STEMI resident survival guide: Difference between revisions

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==Don'ts==
==Don'ts==
* Do not administer IV GP IIb/IIIa inhibitors to patients with low risk of ischemic events or at high risk of bleeding and who are already on aspirin and P2Y12 receptor inhibitors therapy.
* Do not administer IV [[GP IIb/IIIa inhibitors]] to patients with low risk of ischemic events or at high risk of bleeding and who are already on aspirin and P2Y12 receptor inhibitors therapy.


* Do not administer [[prasugrel]] among patients with prior history of strokes o TIAs.
* Do not administer [[prasugrel]] among patients with prior history of strokes o TIAs.


* Do not administer IV beta-blockers among hemodynamically unstable patients.
* Do not administer IV [[beta-blockers]] among hemodynamically unstable patients.
 
* Do not administer [[nitroglycerine]] to patients with systolic BP < 90 mm Hg or ≥ to 30 mm Hg below baseline, severe bradycardia (< 50 bpm),
tachycardia (> 100 bpm), or suspected RV infarction.  


* Do not administer a complete dose of prasugrel among patients under 60kg (132lbs) due to high exposure to the active metabolite.  They should receive half the dose of prasugrel although there is no evidence that half the dose is as effective as a complete dose.
* Do not administer a complete dose of prasugrel among patients under 60kg (132lbs) due to high exposure to the active metabolite.  They should receive half the dose of prasugrel although there is no evidence that half the dose is as effective as a complete dose.
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*Do not administer abciximab for patients nor scheduled for PCI. <ref name="pmid22809746">{{cite journal| author=Jneid H, Anderson JL, Wright RS, Adams CD, Bridges CR, Casey DE et al.| title=2012 ACCF/AHA focused update of the guideline for the management of patients with unstable angina/non-ST-elevation myocardial infarction (updating the 2007 guideline and replacing the 2011 focused update): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. | journal=J Am Coll Cardiol | year= 2012 | volume= 60 | issue= 7 | pages= 645-81 | pmid=22809746 | doi=10.1016/j.jacc.2012.06.004 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22809746  }} </ref>
*Do not administer abciximab for patients nor scheduled for PCI. <ref name="pmid22809746">{{cite journal| author=Jneid H, Anderson JL, Wright RS, Adams CD, Bridges CR, Casey DE et al.| title=2012 ACCF/AHA focused update of the guideline for the management of patients with unstable angina/non-ST-elevation myocardial infarction (updating the 2007 guideline and replacing the 2011 focused update): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. | journal=J Am Coll Cardiol | year= 2012 | volume= 60 | issue= 7 | pages= 645-81 | pmid=22809746 | doi=10.1016/j.jacc.2012.06.004 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22809746  }} </ref>


==References==
==References==

Revision as of 16:10, 4 March 2014


Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Alejandro Lemor, M.D. [2]

Definition

ST elevation myocardial infarction (STEMI) is a syndrome defined by symptoms of myocardial ischemia (sudden chest pain and pressure, shortness of breath) associated with persistent ECG ST elevation and subsequent release of cardiac enzymes.

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated. STEMI is a life-threatening condition and must be treated as such irrespective of the causes.

Risk Factors

Management

Diagnostic Approach

Shown below is an algorithm summarizing the diagnostic approach to STEMI based on the 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction[1]



 
 
 
 
 
Characterize the symptoms:

Chest pain

❑ Sudden onset
❑ Described as a sensation of tightness, pressure, or squeezing
❑ Radiation to the jaw or left arm
❑ No relief with medications or rest
❑ Worse with time
❑ Shortness of breath (Dyspnea)

Diaphoresis
Light-headedness

Nausea and/or vomiting
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Obtain a detailed history:

❑ Age
❑ Previous MI
❑ Previous PCI or CABG
❑ Cardiac risk factors:

Hypertension
Diabetes
Hypercholesterolemia
Smoking
Obesity
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Examine the patient:

❑ Measure the blood pressure
❑ Measure the heart rate
❑ Auscultate the heart searching for murmurs
❑ Search for signs of CHF

❑ Decreased air entry in the lungs
❑ Edema in the extremities
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Rule out life threatening alternative diagnoses:

Aortic dissection
Pulmonary embolism
Cardiac tamponade
Tension pneumothorax

Esophageal rupture
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Order labs and tests:
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Order EKG
❑ New ST elevation at the J point in at least 2 contiguous leads of 2 mm (0.2 mV) in men or 1.5 mm (0.15 mV) in women in leads V2–V3 and/or of 1 mm (0.1 mV) in other contiguous chest leads or the limb leads
❑ For EKG examples click here
 
