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ST Elevation MyocardialST Elevation Myocardial
Infarction (STEMI)Infarction (STEMI)William J. Mosley II, MDWilliam J. Mosley II, MD
Cardiovascular Disease FelloCardiovascular Disease Fello(!"dated from Jo#n $a"" it# %&&'(!"dated from Jo#n $a"" it# %&&'
uidelines)uidelines)
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E"idemoloy of CDE"idemoloy of CD ( %&*+ )( %&*+ )
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In !S3In !S3
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Hospitalizations in the U.S. Due to Acute
Coronary Syndromes (ACS)
3cute CoronarySyndromes6
*./' Millionos"ital 3dmissions 2 3CS
!3-7STEMI STEMI
*.%+ million3dmissions "er year
.88 million3dmissions "er year
eart Disease and Stro9e Statistics : %&&' !"date. Circulation %&&';**/1
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earts conduction systemearts conduction system
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CDCD
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3CS2STEMI3CS2STEMI
ACUTE CORONARY SYNDROMES
No ST elevation ST elevation
Unstable
angina
NSTEMI STEMIStable
angina
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EBG 4ndins in CDEBG 4ndins in CD
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NutlineNutline
OClass-EvidenceClass-EvidenceOGeneral T#era"yGeneral T#era"yOAeta2?loc9ersAeta2?loc9ersO$e"erfusion$e"erfusion
OFacilitated =CIFacilitated =CIOCom"licationsCom"lications
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Class IBenefit >>> Risk
Procedure/Treatment SHOULDbe perormed/administered
Class IIaBenefit >> Risk
Additional studies withfocused objectivesneeded
IT IS REASONABLE toperormprocedure/administertreatment
Class IIbBenefit Risk
Additional studies withbroad objectivesneeded; Additionalregistry data would be
helpful
Procedure/TreatmentMAY BE CONSIDERED
Class IIIRisk BenefitNo additional studiesneeded
Procedure/Treatment
shouldNOT beperormed/administeredSINCE IT IS NOTHELPFUL AND MAYBE HARMFUL
Applyin! Classiication o "ecommendations
and #e$el o %$idence
Level A: "ecommendation based on e$idence rom multiple randomized trials or meta&analyses'ultiple (&) population ris* strata e$aluated+ ,eneral consistency o direction and ma!nitude o eect
Level B: "ecommendation based on e$idence rom a sin!le randomized trial or non&randomized studies#imited (-&) population ris* strata
e$aluated
Level C: "ecommendation based on epert opinion case studies or standard&o&care0ery limited (1&-) population ris* strata e$aluated
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GeneralGeneral
T#era"yT#era"y
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General T#era"yGeneral T#era"y
O MN73MN73: Mor"#ine (Mor"#ine ( /2*/ min C3SS I)
: NPyen (NPyen ("ulse oPQ
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3s"irin3s"irinO 3s"irin s#ould ?e c#eed ?y "atients #o #ave not
ta9en as"irin ?efore "resentation it# STEMI. T#einitial dose s#ould ?e *1% m (Level of Evidence: A) to8%/ m (Level of Evidence: C). Class I
O In a dose of *1% m or more, as"irin "roduces a ra"idclinical antit#rom?otic eRect caused ?y immediate andnear2total in#i?ition of t#rom?oPane 3% "roduction.(ISIS2%22Q3S3 led to %85 reduction in mortality)
1. Antithrombotic Trialists Collaboration. Collaborative meta-analysis of randomised trials ofantiplatelet therapy for prevention of death, myocardial infarction, and stroke in high riskpatients. BMJ. 2002 !2"# $1%&'.
2. ()()-2 *)econd (nternational )t+dy of (nfarct )+rvival Collaborative ro+p. andomised trialof intraveno+s streptokinase, oral aspirin, both, or neither among 1$1&$ cases of s+spectedac+te m ocardial infarction. /ancet 1&& ii#!"-'0.
