minutes. (Level of Evidence: C)
Class III
In the absence of electrolyte abnormalities or documented torsades, routine IV Mg should not be administered to STEMI patients at any level of risk. (Level of Evidence: A)
Summary
Targeted History Physical (include neuro) ECG (RV, Posterior) Lab CXR O2 Nitrates MSO4 ASA Beta Blockers Select Reperfusion Strategy UFH/LMWH Thienopyridines GPIIb/IIIa ACE-I Glucose Control Magnesium CCB CCU/Stepdown
Summary
PCI Fibrinolysis
Operator experience Prompt on site
Advantages
Superior patency rate Widely available Reduced Mortality, RI, MI Less ICH
Lower early mortality Simple to give a bolus Superior in CG shock Probably superior to fibrinolysis overall
Disadvantages