ACCAHA Guidelines for the Management of Patients with

1

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

2
Management Before STEMI

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

3
Identification 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.
4
Identification 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.
5
Onset of STEMI

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

6
Prehospital Chest Pain Evaluation and 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 nonenteric-coated
formulations.
7
Options for Transport of Patients With STEMI and
Initial Reperfusion Treatment
Hospital fibrinolysis Door-to-Needle within
30 min.
Not PCI capable

• EMS on-scene
• Encourage 12-lead ECGs.
• Consider prehospital fibrinolytic if capable and
  EMS-to-needle within 30 min.

Onset of symptoms of STEMI
EMS Dispatch
EMS Triage Plan
Inter-Hospital Transfer
PCI capable
GOALS
5 min.
8 min.
EMS Transport
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.
Golden Hour first 60 min.
Total ischemic time within 120 min.
8
Options for Transport of Patients With STEMI and
Initial Reperfusion Treatment

• 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.

9
Initial Recognition and Management in the
Emergency Department

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

10
ED Evaluation of Patients With STEMI
Brief Physical Examination in the ED
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)
11
ED Evaluation of Patients With STEMI
Differential Diagnosis of STEMI Life-Threatening
Aortic dissection Pulmonary embolus Perforating
ulcer
Tension pneumothorax Boerhaave syndrome
(esophageal rupture with mediastinitis)
12
ED Evaluation of Patients With STEMI
Differential Diagnosis of STEMI Other
Cardiovascular and Nonischemic
LV hypertrophy with strain Brugada
syndrome Myocarditis Hyperkalemia Bundle-branch
blocks Vasospastic angina Hypertrophic
cardiomyopathy
Pericarditis Atypical angina Early
repolarization Wolff-Parkinson-White
syndrome Deeply inverted T-waves suggestive of a
central nervous system lesion or apical
hypertrophic cardiomyopathy
13
ED Evaluation of Patients With STEMI
Differential Diagnosis of STEMI Other Noncardiac
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
14
Electrocardiogram
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.
15
Electrocardiogram
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.
16
Laboratory 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

17
Biomarkers of Cardiac Damage
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.
18
Imaging
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.
19
Oxygen
Supplemental oxygen should be administered to
patients with arterial oxygen desaturation (SaO2
supplemental oxygen to all patients with
uncomplicated STEMI during the first 6 hours.
20
Nitroglycerin
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.
21
Nitroglycerin
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 below baseline
• severe bradycardia (
• tachycardia ( 100 bpm) or
• suspected RV infarction.

22
Analgesia
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.
23
Aspirin
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 nonenteric-coated
formulations.
24

Beta-Blockers
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.
25
Reperfusion

• 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

26
Reperfusion
The medical system goal is to facilitate rapid
recognition and treatment of patients with STEMI
such that door-to- needle (or medical
contactto-needle) time for initiation of
fibrinolytic therapy can be achieved within 30
minutes or that door-to-balloon (or medical
contactto- balloon) time for PCI can be kept
within 90 minutes.
27
Reperfusion
Patient
Transport
Inhospital
Reperfusion
Goals
D-N 30 min
5 min

D-B 90 min
Methods of Speeding Time to Reperfusion


Media campaign Patient education
Prehospital ECG
MI protocol Critical pathway Quality improvement
program
Bolus lytics Dedicated PCI team
Greater use of 9-1-1 Prehospital Rx
28
Treatment Delayed is Treatment Denied
Cath Lab
Symptom Recognition
Call to Medical System
ED
PreHospital
Increasing Loss of Myocytes
Delay in Initiation of Reperfusion Therapy
29
Contraindications and Cautions for Fibrinolysis
in STEMI

• 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

Absolute Contraindications
NOTE Age restriction for fibrinolysis has been
removed compared with prior guidelines.
30
Contraindications and Cautions for Fibrinolysis
in STEMI
Absolute Contraindications

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

31
Contraindications and Cautions for Fibrinolysis
in STEMI
Relative Contraindications

• 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 (

32
Contraindications and Cautions for Fibrinolysis
in STEMI
Relative Contraindications

• Recent (
• 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

33
Reperfusion Options for STEMI PatientsStep One
Assess Time and Risk.
Risk of Fibrinolysis
Time Since Symptom Onset
Time Required for Transport to a Skilled PCI Lab
Risk of STEMI
34
Reperfusion Options for STEMI Patients Step 2
Select Reperfusion Treatment.
If presentation is delay to an invasive strategy, there is no
preference for either strategy.