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Aeta2Aloc9ersAeta2Aloc9ers
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I7C!SIN7I7C!SIN7 Q+/,&&& "atients it# sus"ected acuteQ+/,&&& "atients it# sus"ected acuteMI (ST c#ane or AAA) it#in %+ # ofMI (ST c#ane or AAA) it#in %+ # ofsym"tom onsetsym"tom onset
T$E3TME7TT$E3TME7T Meto"rolol */ m iv over */ mins, t#enMeto"rolol */ m iv over */ mins, t#en%&& m oral daily vs matc#in "lace?o%&& m oral daily vs matc#in "lace?o
EC!SIN7EC!SIN7 S#oc9, systolic A= *&& mm, #eartS#oc9, systolic A= *&& mm, #eart
rate /&-min or II-III 3K ?loc9rate /&-min or II-III 3K ?loc9
**N!TCNMESN!TCNMES Deat# U deat#, re2MI or KF-arrest u" toDeat# U deat#, re2MI or KF-arrest u" to+ ee9s in #os"ital (or "rior disc#are)+ ee9s in #os"ital (or "rior disc#are)
Mean treatment and follo2u" *1 daysMean treatment and follo2u" *1 days
COMMITCOMMIT Study desin Study desin
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ERects of Meto"rololERects of Meto"rolol
Lancet !""#$%&&:'&!!
Deat(
'%)
P*""""&
ReMI
!!)
P*""""!
+F'#)
P*"""!
Totality of Evidence (N = 52,411)COMMIT (N = 45,852)
%") ,elative
in-,ease in
.-a,/iogeni-
s(o-0
.Ris0 1a-to,s 1o, -a,/iogeni- s(o-0 :(ea,t 1ail2,e3 age 4 5" 3 s6stoli- bloo/7,ess2,e 8 '!"3 sin2s ta-(6-a,/ia 4 ''" o, (ea,t ,ate 8 &"3 in-,ease/ ti9e
sin-e onset o1 STEMI s697to9s
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$ecommendations 2 Class (a*
O A/?eta2?loc9er t#era"y )34/5 6initiatedin t#e 4rst %+ #ours for "atients #o 5 7T
#ave any of t#e folloin*) sins of #eart failure,%) evidence of a lo out"ut state,8) increased ris9 for cardioenic s#oc9, or+) relative contraindications to ?eta ?loc9ade
*3KA Q &.%+ sec, %nd2 or 8rd2deree #eart ?loc9
reactive airay disease88 T#ere is no study evaluatin oral ?eta ?loc9ers
alone
2eta&2loc*ers
.Ris0 1a-to,s 1o, -a,/iogeni- s(o-0 :(ea,t 1ail2,e3 age 4 5" 3 s6stoli- bloo/ 7,ess2,e 8 '!"3
sin2s ta-(6-a,/ia 4 ''" o, (ea,t ,ate 8 &"3 in-,ease/ ti9e sin-e onset o1 STEMI s697to9s
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$ecommendations 2 Class ((a*
O It is reasona?le to administer an (9 6TA/C:6at t#e time of "resentation to STEMI
"atients #o are 3;
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$ecommendations 2 Class (((*A
O IK ?eta ?loc9ers )34/5 7T?e administeredto STEMI "atients #o #ave any of t#e folloin
*) sins of #eart failure
%) evidence of a lo out"ut state
8) increased ris96 for cardioenic s#oc9+) relative contraindications to ?eta ?loc9ade
*3KA Q &.%+ sec, %nd2 or 8rd2deree #eart ?loc9 reactive airay disease
2eta&2loc*ers
.Ris0 1a-to,s 1o, -a,/iogeni- s(o-0 :(ea,t 1ail2,e3 age 4 5" 3 s6stoli- bloo/
7,ess2,e 8 '!"3 sin2s ta-(6-a,/ia 4 ''" o, (ea,t ,ate 8 &"3 in-,ease/ ti9e
sin-e onset o1 STEMI s697to9s
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$e"erfusion$e"erfusion
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VVTime is MuscleTime is Muscle
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"eperusion
O STEMI "atients "resentin to a #os"ital it# =CIca"a?ility s#ould ?e treated it# "rimary =CI=ithin 0 minof 4rst medical contact as asystems oal. Class (a
O STEMI "atients "resentin to a #os"ital it#out=CI ca"a?ility, and #o cannot ?e transferred to a=CI center and undero =CI it#in
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PC3 $s 4ibrinolysis or ST%'35
Short&Term Clinical 6utcomesPCI
F,e:2en-
6;)cacy *thro+gh !0 d6>cacy *thro+gh !0 d )afety)afety 4se 5+ring
7o data on revi"arin alone7o data on revi"arin alone
durin =CI. 3dditionaldurin =CI. 3dditionalanticoaulant it# anti2IIaanticoaulant it# anti2IIaactivity, suc# as !F oractivity, suc# as !F or?ivalirudin, recommended.?ivalirudin, recommended.
