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STEMI-WRAP on Evidence-Based Management of STEMI: The Emergency Department Perspective Charles V. Pollack, Jr., M.A., M.D., FACEP, FAHA Professor and Chair,

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Presentation on theme: "STEMI-WRAP on Evidence-Based Management of STEMI: The Emergency Department Perspective Charles V. Pollack, Jr., M.A., M.D., FACEP, FAHA Professor and Chair,"— Presentation transcript:

1 STEMI-WRAP on Evidence-Based Management of STEMI: The Emergency Department Perspective Charles V. Pollack, Jr., M.A., M.D., FACEP, FAHA Professor and Chair, Emergency Medicine, Pennsylvania Hospital University of Pennsylvania Health System Philadelphia Charles V. Pollack, Jr., M.A., M.D., FACEP, FAHA Professor and Chair, Emergency Medicine, Pennsylvania Hospital University of Pennsylvania Health System Philadelphia

2 STEMI n Accounts for 15-20% of cases of ACS seen in ED; UA/NSTEMI (collectively, NSTE ACS) account for majority n High-visibility diagnosis because of its high morbidity and mortality, patient and family fears and expectations, and intensity of monitoring by observers inside and outside the hospital—QI, payors, JCAHO, P4P n Accounts for 15-20% of cases of ACS seen in ED; UA/NSTEMI (collectively, NSTE ACS) account for majority n High-visibility diagnosis because of its high morbidity and mortality, patient and family fears and expectations, and intensity of monitoring by observers inside and outside the hospital—QI, payors, JCAHO, P4P

3 STEMI n Pathophys: STEMI is caused by complete obstruction of an epicardial vessel, which causes angina or anginal equivalent and diagnostic ECG changes of ST-segment elevation n Recognition of STEMI, which by GLs should occur within 10 minutes of ED arrival, launches the ED- cardiology team on a fast-moving track that demands prompt stabilization, evidence-based medical management, and quick decisions regarding reperfusion therapy n Dx of STEMI is clinical + electrocardiographic and DOES NOT require assessment of cardiac markers n Pathophys: STEMI is caused by complete obstruction of an epicardial vessel, which causes angina or anginal equivalent and diagnostic ECG changes of ST-segment elevation n Recognition of STEMI, which by GLs should occur within 10 minutes of ED arrival, launches the ED- cardiology team on a fast-moving track that demands prompt stabilization, evidence-based medical management, and quick decisions regarding reperfusion therapy n Dx of STEMI is clinical + electrocardiographic and DOES NOT require assessment of cardiac markers

4 STEMI n STEMI typically result from fissure or frank rupture of an atherosclerotic plaque l Stimulates local activation of: platelets coagulation cascade complement l Platelet aggregate forms over site of plaque injury and as it matures (fibrinogen→fibrin) causes complete obstruction of distal flow. To the extent that collateral flow downstream is lacking, ischemia quickly ensues and infarction starts to occur within minutes n STEMI typically result from fissure or frank rupture of an atherosclerotic plaque l Stimulates local activation of: platelets coagulation cascade complement l Platelet aggregate forms over site of plaque injury and as it matures (fibrinogen→fibrin) causes complete obstruction of distal flow. To the extent that collateral flow downstream is lacking, ischemia quickly ensues and infarction starts to occur within minutes

5 STEMI n Pharmacologic therapy in STEMI is therefore directed at this triad of abnormal activity: l Platelet activation—anti-activation and anti- aggregation ASA and clopidogrel GPIs l Coagulation activation—anticoagulants l Complement activation—anti-inflammatories... ? Statins l In preparation for reperfusion therapy by lysis or angiography and primary PCI n Pharmacologic therapy in STEMI is therefore directed at this triad of abnormal activity: l Platelet activation—anti-activation and anti- aggregation ASA and clopidogrel GPIs l Coagulation activation—anticoagulants l Complement activation—anti-inflammatories... ? Statins l In preparation for reperfusion therapy by lysis or angiography and primary PCI