• 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

35
Reperfusion Options for STEMI Patients Step 2
Select Reperfusion Treatment.
If presentation is delay to an invasive strategy, there is no
preference for either strategy.

• Invasive strategy generally preferred
• Skilled PCI lab available with surgical backup
  ? Door-to-balloon
• 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

36
Fibrinolysis
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).
37
Fibrinolysis
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.
38
Fibrinolysis
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.
39
Evolution of PCI for STEMI
40
Primary PCI for STEMI General 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

41
Primary PCI for STEMI Specific Considerations
Medical contactto-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.
42
Primary PCI for STEMI Specific Considerations
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.
43
Primary PCI for STEMI Specific Considerations
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.
44
Primary PCI for STEMI Specific Considerations
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.
45

Rescue 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
performed within 18 hours of shock. Rescue PCI
should be performed in patients with severe CHF
and/or pulmonary edema (Killip class 3) and onset
of symptoms within 12 hours.
46

Rescue 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.
47

PCI 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
performed within 18 hours of shock.
48
PCI for Cardiogenic Shock
Cardiogenic Shock
Early Shock, Diagnosed on Hospital Presentation
Delayed Onset Shock Echocardiogram to Rule Out
Mechanical Defects
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
Arrange rapid transfer to invasive
procedure-capable center
IABP
Cardiac Catheterization and Coronary Angiography
1-2 vessel CAD
Moderate 3-vessel CAD
Severe 3-vessel CAD
Left main CAD
PCI IRA
PCI IRA
Immediate CABG
Cannot be performed
Staged Multivessel PCI
Staged CABG
49

PCI 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.

50

PCI After Fibrinolysis
It is reasonable to perform routine PCI in
patients with left ventricular ejection fraction
(LVEF) 0.40, CHF, or serious ventricular
arrhythmias.
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).
Routine PCI might be considered as part of an
invasive strategy after fibrinolytic therapy.
51

Assessment 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.

52
Ancillary 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.

53

Ancillary Therapy to Reperfusion
Platelet counts should be monitored daily in
patients taking UFH.
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.
54

Aspirin
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.
55

Thienopyridines
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.

56

Thienopyridines
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.
57

Thienopyridines
Clopidogrel is probably indicated in patients
receiving fibrinolytic therapy who are unable to
take aspirin because of hypersensitivity or
gastrointestinal intolerance.
58

Glycoprotein 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.
59
Other 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
60

ACE/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

An ARB should be given to ACE-intolerant patients
with either clinical or radiological signs of HF
or LVEF
61

ACE/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

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).
62

Strict 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.
63
Hospital Management

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

64
Sample Admitting Orders for the Patient 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
65
Sample Admitting Orders for the Patient 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 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
66
Emergency Management of Complicated STEMI
Clinical signs Shock, hypoperfusion, congestive
heart failure, acute pulmonary edema Most likely
major underlying disturbance?
Arrhythmia
Low Output - Cardiogenic Shock
Hypovolemia
Acute Pulmonary Edema

• 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

Bradycardia
Tachycardia

• Administer
• Fluids
• Blood transfusions
• Cause-specific interventions
• Consider vasopressors