Order Cardiac Enzymes
Troponin I
CK-MB
 
Other labs:

Creatinine
Glucose

Hemoglobin
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Symptoms + increase in Troponin
+ EKG ST elevation
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Start treatment for STEMI
 
 
 
 
 

Therapeutic Apporach

Shown below is an algorithm depicting the therapeutic approach to STEMI based on the 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction.[1]

 
 
 
 
Initial Treatment
❑ Administer 162 - 325 mg of aspirin[2]

❑ Administer oxygen when Sat <90%[3]
❑ Administer beta-blockers (unless contraindicated)[4] [5]
❑ Administer sublingual nitroglycerin (0.4 mg) every 5 minutes for a total of 3 doses[6]
❑ Monitor with a 12-lead EKG all the time

❑ Administer morphine IV (initial dose 2-4 mg with increments of 2-8 mg every 5 to 15 minutes)[6]
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Is PCI available?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Send to cath lab for primary PCI
 
 
 
 
Evaluate for
❑ The time from onset of symptoms
❑ The risk of complications related to STEMI
❑ The risk of bleeding with fibrinolysis
❑ The presence of shock or severe HF
❑ The time required for transfer to a PCI-capable hospital
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Adjunctive Antithrombotic Therapy to Support Reperfusion With Primary PCI
 
 
❑ Transfer for primary PCI
❑ FMC to device time as soon as possible and ≤ 120 min.
 
❑ Administer fibrinolytic agent within 30 min of arrival when anticipated FMC to device ≥ 120 min
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Antiplatelet Therapy

P2Y12 receptor inhibitors

Clopidogrel (600 mg), or
Ticagrelor (180 mg), or

❑ IV GP IIb/IIIa inhibitors

Abciximab
❑ Loading dose 0.25 mg/kg IV bolus
❑ Maintenance dose 0.125 mg/kg/min, or
Eptifibatide
❑ Loading dose 180 mcg/kg IV bolus followed by another bolus after 10 minutes
❑ Maintenance dose 2 mcg/kg/min, or
Tirofiban
❑ Loading dose 25 mcg/kg
❑ Maintenance dose 0.15 mcg/kg/min
 
Anticoagulant Therapy

UFH

❑ With GP IIb/IIIa receptor antagonist planned: 50- to 70-U/kg IV bolus to achieve therapeutic ACT of 200-250 s.
❑ With no GP IIb/IIIa receptor antagonist planned: 70- to 100-U/kg bolus to achieve therapeutic ACT of 250-300 s.
Bivalirudin: 0.75-mg/kg IV bolus, then 1.75–mg/kg/h infusion with or without prior treatment with UFH. An additional bolus of 0.3 mg/kg may be given if needed.

FMC: First medical contact; UFH: Unfractionated Heparin; ACT: Activated clothing time


Do´s

  • Administer a loading dose followed by a maintenance dose of clopidogrel, ticagrelor or prasugrel (if PCI is planned) as initial treatment instead of aspirin among patients with gastrointestinal intolerance or hypersensitivity reaction to aspirin.
  • Administer sublingual nitroglycerin in patients with ischemic chest pain; however, administer IV nitroglycerin among patients with persistent chest pain after three sublingual nitroglycerins.[7]
  • Discontinue non-steroidal anti-inflamatory drugs immediately. [8] [9]

Don'ts

  • Do not administer IV GP IIb/IIIa inhibitors to patients with low risk of ischemic events or at high risk of bleeding and who are already on aspirin and P2Y12 receptor inhibitors therapy.
  • Do not administer prasugrel among patients with prior history of strokes o TIAs.
  • Do not administer IV beta-blockers among hemodynamically unstable patients.
  • Do not administer nitroglycerine to patients with systolic BP < 90 mm Hg or ≥ to 30 mm Hg below baseline, severe bradycardia (< 50 bpm),

tachycardia (> 100 bpm), or suspected RV infarction.

