1. ACC/AHA Guidelines for the Management of Patients with ST Elevation Myocardial Infarction; 2004 Ahmad Aslam, M.D. Prasantha Bathini, M.D. Robert Smith, M.D. Cardiac Cath Conference July 13, 2004

2. Participants in Updated Guidelines

3. “There is an unsettling truth about the practice of medicine. …study after study shows that few physicians systematically apply to everyday treatment the scientific evidence about what works best.” Millenson, ML. Demanding Medical Excellence: Doctors and Accountability in the Information Age. 1997 Evidence Based Medicine; What’s the Problem?

4. How Should We Be Dealing With This?

5. ACC/AHA Practice Guidelines: Classification of Benefit Class I Conditions for which there is evidence and/or general agreement that a given procedure or treatment is useful and effective Class IIa Conditions for which there is conflicting evidence and/or divergence of opinion about the usefulness/efficacy of a procedure or treatment. However, the treatment/procedure is reasonable and is probably useful and effective Class IIb Conditions for which there is conflicting evidence and/or divergence of opinion about the usefulness/efficacy of a procedure or treatment. However, the treatment/procedure may be reasonable. The usefulness and effectiveness is not well established Class III Conditions for which there is evidence and/or general agreement that the procedure/treatment is not useful or effective and in some cases may be harmful

6. ACC/AHA Practice Guidelines: Level of Evidence A (highest) The data were derived from multiple randomized clinical trials that involved large numbers of patients B (intermediate) The data were derived from a limited number of randomized trials that involved small numbers of patients, or from careful analysis of non-randomized studies or observational registries C (low) A lower rank was given when expert consensus was the primary basis for the recommendation

7. Epidemiology In the U.S., there were 1,680,000 discharges for ACS in the year 2001 Approximately 500,000 of these were STEMI’s

8. Prehospital Issues Class I Patients with symptoms of STEMI should be transported to the hospital by ambulance rather than by friends or relatives. (Level of Evidence: B) Healthcare providers should instruct patients in whom NTG has been prescribed to take ONE NTG dose sublingually in response to chest pain. If the pain is worsened or unimproved after 5 minutes, the patient should be instructed to call 911 (Level of Evidence: C)

9. Initial Recognition and Management in the ED “Hospitals should establish multidisciplinary teams (including primary care physicians, emergency medicine physicians, cardiologists, nurses, and laboratorians) to develop guideline-based, institution-specific written protocols for triaging and managing patients who are seen in the prehospital setting or present to the ED with symptoms suggestive of STEMI.” Class I, Level of Evidence: B

10. Targeted History Ascertain whether the patient has had prior episodes of myocardial ischemia (stable or unstable angina, MI, CABG, or PCI) Focus on chest discomfort and associated symptoms HTN? DM? Assess for possibility of aortic dissection Assess risk of bleeding Assess for clinical cerebrovascular disease (amaurosis fugax, face/limb weakness or clumsiness, sensory loss, ataxia, vertigo Class I, Level of Evidence: C

11. Physical Exam Class I To aid in the diagnosis and assessment of the extent, localization, and presence of complications of STEMI. (Level of Evidence: C) A brief, focused neurologic exam in order to look for evidence of prior stroke or cognitive defects (before administering fibrinolytics). (Level of Evidence: C)

12. ECG Class I Should be done within 10 minutes of arrival. (Level of Evidence: C) If the initial ECG is not diagnostic of STEMI but the clinical suspicion is high, serial ECG’s (5-10 minute intervals) or continuous 12 lead ST segment monitoring should be performed. (Level of Evidence: C) With inferior STEMI, right sided ECG should be performed in order to look for ST elevation suggestive of RV infarct. (Level of Evidence: B)