6 Guidelines for STEMI diagnosis and management n complex disease state with broad ranges of presentation and a multitude of therapeutic options n Many important and pertinent clinical studies n Information overload! n Need evidence-based guidelines to promote consistency of care and resulting better outcomes n complex disease state with broad ranges of presentation and a multitude of therapeutic options n Many important and pertinent clinical studies n Information overload! n Need evidence-based guidelines to promote consistency of care and resulting better outcomes

7 Guidelines for STEMI management n ACC/AHA Joint Task Force: 1990, 1996, 1999 n Last comprehensive update in 2004 l Widely read, lots of interest l Clear evidence scoring, sensible recommendations, temporal sequencing “soup to nuts” l Recapitulation, interpretation, and promulgation for upstream providers in Annals of Emergency Medicine n ACC/AHA Joint Task Force: 1990, 1996, 1999 n Last comprehensive update in 2004 l Widely read, lots of interest l Clear evidence scoring, sensible recommendations, temporal sequencing “soup to nuts” l Recapitulation, interpretation, and promulgation for upstream providers in Annals of Emergency Medicine

8 Guidelines for STEMI management n ACC/AHA Joint Task Force: presented “focused update” in December 2007 l “focus” (from upstream perspective) on reperfusion strategies and opportunities to minimize delays to reperfusion l Beta blockers l Choices of anticoagulants l New recommendations regarding clopidogrel n ACC/AHA Joint Task Force: presented “focused update” in December 2007 l “focus” (from upstream perspective) on reperfusion strategies and opportunities to minimize delays to reperfusion l Beta blockers l Choices of anticoagulants l New recommendations regarding clopidogrel

9 Class I Benefit >>> Risk Procedure/ Treatment SHOULD be performed/ administered Class IIa Benefit >> Risk Additional studies with focused objectives needed IT IS REASONABLE to perform procedure/administer treatment Class IIb Benefit ≥ Risk Additional studies with broad objectives needed; Additional registry data would be helpful Procedure/Treatment MAY BE CONSIDERED Class III Risk ≥ Benefit No additional studies needed Procedure/Treatment should NOT be per- formed/administered SINCE IT IS NOT HELPFUL AND MAY BE HARMFUL should is recommended is indicated is useful/effective/ beneficial is reasonable can be useful/effective/ beneficial is probably recommended or indicated may/might be considered may/might be reasonable usefulness/effectiveness is unknown /unclear/uncertain or not well established is not recommended is not indicated should not is not useful/effective/ beneficial may be harmful Applying Classification of Recommendations

10 “The Guidelines” Weighing the Evidence n Weight of evidence grades: =Data from many large, randomized trials =Data from fewer, smaller randomized trials, careful analyses of nonrandomized studies, observational registries =Expert consensus n Weight of evidence grades: =Data from many large, randomized trials =Data from fewer, smaller randomized trials, careful analyses of nonrandomized studies, observational registries =Expert consensus

11 Time Delays and 30 Day Outcome in STEMI Collins. NEJM. 1997;336: ,000 patients in placebo controlled lytic trials Hours from onset of symptoms to randomization 3000 Loss of benefit per hour of delay 1.6±0.6 lives per 1000 patients Lives saved/1000 patients 14,000 12,