Check Blood Pressure
First line of action
See Section 7.7 in the ACC/AHA Guidelines for
Patients With ST-Elevation Myocardial Infarction
Check Blood Pressure
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
Systolic BP Greater than 100 mm Hg and not less
than 30 mm Hg below baseline
Second line of action
Norepinephrine 0.5 to 30 mcg/min IV
Dobutamine 2 to 20 mcg/kg per minute IV
Nitroglycerin 10 to 20 mcg/min IV
Dopamine 5 to 15 mcg/kg per minute IV
ACE Inhibitors Short-acting agent such as
captopril (1 to 6.25 mg)
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
Circulation 2000102(suppl I)I-172-I-216.
Third line of action
67
Arrhythmias During Acute Phase of STEMI
Electrical Instability
Arrhythmia Treatment
VPBs K , Mg, beta blocker VT Antiarrhythmics,
DC shock AIVR Observe unless hemodynamic compromis
e NPJT Search for cause (e.g., dig toxicity)
68
Arrhythmias During Acute Phase of STEMI Pump
Failure / Excess Sympathetic Tone
Arrhythmia Treatment
Sinus Tach Treat cause beta blocker Afib /
Flutter Treat cause slow ventricular rate DC
shock PSVT Vagal maneuvers beta blocker,
verapamil / diltiazem DC shock
69
Arrhythmias During Acute Phase of STEMI
Bradyarrhythmias
Arrhythmia Treatment
Sinus Brady Treat if hemodynamic
compromise atropine / pacing Junctional Treat
if hemodynamic compromise atropine / pacing

70
Arrhythmias During Acute Phase of STEMI AV
Conduction Disturbances
Proximal Distal
Escape Rhythm His Bundle Distal 120
ms 45 - 60 Often days Transient Mortality Low High (CHF,
VT) Rx Observe PM (ICD)
71
Recommendations for Treatment of Atrioventricular
and Intraventricular Conduction Disturbances
During STEMI
72
ICD Implantation After STEMI
One Month After STEMI No Spontaneous VT or VF
48 hours post-STEMI
EF EF 0.31 - 0.40

EF 0.40
No
Yes
EPS

-
NEJM 349 1836,2003
73
Algorithm for Management of Recurrent
Ischemia/Infarction After STEMI
Recurrent ischemic
-
type discomfort at rest after STEMI
Recurrent ischemic
-
type discomfort at rest after STEMI

Escalation of medical therapy (nitrates, beta
-

Escalation of medical therapy (nitrates, beta
-
blockers)
blockers)

Anticoagulation if not already given

Anticoagulation if not already given

Consider IABP for hemodynamic instability,

Consider IABP for hemodynamic instability,
poor LV function, or a large area of
poor LV function, or a large area of
Obtain 12
-
lead ECG
Obtain 12
-
lead ECG
myocardium at risk
myocardium at risk

Correct secondary causes of ischemia

Correct secondary causes of ischemia
ST
-
segment elevation?
ST
-
segment elevation?
ST
-
segment elevation?
YES
NO
YES
NO
Is patient
Is ischemia
Is patient
Is patient
Is ischemia
Is ischemia
a candidate for
controlled by escalation
a candidate for
a candidate for
controlled by escalation
controlled by escalation
revascularization
?
of medical therapy?
revascularization
?
revascularization
?
of medical therapy?
of medical therapy?
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
Refer for
Refer for urgent
Refer for
Refer for urgent
Refer for
Refer for urgent
nonurgent
catheterization (consider
Can
nonurgent
catheterization (consider
nonurgent
catheterization (consider
Can
Can
Consider (re)
Consider (re) administration
catheterization
IABP)
catheterization
catheterization
IABP)
catheterization
IABP)
catheterization
catheterization
administration of
of fibrinolytic therapy
be performed promptly?
be performed promptly?
be performed promptly?
Modified from Braunwald. Heart Disease A
Textbook of Cardiovascular Medicine. 6th ed.
Philadelphia, PA WB Saunders Co. Ltd. 20011195.
YES
YES
NO
NO
Coronary
Coronary
Consider (re) administration
angiography
angiography
of fibrinolytic therapy
Revascularization with PCI
Revascularization with PCI
and/or CABG as dictated by
and/or CABG as dictated by
anatomy
anatomy
74
Evidence-Based Approach to Need for
Catheterization and Revascularization After STEMI
STEMI
STEMI
Primary Invasive Strategy
Fibrinolytic Therapy
No Reperfusion Therapy
Primary Invasive Strategy
Fibrinolytic Therapy
No Reperfusion Therapy
Cath
No Cath
Cath
No Cath
EF less
EF greater
EF less
EF greater
Performed
Performed
Performed
Performed
than 0.40
than 0.40
than 0.40
than 0.40
EF greater
EF less
EF greater
EF less
High
-
Risk
No High
-
Risk
High
-
Risk
No High
-
Risk
than 0.40
than 0.40
than 0.40
than 0.40
Features