Fonda"arinuPFonda"arinuP Fi?rinolysis a""ears su"erior toFi?rinolysis a""ears su"erior tocontrol rP ("lace?o-!F). $elativecontrol rP ("lace?o-!F). $elative?ene4t vs "lace?o and !F?ene4t vs "lace?o and !Fse"arately cannot ?e relia?lyse"arately cannot ?e relia?ly
determined from availa?le data.6determined from availa?le data.6
=rimary =CI #en used alone, no=rimary =CI #en used alone, noadvantae over !F and trendadvantae over !F and trendtoard orse outcome.toard orse outcome.
7o re"erfusion a""ears su"erior to7o re"erfusion a""ears su"erior tocontrol t#era"y ("lace?o-!F).control t#era"y ("lace?o-!F).
$elative ?ene4t versus "lace?o and$elative ?ene4t versus "lace?o and!F se"arately cannot ?e relia?ly!F se"arately cannot ?e relia?lydetermined from availa?le data.6determined from availa?le data.6
Trend toard [Trend toard [ris9 of seriousris9 of serious?leeds>?leeds>
ZZ ris9 of cat#eter t#rom?osisris9 of cat#eter t#rom?osis#en fonda"arinuP used#en fonda"arinuP usedalone. 3dditionalalone. 3dditionalanticoaulant it# anti2IIaanticoaulant it# anti2IIa
activity, suc# as !F oractivity, suc# as !F or?ivalirudin, recommended.?ivalirudin, recommended.
EnoPa"arinEnoPa"arin Fi?rinolysis a""ears su"erior to !FFi?rinolysis a""ears su"erior to !F ZZ ris9 of seriousris9 of serious?leeds>?leeds>
EnoPa"arin can ?e used toEnoPa"arin can ?e used tosu""ort =CI after 4?rinolysis.su""ort =CI after 4?rinolysis.7o additional anticoaulant7o additional anticoaulantneeded.needed.
Summary o 6bser$ations rom Trials o Anticoa!ulants or ST%'3
Antman %' et al. A! "oll "ardiol #$$%& Published ahead o print on December 18 -88. A$ailable at
http5//content.onlineBacc.or!/c!i/content/ull/B.Bacc.-88.18.881.Table 18.
http://content.onlinejacc.org/cgi/content/full/j.jacc.2007.10.001http://content.onlinejacc.org/cgi/content/full/j.jacc.2007.10.0017/23/2019 Referensi STEMI
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Facilitated =CIFacilitated =CI
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Meta2analysis Facilitated =CI vsMeta2analysis Facilitated =CI vs
=rimary =CI=rimary =CI
1.0!1.0!
*0.1?-$.1!*0.1?-$.1!!.0$!.0$
*0.1&-?2.0*0.1&-?2.0
1."!1."!
*1.01-2.02*1.01-2.02
1.0!1.0!*0."-2.1$*0."-2.1$
Mo,talit6 Rein1a,-tion Ma>o, Blee/ing
Fa- PCI
Bette,
PPCI
Bette,
Fa- PCI
Bette,
PPCI
Bette,
Fa- PCI
Bette,
PPCI
Bette,
7eeley % et al. Lancet -889+95.
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