12 Time Delays and 30 Day Outcome in STEMI: Primary PCI (NRMI-2) Cannon C, et al. JAMA 2000;283:

13 Time Delays and 30 Day Outcome in STEMI: Primary PCI (NRMI-2) Cannon C, et al. JAMA 2000;283:

14 Prehospital Issues n EMS l Emphasis on early defibrillation; AEDs; 911 dispatchers training & use of national protocols; 12-lead ECGs n Chest Pain Evaluation & Treatment l Emphasis on giving chewable ASA, unless contraindicated & prehospital ECG & checklist n Prehospital Fibrinolysis l Upgraded to a Class IIa (Level B) Recommendation although not particularly likely in most systems n Prehospital Destination Protocols l Where to transport STEMI patients: a plan must be in place l Special considerations Cardiogenic Shock Fibrinolytic contraindicated n EMS l Emphasis on early defibrillation; AEDs; 911 dispatchers training & use of national protocols; 12-lead ECGs n Chest Pain Evaluation & Treatment l Emphasis on giving chewable ASA, unless contraindicated & prehospital ECG & checklist n Prehospital Fibrinolysis l Upgraded to a Class IIa (Level B) Recommendation although not particularly likely in most systems n Prehospital Destination Protocols l Where to transport STEMI patients: a plan must be in place l Special considerations Cardiogenic Shock Fibrinolytic contraindicated

15 Patients Transported by EMS After Calling Onset of STEMI Symptoms Call 911 Call Fast EMS Dispatch EMS on-scene Encourage 12-lead ECG Consider prehospital fibrinolytic if capable and EMS-to-needle < 30 min EMS Triage Plan Not PCI Capable Hospital PCI Capable Hospital Interhospital Transfer Hospital Fibrinolysis: Door-to-needle within<30 min EMS transport:EMS to Balloon within 90 min Patient self-transport: Hospital Door-to-Balloon within 90 min EMS transport EMS on scene Within 8 min Dispatch 1 min Patient 5’ after sx onset Goals Total ischemic time: Within 120 min* PPCI: Door-to-balloon within<90 min PPCI: Door-to-balloon within<90 min

16 ACC/AHA 2007 STEMI Focused Update: Acute Medical Therapy General treatment measures Aspirin, nitrates, oxygen, analgesics a (morphine) Infarct size limitation β-blockers (not for acute use in patients with evidence of heart failure) Reperfusion Thrombolysis (within 30 min) or primary PCI (within 90 min) Anticoagulant and antiplatelet therapy UFH or enoxaparin or fondaparinux b Clopidogrel 75 mg/d added to aspirin for patients undergoing fibrinolysis; 300 mg loading dose for patients <75 y who receive fibrinolytic therapy or who do not receive reperfusion therapy If PCI: clopidogrel, GP IIb/IIIa inhibitors a Patients routinely taking NSAIDs (except for aspirin), both nonselective as well as COX-2 selective agents, before STEMI should have those agents discontinued at the time of presentation with STEMI because of the increased risk of mortality, reinfarction, hypertension, heart failure, and myocardial rupture associated with their use. b Because of the risk of catheter thrombosis, fondaparinux should not be used as the sole anticoagulant to support PCI. An additional anticoagulant with anti-IIa activity should be administered. Antman E, et al. J Am Coll Cardiol. doi: /j.jacc

17 Class I Modified Recommendations Reperfusion Therapy for STEMI STEMI patients presenting to a hospital with PCI capability should be treated with primary PCI within 90 minutes of first medical contact as a systems goal (Level of Evidence: A) STEMI patients presenting to a hospital without PCI capability and who cannot be transferred to a PCI center and undergo PCI within 90 minutes of first medical contact should be treated with fibrinolytic therapy within 30 minutes of hospital presentation as a systems goal unless fibrinolytic therapy is contraindicated (Level of Evidence: B) Antman E, et al. J Am Coll Cardiol. doi: /j.jacc ACC/AHA STEMI Focused Update

18 However, fibrinolysis generally preferred when Invasive strategy not an option –Vascular access difficulties –No access to skilled PCI lab Delay to invasive strategy –Prolonged transport –Door-to-balloon time >90 min –>1 hr vs fibrinolysis (fibrin-specific agent) now No Preference for Either Strategy If Presentation Is  3 hr and There Is No Delay in Invasive Strategy Adapted with permission from Antman EM, et al. J Am Coll Cardiol. 2004;44: Photo courtesy of ACC/AHA guidelines for STEMI slide set. Slides&parsedquery+&x+10&y=5. Accessed January 10, Determine Whether Fibrinolysis or PCI Is Preferred