  • Do not administer a complete dose of prasugrel among patients under 60kg (132lbs) due to high exposure to the active metabolite. They should receive half the dose of prasugrel although there is no evidence that half the dose is as effective as a complete dose.
  • Do not administer fibrinolytic therapy to patients with unstable angina.[10]
  • Do not administer abciximab for patients nor scheduled for PCI. [11]

References

  1. 1.0 1.1 O'Gara, Patrick T.; Kushner, Frederick G.; Ascheim, Deborah D.; Casey, Donald E.; Chung, Mina K.; de Lemos, James A.; Ettinger, Steven M.; Fang, James C.; Fesmire, Francis M.; Franklin, Barry A.; Granger, Christopher B.; Krumholz, Harlan M.; Linderbaum, Jane A.; Morrow, David A.; Newby, L. Kristin; Ornato, Joseph P.; Ou, Narith; Radford, Martha J.; Tamis-Holland, Jacqueline E.; Tommaso, Carl L.; Tracy, Cynthia M.; Woo, Y. Joseph; Zhao, David X. (2013). "2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction". Journal of the American College of Cardiology. 61 (4): e78–e140. doi:10.1016/j.jacc.2012.11.019. ISSN 0735-1097.
  2. Nishimura, R. A.; Otto, C. M.; Bonow, R. O.; Carabello, B. A.; Erwin, J. P.; Guyton, R. A.; O'Gara, P. T.; Ruiz, C. E.; Skubas, N. J.; Sorajja, P.; Sundt, T. M.; Thomas, J. D. (2014). "2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines". Circulation. doi:10.1161/CIR.0000000000000029. ISSN 0009-7322.
  3. Shuvy M, Atar D, Gabriel Steg P, Halvorsen S, Jolly S, Yusuf S; et al. (2013). "Oxygen therapy in acute coronary syndrome: are the benefits worth the risk?". Eur Heart J. 34 (22): 1630–5. doi:10.1093/eurheartj/eht110. PMID 23554440.
  4. Rosendorff C, Black HR, Cannon CP, Gersh BJ, Gore J, Izzo JL; et al. (2007). "Treatment of hypertension in the prevention and management of ischemic heart disease: a scientific statement from the American Heart Association Council for High Blood Pressure Research and the Councils on Clinical Cardiology and Epidemiology and Prevention". Circulation. 115 (21): 2761–88. doi:10.1161/CIRCULATIONAHA.107.183885. PMID 17502569.
  5. López-Sendón J, Swedberg K, McMurray J, Tamargo J, Maggioni AP, Dargie H; et al. (2004). "Expert consensus document on beta-adrenergic receptor blockers". Eur Heart J. 25 (15): 1341–62. doi:10.1016/j.ehj.2004.06.002. PMID 15288162.
  6. 6.0 6.1 Antman, Elliott M.; Hand, Mary; Armstrong, Paul W.; Bates, Eric R.; Green, Lee A.; Halasyamani, Lakshmi K.; Hochman, Judith S.; Krumholz, Harlan M.; Lamas, Gervasio A.; Mullany, Charles J.; Pearle, David L.; Sloan, Michael A.; Smith, Sidney C. (2008). "2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction". Journal of the American College of Cardiology. 51 (2): 210–247. doi:10.1016/j.jacc.2007.10.001. ISSN 0735-1097.
  7. Kaplan K, Davison R, Parker M, Przybylek J, Teagarden JR, Lesch M (1983). "Intravenous nitroglycerin for the treatment of angina at rest unresponsive to standard nitrate therapy". Am J Cardiol. 51 (5): 694–8. PMID 6402912.
  8. Trelle S, Reichenbach S, Wandel S, Hildebrand P, Tschannen B, Villiger PM; et al. (2011). "Cardiovascular safety of non-steroidal anti-inflammatory drugs: network meta-analysis". BMJ. 342: c7086. doi:10.1136/bmj.c7086. PMC 3019238. PMID 21224324. Review in: Evid Based Med. 2011 Oct;16(5):142-3
  9. Coxib and traditional NSAID Trialists' (CNT) Collaboration. Bhala N, Emberson J, Merhi A, Abramson S, Arber N; et al. (2013). "Vascular and upper gastrointestinal effects of non-steroidal anti-inflammatory drugs: meta-analyses of individual participant data from randomised trials". Lancet. 382 (9894): 769–79. doi:10.1016/S0140-6736(13)60900-9. PMC 3778977. PMID 23726390. Review in: Ann Intern Med. 2013 Oct 15;159(8):JC12
  10. Anderson HV (1995). "Intravenous thrombolysis in refractory unstable angina pectoris". Lancet. 346 (8983): 1113–4. PMID 7475596.
  11. Jneid H, Anderson JL, Wright RS, Adams CD, Bridges CR, Casey DE; et al. (2012). "2012 ACCF/AHA focused update of the guideline for the management of patients with unstable angina/non-ST-elevation myocardial infarction (updating the 2007 guideline and replacing the 2011 focused update): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines". J Am Coll Cardiol. 60 (7): 645–81. doi:10.1016/j.jacc.2012.06.004. PMID 22809746.


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