Malaysia CPG for STEMI

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1 DO /s SEN Heart Journal Vol. 22, no. 1, (2014) SSN: Clinical Practice Guidelines Malaysia CPG for STEM Expert Panel: Robaayah Zambahari 1 (Chairperson), Jeyamalar Rajadurai 2 (Secretary), lan Fong 3, ris Chandran 4, Choo Gim Hooi 5, Nurul ida Salleh 6, Omar smail 7, Oteh Maskon 8, Rahal Yusoff 9, Rosli Mohd li 10, Wan zman Wan hmad 11 1 Senior Consultant Cardiologist, National Heart nstitute Kuala Lumpur 2 Consultant Cardiologist, Subang Jaya Medical Centre, Selangor 3 Consultant Cardiologist, Sarawak General Hospital Heart Centre 4 Consultant Physician, Hospital Raja Permaisuri ainun, poh 5 Consultant Cardiologist, Subang Jaya Medical Centre, Selangor 6 Family Medicine Specialist, Primary Health Clinic Tanglin, Kuala Lumpur 7 Consultant Cardiologist, Hospital Pulau Pinang, Penang 8 Consultant Cardiologist, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur 9 Specialist in nternal Medicine, Hospital Kuala Lumpur, Kuala Lumpur 10 Consultant Cardiologist, National Heart nstitute Kuala Lumpur 11 Consultant Cardiologist, University Malaya Medical Centre Kuala Lumpur The uthor(s) This article is published with open access by SEN Federation of Cardiology cute Myocardial nfarction (M) continues to be a major health problem for Malaysians due to a more sedentary lifestyle, increasing trends of hypertension, diabetes, obesity and dyslipidaemia. There is also a high prevalence of smoking. The 1 st CPG on STEM was published in 2001 with a 2 nd edition in 2007.This is the 3 rd Edition. Objectives These guidelines are intended to provide awareness and education in order to reduce the morbidity and mortality associated with ST segment Elevation Myocardial nfarction (STEM) by: Early recognition and appropriate timely reperfusion strategies. Evidence-based management. Effective secondary prevention measures to prevent recurrence. Process Evidence was obtained by systematic review of current medical literature on STEM using search engines such as PubMed, OVD and MEDLNE. The other international guidelines on STEM were also taken into consideration. The draft was reviewed by the Hospital technical committee, Ministry of Health and leading medical professionals in the public and private sectors. The level of recommendation and grading of evidence used in this CPG was adapted from the merican Heart ssociation (H) and the European Society of Cardiology (ESC). Clinical Questions ddressed How do you diagnose STEM? What is the best strategy to treat STEM patients based on the current evidence available? How to improve early diagnosis and treatment prehospitalisation? How do you identify high-risk STEM patients at diagnosis? How to evaluate reperfusion strategies? How to reduce door-to-needle time (DNT) and doorto-balloon time (DT)? When to transfer from non-percutaneous coronary intervention (PC) to PC centres? How to identify complications and manage appropriately? How to risk stratify post-stem patients? How to reduce the risk of a subsequent cardiovascular event (secondary prevention)? What is the role of cardiac rehabilitation? What are the psychological aspects of post-stem patients? How to treat the following special groups? Elderly Diabetics Women Chronic Kidney Disease (CKD) What are the follow-up strategies for these patients? Target Group: These guidelines are developed for all healthcare providers involved in the management of STEM in adults. Correspondence to: Dr. Robaayah Zambahari, Senior Consultant Cardiologist, National Heart nstitute, Kuala Lumpur, Malaysia. robaayah@ijn.com.my. 73

2 LEVELS OF EVDENCE ND GRDES OF RECOMMENDTONS -a -b GRDES OF RECOMMENDTON Conditions for which there is evidence and/or general agreement that a given procedure/therapy is beneficial, useful and/or effective. Conditions for which there is conflicting evidence and/or divergence of opinion about the usefulness/efficacy of a procedure/therapy. Weight of evidence/opinion is in favor of its usefulness/efficacy. Usefulness/efficacy is less well established by evidence/opinion Conditions for which there is evidence and/or general agreement that a procedure/therapy is not useful/effective and in some cases may be harmful. LEVELS OF EVDENCE C Data derived from multiple randomized clinical trials or meta analyses Data derived from a single randomized clinical trial or large non randomized studies Only consensus of opinions of experts, case studies or standard of care dapted from the merican College of Cardiology Foundation / merican Heart ssociation and the European Society of Cardiology (vailable at: and at SUMMRY The diagnosis of STEM depends on the presence of ischaemic type chest pain and ST elevation in the resting ECG or new onset L. t should be supported by a rise and fall in cardiac biomarkers. TME LOST S MYOCRDUM LOST, thus early diagnosis and treatment is important. Early management of STEM involves pain relief, stabilisation of haemodynamics and assessment for reperfusion. The occluded infarct-related artery should be opened as soon as possible. The appropriate and timely use of some form of reperfusion therapy is more important than the choice of therapy.( Flowchart 1) Primary PC is the reperfusion strategy of choice if it can be done in a timely manner by an experienced operator. The DT should be <90 mins or < 120 mins if transferred from a non PC capable hospital. than 30 minutes. The role of PC in the management of patients with STEM is as listed in Table 1. Concomitant pharmacotherapy includes aspirin, clopidogrel (prasugrel or ticagrelor), β-blockers, CE- s/rs and statins. (Table 2) Complications of STEM include arrhythmias, LV dysfunction and shock. High-risk patients who have received fibrinolysis, should have early coronary angiography with view to revascularisation. The others should be risk stratified according to the presence or absence of ischaemia, arrhythmias and LV function. Secondary prevention is important and includes the use of aspirin, β-blockers, CE-s/Rs and statins. (Table 3) ll patients should be encouraged to undergo cardiac rehabilitation. f primary PC cannot be performed, then fibrinolytic therapy should be administered with a DNT of less 74