19 Determine Whether Fibrinolysis or PCI Is Preferred (cont.) However, invasive strategy generally preferred when Skilled PCI lab is available with surgical backup –Door-to-balloon time <90 min High risk from STEMI –Cardiogenic shock*, Killip class ≥III Contraindications to fibrinolysis, including increased risk of bleeding and ICH Late presentation –>3 hr from symptom onset Diagnosis of STEMI is in doubt *PCI strongly preferred, but if immediate PCI not available/transfer for PCI delayed and presentation ≤3 hours, treat with fibrinolytic therapy and transfer to a skilled PCI lab. Adapted from Antman EM, et al. J Am Coll Cardiol. 2004;44: Photo courtesy of ACC/AHA guidelines for STEMI slide set. Slides&parsedquery+&x+10&y=5. Accessed January 10, No Preference for Either Strategy If Presentation Is  3 hr and There Is No Delay in Invasive Strategy

20 Primary PCI vs Thrombolysis in STEMI: Quantitative Analysis (23 RCTs*, N=7739) Adapted with permission from Keeley EC, et al. Lancet. 2003;361: Frequency, % Short-term outcomes (4–6 wk) Death P =.0002 Nonfatal MI P <.0001 Recurrent Ischemia P <.0001 Hemor- rhagic Stroke P <.0001 Major Bleed P =.032 PCI Thrombolytic therapy Death, Nonfatal Reinfarction, or Stroke P <.0001 *The criterion for time to treatment was 6 h or less in 9 of the trials, 12 h in 13 trials, and up to 36 h in the SHOCK trial.

21 NRMI: Advantage of PCI Compared With Fibrinolysis Decreases as PCI-Related Delay Increases Adapted with permission from Pinto DS, et al. Circulation. 2006;114: Odds of Death With Fibrinolysis PCI-Related Delay (door-to-balloon–door-to-needle time), min PCI Better Fibrinolysis Better

22 Door to Balloon (D2B): An Alliance for Quality Campaign Door to Balloon (D2B) Campaign—joint program of ACC, AHA, and other health organizations Aims to increase percentage of AMI patients who receive primary angioplasty within 90 minutes of hospital presentation to 75%; current figures indicate only 35% achieve this goal D2B implementation kit contains 6 evidence- based strategies for reducing door-to-balloon times D2B: An Alliance for Quality Web site. Accessed December 27, 2007.

23 *P<.05 for all. Bradley EH, et al. N Engl J Med. 2006;355: Door to Balloon (D2B): An Alliance for Quality Campaign Strategies Associated With a Significant Reduction in DTB Time Strategy Mean reduction in door-to-balloon time (min)* Having emergency medicine physicians activate the cath lab 8.2 Having a single call to a central page operator activate the cath lab 13.8 Having the ED activate the cath lab while patient is still en route 15.4 Expecting staff to arrive at the cath lab within 20 minutes after page 19.3 Having an attending cardiologist always on site14.6 Having staff in the ED and cath lab use and receive real-time feedback 8.6

24 Anticoagulants as Ancillary Therapy to Reperfusion Therapy ● Patients undergoing reperfusion with fibrinolytics should receive anticoagulant therapy for a minimum of 48 hours and preferably for the duration of the index hospitalization, up to 8 days (regimens other than UFH are recommended if anticoagulant therapy is given for more than 48 hours because of the risk of heparin-induced thrombocytopenia with prolonged UFH treatment) ● Anticoagulants regimens with established efficacy include: ●UFH ●Enoxaparin ●Fondaparinux New Class I Recommendation Antman E, et al. J Am Coll Cardiol. doi: /j.jacc ACC/AHA STEMI Focused Update

25 Anticoagulants ● It is reasonable for patients with STEMI who do not undergo reperfusion therapy to be treated with anticoagulant therapy (non-UFH regimen) for the duration of the index hospitalization, up to 8 days (Level of Evidence: B). Convenient strategies that can be used include those with LMWH (Level of Evidence: C) or fondaparinux (Level of Evidence: B) using the same dosing regimens as for patients who receive fibrinolytic therapy Modified Class IIa Recommendation Antman E, et al. J Am Coll Cardiol. doi: /j.jacc ACC/AHA STEMI Focused Update

