Aha Guidelines Stemi

7/18/2019 Aha Guidelines Stemi

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ACC/AHA Guidelines for the

Management of Patients withST-Elevation Myocardial nfarction


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Management !efore STEMManagement !efore STEM




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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


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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


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$nset of STEM$nset of STEM




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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


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$%tions for Trans%ort of Patients &ith$%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


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7 'atients receivin# fibrinolysis should be risk"stratified to identify needfor further revasculari


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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


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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'


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4ortic dissection

'ulmonary embolus

'erforatin# ulcer

Tension pneumothorax

=oerhaave syndrome

)esopha#eal rupture $ith

mediastinitis.

'ifferential 'iagnosis of STEM* Life-Threatening


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'ericarditis

4typical an#ina

0arly repolariasospastic an#inaHypertrophic

cardiomyopathy

'ifferential 'iagnosis of STEM* Other Cardiovascular andNonischemic


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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


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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


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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


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(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


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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


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'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


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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


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'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


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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


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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


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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.


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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


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"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


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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


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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



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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


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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


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4bsoluteContraindications

7 uspected aortic dissection

7 4ctive bleedin# or bleedin# diathesis

)excludin# menses.

7 i#nificant closed"head or facial trauma$ithin 3 months


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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


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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#


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"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


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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$


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


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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


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.


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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 )@===.


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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


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-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


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Evolution of PC for STEMEvolution of PC for STEM

Primary PC for STEM*Primary PC for STEM*


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$eneral Considerations$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


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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


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&2



'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


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'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


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&&

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




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"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


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"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


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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


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&;

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


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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



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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


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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


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Bnfractionated heparin )B-H. should be #iven

intravenously inG

'atients under#oin# 'C or sur#ical

revasculari


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@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


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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


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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#



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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


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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


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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


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$ther Pharmacological Measures$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


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/!


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 !&!



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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


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Strict Glucose Control 'uring STEMStrict Glucose Control 'uring STEM

4n insulin infusion to normali


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Hos%ital ManagementHos%ital Management


Management of Patients with

ST-Elevation Myocardial nfarction

Sam%le Admitting $rders for theSam%le Admitting $rders for the


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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



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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


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//

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


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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*


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inus Tach Treat causeK beta blocker

4fib -lutter Treat causeK slo$ ventricular rateK DC shock

'>T >a#al maneuversK beta blocker*

verapamil diltia


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inus =rady Treat if hemodynamic compromiseK

atropine pacin#

Nunctional Treat if hemodynamic compromiseK

atropine pacin#


+rad'arrh'thmias+rad'arrh'thmias

Arrhythmia Treatment



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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


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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$


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


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


74/94

(ong-Term Antithrom)otic Thera%y atHos%ital 'ischarge After STEM


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


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


77/94

66

(ong-Term Management(ong-Term Management



Secondary Prevention and (ong Term Management


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



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


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




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


('(-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



82/94

;2

f TGs are K 17 mg/d( or H'(-C is 8 ? mg/d(*0mphasi


83/94

;3


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


84/94

;&

y g g


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 & >?



85/94

;5



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



86/94

;/



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



87/94

;6



tart in all patients Continue indefinitely

Ebserve usual contraindications

!eta-

!loc#ers

Summary of Pharmacologic "4*Summary of Pharmacologic "4*%schemia%schemia


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


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


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


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


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


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


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

Aha Guidelines Stemi

Documents