13. Inferior Infarct

14. V6 V1V2 V3 V4 V5

15. Right Sided Leads

16. V1 (R)V2 (R) V3(R) V6(R) V4(R) V5(R)

17. (R) Inferior/RV Infarct

18. Laboratory Examinations Class I Cardiac-specific troponins should be used as the optimum biomarkers for the evaluation of patients with STEMI who have coexistent skeletal muscle injury. (Level of Evidence: C) For patients with STEMI on the ECG and symptoms, reperfusion therapy should be initiated immediately and is not contingent on a biomarker assay. (Level of Evidence: C)

19. ECG The 12 lead ECG is the center of the therapeutic decision pathway because of the strong evidence that ST segment elevation identifies patients who benefit from reperfusion therapy

20. Imaging Class I Patients with STEMI should have a portable CXR, but this should not delay implementation of reperfusion therapy unless a contraindication, such as aortic dissection, is suspected. (Level of Evidence: C) High quality pCXR, TTE and or TEE, and contrast chest CT or MRI should be used to differentiate STEMI from dissection in patients for whom this distinction is unclear. (Level of Evidence: B)

21. Initial Management; Oxygen Class I Supplemental O 2 should be administered to patients with arterial oxygen desaturation (SaO 2 less than 90%). (Level of Evidence: B) Class IIa It is reasonable to administer O 2 to all patients with uncomplicated STEMI during the first 6 hours. (Level of Evidence: C)

22. Initial Management: Nitrates Class I Patients with ongoing ischemic discomfort should receive SL NTG (0.4mg) every 5 minutes for a total of 3 doses, after which an assessment should be made about the need for IV NTG. (Level of Evidence: C) IV NTG is indicated for relief of ongoing ischemic discomfort, control of HTN, or management of pulmonary congestion. (Level of Evidence: C)

23. Initial Management: Nitrates Class III Nitrates in all forms should be avoided in patients with an initial systolic blood pressure less than 90mmHg or greater than or equal to 30mmHg below baseline, in patients with marked bradycardia or tachycardia, and in patients with known or suspected RV infarction. In view of their marginal treatment benefits, nitrates should not be used if hypotension limits the administration of Beta Blockers

24. Initial Management: Analgesia Class I MSO4 (2-4mg IV with increments of 2-8mg IV repeated at 5-15 minute intervals) is the analgesic of choice for management of pain associated with STEMI. (Level of Evidence: C)

25. Initial Management: Aspirin Class I Aspirin should be chewed by patients who have not taken aspirin before presentation with STEMI. The initial dose should be 162mg (Level of Evidence: A) to 325 mg. (Level of Evidence: C) Although some trials have used enteric-coated ASA for initial dosing, more rapid buccal absorption occurs with non-enteric coated formulations

26. Initial Management: Beta-Blockers Class I Oral BB therapy should be administered promptly to those patients without a contraindication, irrespective of concomitant fibrinolytic therapy or performance of primary PCI. (Level of Evidence: A) Class IIa It is reasonable to administer IV BB promptly to STEMI patients without contraindications, especially if a tachyarrhythmia or HTN is present. (Level of Evidence: B)

27. Reperfusion Class I All STEMI patients should undergo rapid evaluation for reperfusion and have a reperfusion strategy implemented promptly after contact with the medical system. (Level of Evidence: A)

28. Reperfusion For fibrinolytic therapy, goal is door to needle time of 30 minutes For PCI, goal is door to balloon inflation time of 90 minutes These goals may not be relevant for patients with an appropriate reason for delay such as uncertainty about the diagnosis, life threatening conditions (e.g., respiratory failure), or delays associated with patient’s informed failure to consent

29. Reperfusion These goals should not be understood as “ideal” times, but the rather the longest times that should be considered acceptable Systems that are able to achieve more rapid times should be encouraged

30. Selection of Reperfusion Strategy Several issues should be considered in selecting the type of reperfusion therapy –Time From Onset of Symptoms –Risk from STEMI –Risk of Bleeding –Time Required for Transport to a Skilled PCI laboratory