26 Main Results From ExTRACT–TIMI 25 Primary End Point: Death or nonfatal re-MI by 30 days Main Secondary End Point: Death, nonfatal re-MI, or urgent revascularization by 30 days UFH ENOX % % RR=0.83 P<.001 RR=0.81 P< Days Adapted with permission from Antman EM, et al. N Engl J Med. 2006;354: Major bleeding at 30 days: 1.4% with UFH vs 2.1% with enoxaparin (P<.001) ICH: 0.7% for UFH vs 0.8% for enoxaparin (P=.14) RR=0.88 P=.02

27 ExTRACT–TIMI 25: For Every 1000 Patients Treated With Enoxaparin vs UFH Events/1000 Patients Nonfatal reMI Urgent Revasc. Death Nonfatal TIMI Major Bleed (No increase in nonfatal ICH) Antman EM, et al. N Engl J Med. 2006;354: Adapted with permission from clinicaltrialresults.org

28 12,092 patients presenting with STEMI within 24 hours of symptom onset (shortened to 12 hours of symptom onset midway through trial) Randomized. Blinded. Factorial. 28% female; mean age, 62 years; mean follow-up, 3-6 months OASIS-6 Trial: Study Design Fondaparinux n= mg/day for up to 8 days or hospital discharge Placebo n=2835 Fondaparinux n= mg/day for up to 8 days or hospital discharge UFH n=3221  Primary end point: composite of death or reinfarction at 30 days  Secondary end point: composite of death or reinfarction at 9 days and at final follow- up Stratum 1 (No UFH) n=5658 Stratum 2 (UFH) n=6434 Yusuf S, et al. JAMA. 2006;295: Adapted with permission from

29 OASIS-6 Trial: Results Frequency 15% Primary End Point: Death/Reinfarction (%) P=.008 P=.003P= % 9% 6% 3% 0% 9.7% 11.2% 7.4% 8.9% 13.4% 14.8% 30 days9 days3-6 months Fondaparinux (n=6036 ) Control (n=6056) 14% Reduction in Death/MI at 30 days: Stratum 1 (No UFH Indicated) P<.05 Reduction in Death/MI: Stratum 2 (UFH Indicated) P=NS p= % 10% 8% 6% 4% 2% 0% 11.2% 14% FondaparinuxPlacebo 14% 12% 10% 8% 6% 4% 2% 0% FondaparinuxUFH 8.3% 8.7% Yusuf S, et al. JAMA. 2006;295: Adapted with permission from clinicaltrialresults.org. Severe Bleeding at 9 Days Fonda-Placebo/U FH HRP All cases1.0%1.3% Stratum 1 vs placebo 1.0%1.6% Stratum 2 vs UFH1.1%

30 OASIS-6: PCI Substudy at 30 Days  Guiding catheter thrombosis in the primary PCI cohort occurred more often with fondaparinux compared with control (n=22 vs n=0, P<.001) Primary End Point of Death or MI in Primary PCI Cohort (%) P=.04 Yusuf S, et al. JAMA. 2006;295: Adapted with permission from 6.0% 4.9% 0% 2% 4% 6% 8% FondaparinuxControl

31 HORIZONS AMI: Bivalirudin vs Heparin + GP IIb/IIIa for Primary PCI in STEMI a Not related to CABG; b MACE = All-cause death, reinfarction, ischemic TVR or stroke. Stone GW, et al. Presented at: Transcatheter Cardiovascular Therapeutics 2007; October 20-25, 2007; Washington, DC. Diff = 0.0% [-1.6, 1.5] RR = 0.99 [0.76, 1.30] P sup = 1.00 Diff = -3.3% [-5.0, -1.6] RR = 0.60 [0.46, 0.77] P NI ≤.0001 P sup ≤.0001 Diff = -2.9% [-4.9, -0.8] RR = 0.76 [0.63, 0.92] P NI ≤.0001 P sup =  end point Net adverse clinical events Major bleeding a MACE b 30-day event rates (%) Bivalirudin monotherapy (n=1800) Heparin + GP IIb/IIIa inhibitor (n=1802)

