7 NSTEACS vs. STEACS Non occluding culprit lesion in 60-85 % Autolysis Recurrent ischemia/MINo time dependent muscle loseGrayish-white (platelet-rich) vs. reddish (fibrin- rich)No role of fibrinolysis in STEACS (TIMI IIIB: ↑MI,↑trend of bleeding)
10 ED Evaluation of Patients With STEMI Differential Diagnosis of STEMI: Life-ThreateningAortic dissectionPulmonary embolusPerforating ulcerTension pneumothoraxBoerhaave syndrome (esophageal rupture with mediastinitis)
31 FibrinolysisIn the absence of contraindications, fibrinolytic therapy should be administered to STEMI patients with symptom onset within the prior 12 hours.In the absence of contraindications, fibrinolytic therapy should be administered to STEMI patients with symptom onset within the prior 12 hours and new or presumably new left bundle branch block (LBBB).
38 AspirinAspirin should be chewed by patients who have not taken aspirin before presentation with STEMI. The initial dose should be 162 mg (Level of Evidence: A) to 325 mg (Level of Evidence: C)Although some trials have used enteric-coated aspirin for initial dosing, more rapid buccal absorption occurs with non–enteric-coated formulations.
44 Death/non-fatal MI at day 30 for the major subgroups All interaction tests p = NSp <0.512Enoxaparin betterUFH betterSex MaleFemaleAge (years) < 75 75Infarct location AnteriorOtherDiabetes No diabetesDiabetesPrior MI No prior MIPrior MIFibrinolytic StreptokinaseFibrin specificTime-to-treatment < Median MedianOVERALL N = 20,479Reduction in risk (%)1816206112317211312The beneficial effect of enoxaparin on the primary endpoint was consistent across key pre-specified major subgroups including sex, age (< 75 years), infarct location, diabetes, history of myocardial infarction, type of fibrinolytic drug prescribed for the index event, and the time from the onset of symptoms to administration of the study drug.The p values for all interaction tests were not statistically significant.NS = not significant.Adapted with permission from Antman EM, et al. N Engl J Med. 2006;354:
53 NitroglycerinPatients with ongoing ischemic discomfort should receive sublingual NTG (0.4 mg) every 5 minutes for a total of 3 doses, after which an assessment should be made about the need for intravenous NTG.Intravenous NTG is indicated for relief of ongoing ischemic discomfort that responds to nitrate therapy, control of hypertension, or management of pulmonary congestion.
54 Nitroglycerin Nitrates should not be administered to patients with: Nitrates should not be administered to patients who have received a phosphodiesterase inhibitor for erectile dysfunction within the last 24 hours (48hours for tadalafil).systolic pressure < 90 mm Hg or ≥ to 30 mm Hg below baselinesevere bradycardia (< 50 bpm)tachycardia (> 100 bpm) orsuspected RV infarction.
99 PPIs and Antiplatelet Therapy IIaIIbIIIPPI should be used in patients with history of prior GI who require DAPT.PPI use is reasonable in patients with increased risk of gastrointestinal bleeding (advanced age, concomitant use of warfarin, steroids, nonsteroidal anti-inflammatory drugs, H pylori infection, etc.) who require DAPT.Routine use of a PPI is not recommended for patients at low risk of gastrointestinal bleeding, who have much less potential to benefit from prophylactic therapy.IIIaIIbIIIIIIaIIbIIINo Benefit99