Features
Features

Features
Catheterization and
Catheterization and
Revascularization as
Revascularization as
No High
-
Risk
High
-
Risk
No High
-
Risk
High
-
Risk
Indicated
Indicated
Features

Features

Features
Features
Revascularization as
Revascularization as
Functional
Functional
Indicated
Indicated
Evaluation
Evaluation
ECG Interpretable
ECG Uninterpretable
ECG Interpretable
ECG Uninterpretable
Unable to Exercise
Unable to Exercise
Able to Exercise
Able to Exercise
Able to Exercise
Able to Exercise
Pharmacological Stress
Pharmacological Stress
Submaximal
Submaximal
Symptom
-
Limited
Symptom
-
Limited
Adenosine
Exercise
Exercise
Exercise
Exercise
Dobutamine
Dobutamine
Exercise Test
Exercise Test
Exercise Test
Exercise Test
or Dipyridamole
Echo
Nuclear
Echo
Nuclear
Echo
Echo
Before Discharge
Before or After Discharge
Before Discharge
Before or After Discharge
Nuclear Scan
Catheterization and
Catheterization and
Clinically Significant
No Clinically Significant
Medical
Clinically Significant
No Clinically Significant
Medical
Revascularization as
Revascularization as
Ischemia
Ischemia
Therapy
Ischemia
Ischemia
Therapy
Indicated
Indicated
75
Long-Term Antithrombotic Therapy at Hospital
Discharge After STEMI
STEMI Patient at Discharge
No Stent Implanted
No ASA allergy
ASA Allergy
Indications for Anticoagulation
No Indications for Anticoagulation
No Indications for Anticoagulation
Indications for Anticoagulation
Preferred ASA 75 to 162 mg Class I LOE A
Preferred Clopidogrel 75 mg Class I LOE C
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
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
76
Long-Term Antithrombotic Therapy at Hospital
Discharge After STEMI
STEMI Patient at Discharge
Stent Implanted
No ASA Allergy
ASA Allergy
No Indications for Anticoagulation
Indications for Anticoagulation
Indications for Anticoagulation
No Indications for Anticoagulation
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
77
Long-Term Management

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

78
Goals Recommendations

• 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
79
Goals Recommendations
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 diabetes
80
Goals Recommendations

• 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
81
Goals Recommendations

• Start dietary therapy in all patients (total calories as saturated fat and 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
LDL-C treatment) Statins should be used to lower
LDL-C. LDL-C 100 mg/dL (baseline or
on treatment) Intensify LDL-Clowering therapy
with drug treatment, giving preference to statins.
82
If TGs are 150 mg/dL or HDL-C is mg/dL Emphasize weight management and physical
activity. Advise smoking cessation. If TG is 200
to 499 mg/dL After LDL-Clowering therapy,
consider adding fibrate or niacin. If TG is
500 mg/dL Consider fibrate or niacin before
LDL-Clowering therapy. Consider omega-3 fatty
acids as adjunct for high TG.
Lipid management (TG 200 mg/dL or
greater) Primary goal NonHDL-C
83
Weight management Goal BMI 18.5 to 24.9
kg/m2 Waist circumference Women
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.
84
Goals Recommendations
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
85
Goals Recommendations

• 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
86
Goals Recommendations
Renin-Angiotensin-Aldosterone System Blockers
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 Angiotensin receptor blockers in patients who
are intolerant of ACE inhibitors and with either
clinical or radiological signs of heart failure
or LVEF 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.
87
Goals Recommendations
Start in all patients. Continue indefinitely.
Observe usual contraindications.
Beta- Blockers
88
Summary of Pharmacologic Rx Ischemia
JACC 200444 671Circulation 2004110 588
89
Summary of Pharmacologic Rx LVD, Sec. Prev.,
JACC 200444671Circ 2004110588
90

Hormone Therapy
Hormone therapy with estrogen plus progestin
should not be given de novo to postmenopausal
women after STEMI for secondary prevention of
coronary events.
91

Hormone 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.
92

Antioxidants
Antioxidant vitamins such as vitamin E and/or
vitamin C supplements should not be prescribed to
patients recovering from STEMI to prevent
cardiovascular disease.
93

Psychosocial 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.
94

Cardiac 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.