32 Thienopyridines ● Clopidogrel 75 mg per day orally should be added to aspirin in patients with STEMI regardless of whether they undergo reperfusion with fibrinolytic therapy or do not receive reperfusion therapy. Treatment with clopidogrel should continue for at least 14 days 2004 Class I Recommendation (remains current) ● 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 risks of excess bleeding New Class I Recommendation Antman E, et al. J Am Coll Cardiol. doi: /j.jacc ACC/AHA STEMI Focused Update

33 Thienopyridines (cont.) ● In patients less than 75 years of age who receive fibrinolytic therapy or who do not receive reperfusion therapy, it is reasonable to administer an oral loading dose of clopidogrel 300 mg (No data are available to guide decision making regarding an oral loading dose in patients 75 years of age or older) ● Long-term maintenance therapy (eg, 1 year) with clopidogrel (75 mg per day orally) is reasonable in STEMI patients regardless of whether they undergo reperfusion with fibrinolytic therapy or do not receive reperfusion therapy New Class IIa Recommendations Antman E, et al. J Am Coll Cardiol. doi: /j.jacc ACC/AHA STEMI Focused Update

34 CLARITY- TIMI 28 Trial: Study Design Fibrinolytic, ASA, Heparin Clopidogrel 300 mg + 75 mg qd Coronary Angiogram (2-8 days) Primary end point: Occluded artery (TIMI flow grade 0/1) or death/MI by time of angio Randomized Placebo Double-blind, randomized, placebo-controlled trial in 3491 patients, aged yrs, with STEMI <12 hours Study Drug 30-day clinical follow-up Open-label clopidogrel per MD in both groups Sabatine MS, et al. N Engl J Med. 2005;352:

35 CLARITY–TIMI 28: Clopidogrel 300 mg/75 mg qd vs Placebo With Thrombolysis for STEMI (n = 3491) PlaceboClopidogrel n=1752n= % Odds Reduction Occluded Artery or Death/MI, % Days End Point, % Placebo Clopidogrel Odds Ratio: 0.80 (95% CI, ) P=.03 20% CV Death, MI, RI  Urg Revasc Primary End Point: Occluded Artery (or Death/MI Through Angio/HD) Adapted with permission from Sabatine MS, et al. N Engl J Med. 2005;352: P <.001

36

37 COMMIT/CCS-2: Effect of Clopidogrel 75 mg qd vs Placebo (n = 45,852) 9% (SE 3) relative risk reduction (P=.002) Placebo + ASA: 2310 events (10.1%) Clopidogrel + ASA: 2121 events (9.2%) Days Since Randomization (up to 28 days) Event, % a All patients received aspirin 162 mg/d. SE = standard error. Adapted with permission from COMMIT Collaborative Group. Lancet. 2005;366: Mortality, % Days Since Randomization (up to 28 days) Placebo + ASA: 1845 deaths (8.1%) Clopidogrel + ASA: 1726 deaths (7.5%) 7% (SE 3) relative risk reduction (P=.03) Death, Re-MI, or Stroke Death in the Hospital

38 CLARITY–TIMI 28 and COMMIT/CCS-2: Intracranial Hemorrhage and Major Bleeding CLARITY–TIMI 28 1Clopidogrel n=1733 (%) Placebo n=1719 (%) P Value ICH 8 (0.5)12 (0.7).38 Major Bleeding23 (1.3)19 (1.1) day Major Bleeding33 (1.9)30 (1.7).80 COMMIT-CCS-2 2 Clopidogrel n=22,961 (%) Placebo n=22,891 (%)P Value ICH 55 (0.2)56 (0.2).90 Major Bleeding134 (0.6)125 (0.5) Sabatine MS, et al. N Engl J Med. 2005;352: Chen Z, et al. Lancet. 2005;366:

39 Other cardiac arrest < Cardiogenic shock Ventricular fibrillation Reinfarction All-cause mortality Death, reinfarction, or cardiac arrest PPlacebo, n=22,923 Metoprolol, n=22,929 End Point (%) COMMIT/CCS-2: Metoprolol Results COMMIT = ClOpidogrel & Metoprolol in Myocardial Infarction Trial. Adapted with permission from Chen ZM, et al. Lancet. 2005;366:

40 Implications for the ED Lytics are underused, even when preference for PPCI is accepted Lytic therapy can be optimized with proper use of adjunctive medications –Enoxaparin –Clopidogrel Beta blockers should be used appropriately

41  -Blockers Oral  -blocker therapy should be initiated in the first 24 hours for patients who do not have any of the following: –Signs of heart failure –Evidence of a low output state –Increased risk a for cardiogenic shock –Other relative contraindications to  -blockade (PR interval >0.24 second, second- or third-degree heart block, active asthma, or reactive airway disease) Modified Class I Recommendation Antman E, et al. J Am Coll Cardiol. doi: /j.jacc ACC/AHA STEMI Focused Update a Risk factors for cardiogenic shock: age >70 years, systolic blood pressure 110 bpm or heart rate <60 bpm, and increased time since onset of symptoms of STEMI.

42  -Blockers (cont.) IV  -blockers should not be administered to STEMI patients who have any of the following: –Signs of heart failure –Evidence of a low output state –Increased risk a for cardiogenic shock, –Other relative contraindications to  -blockade (PR interval >0.24 second, second- or third-degree heart block, active asthma, or reactive airway disease) New Class III Recommendation Antman E, et al. J Am Coll Cardiol. doi: /j.jacc ACC/AHA STEMI Focused Update a Risk factors for cardiogenic shock: age >70 years, systolic blood pressure 110 bpm or heart rate <60 bpm, and increased time since onset of symptoms of STEMI.

43 Anticoagulants as Ancillary Therapy to Reperfusion Therapy in PCI ● For patients undergoing PCI after having received an anticoagulant regimen, the following dosing recommendations should be followed: ●For prior treatment with UFH, administer additional boluses of UFH as needed to support the procedure, taking into account whether GP IIb/IIIa receptor antagonists have been administered. Bivalirudin may also be used in patients treated previously with UFH ●For prior treatment with enoxaparin, if the last SC dose was administered within the prior 8 hours, no additional enoxaparin should be given; if the last SC dose was administered at least 8 to 12 hours earlier, an IV dose of 0.3 mg per kg of enoxaparin should be given ●For prior treatment with fondaparinux, administer additional IV treatment with an anticoagulant possessing anti-IIa activity, taking into account whether GP IIb/IIIa receptor antagonists have been administered New Class I Recommendation Antman E, et al. J Am Coll Cardiol. doi: /j.jacc ACC/AHA STEMI Focused Update

44 PCI After Fibrinolysis or for Patients Not Undergoing Primary Reperfusion Modified Class IIb Recommendation PCI of a hemodynamically significant stenosis in a patent infarct artery >24 hours after STEMI may be considered as part of an invasive strategy New Class III Recommendation PCI of a totally occluded infarct artery >24 hours after STEMI is not recommended in asymptomatic patients with 1- or 2-vessel disease if they are hemodynamically and electrically stable and do not have evidence of severe ischemia 2007 ACC/AHA STEMI Focused Update Antman E, et al. J Am Coll Cardiol. doi: /j.jacc

45 Antiplatelet Therapy: Clopidogrel Modified Class I Recommendations ● A loading dose of clopidogrel, generally 600 mg, should be administered before or when PCI is performed ● In patients undergoing PCI within 12 to 24 hours of receiving fibrinolytic therapy, a clopidogrel oral loading dose of 300 mg may be considered King SB III, et al. J Am Coll Cardiol. doi: /j.jacc ACC/AHA/SCAI PCI Focused Update