31. Time From Onset of Symptoms Time from onset of symptoms to fibrinolytic therapy is an important predictor of MI size and patient outcome 1 The efficacy of fibrinolytic agents for lysing thrombus diminishes with time 2 Fibrinolytic therapy administered within the first 2 hours (especially the first hour) can occasionally abort MI and dramatically reduce mortality 3,4 1 Boersma, E., et al. Lancet, 1996;348:771-775 2 Zeymer et al. Am Heart J, 1999:137:34-38 3 FTT Collaborative Group. Lancet, 1994;343:311-322 4 Weaver, WD et al. JAMA, 1993;270:1211-1216

32. Time From Onset of Symptoms Conversely, the ability to produce a patent infarct artery is much less dependent on symptom duration in patients undergoing PCI Several reports claim no influence of time delay on mortality rates when PCI is performed after 2-3 hours of symptom duration 1,2 However, after adjustment for baseline characteristics, time from symptom onset to balloon inflation is significantly correlated with 1 year mortality in patients undergoing primary PCI for STEMI 3 1 FTT Collaborative Group. Lancet, 1994;343:311-322 2 Brodie et al. Am J Cardiol, 2001;88:1085-1090 3 Williams, D. Circ, 2004;109:1806-1808

33. Risk From STEMI In patients at high risk for adverse outcome from STEMI, such as those with cardiogenic shock or high TIMI risk score 1, compelling evidence exists that favors a PCI strategy 1 Morrow et al. Circ. 2000;102:2031-2037

34. Risk of Bleeding If both types of reperfusion therapy are available, PCI is favored in patients at high risk for bleeding If PCI is not available, the risks and benefits of fibrinolysis must be weighed

35. Transport Time to PCI Lab For facilities that can offer PCI, the literature suggests that this approach is superior to fibrinolysis 1 The trials comparing fibrinolysis to PCI, however, were conducted prior to the advent of more recent PCI and pharmacologic therapies When a composite end point of death, nonfatal recurrent MI, or stroke is analyzed, much of the superiority of PCI is driven by the reduction of nonfatal recurrent MI 2 1 Magid et al. JAMA. 2000;284:3131-3138 2 Boersma, E., et al. Lancet, 1996;348:771-775

36. PCI vs. Fibrinolysis; 4-6 Weeks

37. PCI vs. Fibrinolysis; Long Term

38. Reperfusion Strategy (cont.) As the time delay for performing PCI increases, the mortality benefit of PCI over fibrinolysis decreases 1 Compared with a fibrin-specific lytic agent, a PCI strategy may not reduce mortality when a delay greater than 60 minutes is anticipated vs. immediate lytic therapy 1 Nallamothu et al. Am J. Cardiol. 2003;92:824-826

39. Reperfusion Strategy (cont.) Given the current literature, it is not possible to say definitively that a particular reperfusion approach is superior for all patients 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 patients with suspected STEMI The appropriate and timely use of some reperfusion therapy is likely more important than the choice of therapy

40. Step II: Determine whether fibrinolysis or invasive strategy is preferred Step I: Assess time and risk - Time since onset of symptoms - Risk from STEMI - Risk of fibrinolysis - Time required for transport to a skilled PCI lab Fibrinolysis is generally preferred if - Early presentation (3 hours or less and delay to invasive strategy) - Invasive strategy is not an option - Cath lab not available - Vascular access difficulties - Lack of access to a skilled lab - Delay to invasive strategy Invasive strategy is generally preferred if - Skilled PCI lab available with surgical backup - High risk from STEMI - Cardiogenic shock - Killip class > or = to 3 - Contraindications to fibrinolysis including increased risk of bleeding and ICH - Late presentation - Symptom onset more than 3 hours - Diagnosis of STEMI is in doubt

41. Fibrinolytic Therapy Class I STEMI patients presenting to a facility without the capacity for expert, prompt intervention (primary PCI with 90 minutes of first medical contact) should undergo fibrinolytic therapy. (Level of Evidence: A) In the absence of contraindications, fibrinolytic therapy should be administered to STEMI patients with symptom onset within the prior 12 hours and ST elevation greater than 0.1mV in at least 2 contiguous precordial leads or at least 2 adjacent limb leads. (Level of Evidence: A) In the absence of contraindications, fibrinolytic therapy should be administered to patients with symptom onset within the prior 12 hours and new or presumably new LBBB. (Level of Evidence: A)