3 Flow chart 1: Management of patients presenting with STEM Electrocardiographic (ECG) Cardiac iomarkers Concomitant initial management includes: ssessment for reperfusion: CHEST PN/CHEST PN EQUVLENT Continuous ECG monitoring Sublingual glyceryl trinitrate (GTN) (if no contraindication) spirin Clopidogrel nalgesia Oxygen(if SpO 2 < 95%) Onset of symptoms: < 3 hours 3-12 hours > 12 hours Preferred option: Primary PC** or Fibrinolytic Therapy Primary PC*** Medical Therapy ± ntithrombotics Second option: Fibrinolytics Primary PC* Subsequent management: Consider PC within 3-24 hours f fibrinolytic is administered as part of pharmacoinvasive strategy PC if ongoing ischaemia or haemodynamic instability Concomitant Therapy: ntithrombotics* -blockers ngiotensin converting enzyme inhibitors (CE-)/ ngiotensin receptor blockers (R) Statins Nitrates* Calcium antagonists* *when clinically indicated **Preferred option in: - high-risk patients - presence of contraindications to fibrinolytic therapy and/or - PC time delay [(DT) (DNT)] is less than 60 minutes ***f DT is within 90 minutes 75

4 Table 1: ndications for PC in STEM NDCTONS CC/ESC CLSSFCTON Primary PC in patients presenting < 12 hours of ischaemic symptoms : < 3 hours and PC time delay is < 60 minutes., 3-12 hours in a PC centre or PC transfer delay < 2 hours., Primary PC in patients presenting 12 to 24 hours of symptom onset with evidence of ongoing ischaemia. -a, Primary PC in patients who have: High-risk features section 4.2 (C)., Contraindications to fibrinolytics section 4.2 ()., Rescue PC in patients who have evidence of failed reperfusion of the infarct related artery (R) diagnosed by persistent ST elevation and/or recurrent/ongoing chest pain. Facilitated PC a strategy of immediate PC < 1 hour after an initial pharmacologic regimen. Post-fibrinolysis and: Routine angiography with view to PC and stenting between 3-24 hours in all patients (pharmacoinvasive therapy). Delayed selective angiography depending on presence of haemodynamic instability or residual ischaemia. PC of totally occluded vessel 3-28 days after M and no reversible ischaemia.,, -a,,, 76

5 Table 2: Grades of recommendation and level of evidence for acute therapy of STEM RECOMMENDTON REPERFUSON THERPY *Primary PC: Strategy of choice if: DT < 90 minutes. There are contraindications to fibrinolysis. High-risk patients. *Fibrinolytic therapy: Strategy of choice if: f the DT is > 90 minutes. No contraindications to fibrinolysis. CONCOMTNT PHRMCOTHERPY GRDES LEVELS OF RECOMMENDTON EVDENCE GRDES LEVELS OF RECOMMENDTON EVDENCE spirin: Loading dose of 300 mg followed by maintenance dose of 75 mg 150 mg daily. Clopidogrel: Loading dose of 300 mg followed by maintenance dose of 75 mg daily (for at least 1 month). Prasugrel: Loading dose of 60 mg followed by maintenance dose of 10 mg (to be administered -a only prior to primary PC). Ticagrelor: Loading dose of 180 mg followed by maintenance dose of 90 mg twice daily (bd) -a to be administered to patients undergoing primary PC. ntithrombotic (heparin/ enoxaparin/ fondaparinux) to be given to patients: Who received fibrin selective lytic agents. With atrial fibrillation (F). C With mural thrombus. C Routine administration to patients following -a fibrinolysis. -blockers: For all patients if no contraindications. CE-s: For all patients with no contraindications. Statins: For all patients if no contraindications. * please refer to flow chart 1 for details 77

6 Table 3: Grade of recommendation and level of evidence for secondary prevention post-stem STRTEGY LEVELS GRDES OF GRDES LEVELS OF COMMENTS RECOMMENDTON EVDENCE RECOMMENDTON EVDENCE Smoking Cessation Exercise t least minutes most days of the week. CONCOMTNT PHRMCOTHERPY spirin Maintenance dose: mg daily. Clopidogrel Maintenance dose 75 mg daily to be given for 1 month following fibrinolytic therapy and for longer periods postprimary PC. -blockers Consider long-term therapy for all patients if no contraindications. CE-s Started on first day and continued longterm for all patients if no contraindications. Rs For CE- intolerant patients, consider valsartan. Statins im for a low density lipoproteincholesterol (LDL-C) <2.0 mmol/l (preferably <1.8 mmol/l). Open ccess: This article is distributed under the terms of the Creative Commons ttribution License (CC-Y 4.0) which permits any use, distribution, and reproduction in any medium, provided the original author(s) and the source are credited. 78