46 Antiplatelet Therapy: Clopidogrel (cont.) Modified Class IIa Recommendation ● If clopidogrel is given at the time of the procedure, supplementation with GP IIb/IIIa receptor antagonists can be beneficial Class IIa Recommendation (No Change) ● For patients with an absolute contraindication to aspirin, it is reasonable to give a 300 mg to 600 mg loading dose of clopidogrel, administered at least 6 hours before PCI, and/or GP IIb/IIIa antagonists, administered at the time of PCI King SB III, et al. J Am Coll Cardiol. doi: /j.jacc ACC/AHA/SCAI PCI Focused Update

47 DES vs BMS in STEMI: Meta-analysis Primary Efficacy End Point: Reintervention Reintervention = target lesion revascularization. Reproduced with permission from Kastrati A, et al. Eur Heart J. 2007;28: % 5.0% 13.3% 5.0%

48 DES vs BMS in STEMI: Meta-analysis Primary Safety End Point: Stent Thrombosis Reproduced with permission from Kastrati A, et al. Eur Heart J. 2007;28:

49 PCI without stenting –ASA mg/d indefinitely and –Clopidogrel 75 mg/d for at least 14 d Bare-metal stent –ASA mg/d for at least 1 mo, mg/d indefinitely and –Clopidogrel 75 mg/d for at least 1 mo, ideally up to 1 y Drug-eluting stent –ASA mg/d for at least 3 (sirolimus) to 6 (paclitaxel) mo, mg/d indefinitely and –Clopidogrel 75 mg/d for at least 1 y 2007 ACC/AHA STEMI Focused Update Antiplatelet Therapy for Post-PCI Patients Class I Recommendations Antman E, et al. J Am Coll Cardiol. doi: /j.jacc

50 Secondary Prevention: Clopidogrel New Class I Recommendation For all STEMI patients not undergoing stenting (medical therapy alone or PTCA without stenting), treatment with clopidogrel should continue for at least 14 days New Class IIa Recommendation Long-term maintenance therapy (eg, 1 year) with clopidogrel (75 mg per day orally) is reasonable in STEMI patients regardless of whether they undergo reperfusion with fibrinolytic therapy or do not receive reperfusion therapy 2007 ACC/AHA STEMI Focused Update Antman E, et al. J Am Coll Cardiol. doi: /j.jacc

51 Secondary Prevention: Additional Recommendations Smoking cessation –At each visit, every tobacco user and family members who smoke should be advised to quit (Class I, B) –Exposure to environmental tobacco smoke at work and at home should be avoided (Class I, B) Statin goal –LDL-C <100 mg/dL (Class I, A) –Consider LDL-C <70 mg/dL (Class IIa, A) Daily physical activity 30 min/d, min 5 d/wk (Class I, B) Annual influenza immunization (Class I, B) 2007 ACC/AHA STEMI Focused Update Antman E, et al. J Am Coll Cardiol. doi: /j.jacc

52 Optimal medical care of STEMI begins in the prehospital setting, continues in the ED, and culminates in a prompt and informed decision about reperfusion strategy. Optimal outcomes in STEMI can be achieved only with a multidisciplinary approach. The ACC/AHA GLs invest initial decisionmaking authority in the emergency physician. Optimal medical care of STEMI begins in the prehospital setting, continues in the ED, and culminates in a prompt and informed decision about reperfusion strategy. Optimal outcomes in STEMI can be achieved only with a multidisciplinary approach. The ACC/AHA GLs invest initial decisionmaking authority in the emergency physician. Conclusion: STEMI

53 Summary ● Acute therapy in STEMI focuses on reperfusion and antithrombotic therapy – new ACC/AHA guidelines provide current recommendations ● Long-term treatment involves aggressive multifactorial lifestyle modification and both antithrombotic and anti- ischemic therapies


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