42. Fibrinolytic Therapy Class IIa In the absence of contraindications, it is reasonable to administer fibrinolytic therapy to STEMI patients with symptom onset within the prior 12 hours and ECG findings consistent with true posterior MI. (Level of Evidence: C) In the absence of contraindications, it is reasonable to administer fibrinolytic therapy to patients with symptoms of STEMI beginning within the prior 12-24 hours who have continuing ischemic symptoms and ST elevation greater than 0.1mV in at least 2 contiguous precordial leads or at least 2 adjacent limb leads. (Level of Evidence: B)

43. True Posterior MI

44. V6 V1V2 V3 V4 V5

45. True Posterior MI

46. V6 V1V2 V3 V4 V5 V9V8 V7

47. True Posterior MI

48. Fibrinolytic Therapy Class III Fibrinolytic therapy should not be administered to asymptomatic patients whose initial symptoms of STEMI began more than 24 hours earlier. (Level of Evidence: C) Fibrinolytic therapy should not be administered to patients whose ECG shows only ST segment depression unless true posterior MI is suspected. (Level of Evidence: A)

49. Contraindications and Cautions for Fibrinolysis use in STEMI Absolute Contraindications - Any prior ICH - Known structural cerebral vascular lesion (e.g., AVM) - Known malignant intracranial neoplasm (1 o or 2 o ) - Ischemic stroke within 3 months except acute ischemic stroke within 3 hours - Suspected aortic dissection - Active bleeding or bleeding diathesis (except menses) - Significant closed head or facial trauma within 3 months Relative Contraindications - History of chronic, severe, poorly controlled HTN - Severe, uncontrolled HTN on presentation (SBP>180, DBP>110) - Hx of prior ischemic stroke >3 months, dementia, or known IC pathology not listed in contraindications - Traumatic or prolonged CPR (>10 min) or major surgery (<3 weeks) - Recent internal bleeding (2-4 weeks) - Noncompressible vascular punctures - For Streptokinase/Anistreplase: prior exposure (>5 days) or prior allergic rxn - Pregnancy - Active peptic ulcer - Current use of anticoagulants; the higher the INR, the higher the risk

50. Percutaneous Coronary Intervention Class I If immediately available, primary PCI should be performed in patients with STEMI (including posterior MI), or in patients with new LBBB who can undergo PCI of the infarct artery within 12 hours of onset of symptoms. (Level of evidence: A) PCI must be performed in a timely fashion (door  balloon time 90 minutes) by persons skilled in the procedure (greater than 75/year). (Level of evidence: A)

51. Percutaneous Coronary Intervention Class I Primary PCI should be performed for patients younger than 75 years with STEMI or LBBB who develop shock within 36 hours of MI and are suitable for revascularization that can be performed within 18 hours of shock. (Level of Evidence: A) Primary PCI should be performed in patients with severe CHF and/or pulmonary edema (Killip class III) and onset of symptoms within 12 hours. Door  balloon should be within 90 minutes. (Level of Evidence: B)

52. Percutaneous Coronary Intervention Class IIa Primary PCI is reasonable for patients >75 yrs who develop shock within 36 hours of MI and are suitable for revascularization that can be performed within 18 hours of shock. (Level of Evidence: B) It is reasonable to perform primary PCI for patients with onset of symptoms in prior 12-24 hours and severe CHF (Level of Evidence: C), hemodynamic or electrical instability (Level of Evidence: C), or persistent ischemic symptoms (Level of Evidence: C)

53. Percutaneous Coronary Intervention Class III PCI should not be performed in a non-infarct artery at the time of PCI in patients without hemodynamic compromise. (Level of Evidence: C) Primary PCI should not be performed in asymptomatic patients more than 12 hours after onset of STEMI if they are hemodynamically and electrically stable. (Level of Evidence: C)