2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction

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1 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction Developed in Collaboration with American College of Emergency Physicians and Society for Cardiovascular Angiography and Interventions American College of Cardiology Foundation and American Heart Association, Inc.

2 Classification of Recommendations and Levels of Evidence A recommendation with Level of Evidence B or C does not imply that the recommendation is weak. Many important clinical questions addressed in the guidelines do not lend themselves to clinical trials. Although randomized trials are unavailable, there may be a very clear clinical consensus that a particular test or therapy is useful or effective. *Data available from clinical trials or registries about the usefulness/ efficacy in different subpopulations, such as sex, age, history of diabetes, history of prior myocardial infarction, history of heart failure, and prior aspirin use. For comparative effectiveness recommendations (Class I and IIa; Level of Evidence A and B only), studies that support the use of comparator verbs should involve direct comparisons of the treatments or strategies being evaluated.

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6 Guidelines Basics STEMI Guidelines Jeopardy Thrombolytics Medicines Primary PCI Wierd guidelines $100 $100 $100 $100 $100 $200 $200 $200 $200 $200 $300 $300 $300 $300 $300 $400 $400 $400 $400 $400 $500 $500 $500 $500 $500 Final Jeopardy

7 1 - $100 This is evidence that is supported by multiple randomized clinical trials or meta-analyses. What is level of evidence A

8 1 - $200 This is a guideline class that is something which is potentially harmful or at least not beneficial What is a class III guideline?

9 1 - $300 This is the allotted time for revascularization of a patient transferred from a STEMI referring facility. What is 120 minutes? (Class I, Level B)

10 1 - $400 The most beneficial mode of revascularization. What is PCI? (Class IIa, Level B)

11 1 - $500 The symptom duration where PCI is still beneficial in uncomplicated STEMI. What is 12 hours? (Class I, Level A)

12 2 - $100 When anticipating FMC to revasc time of > 120 minutes, fibrinolytics should be given within this many minutes. What is 30 minutes? (Class I, Level B)

13 2 - $200 These are two definitions of failed reperfusion with thrombolytics. What is persistent ST elevation and continued chest pain?

14 2 - $300 The approved Clopidogrel load for patients <75 years old receiving thrombolytics. What is 300mg? (Class I, Level A)

15 2 - $400 The only time when thrombolytics should be given to a patient with only ST depression. What is a posterior infarct? (Class III, Level B)

16 2 - $500 The loading dose for Clopidogrel with thrombolytic use in patients age > 75. What is 75mg? (Class I, Level A)

17 3 - $100 This is a contraindication to giving Prasugrel. What is a history of stroke or TIA? (Class III, Level B)

18 3 - $200 What is the dose of aspirin that should be given with Ticagrelor? What is a 325mg load and 81mg maintenance dose? (Class I, Level B)

19 3 - $300 When should Fondaparinux as the anticoagulant of choice for primary PCI? What is never? (Class III, Level )

20 3 - $400 In a patient who receive LMWH with thrombolytic this is the dose the booster dose that should be given is the last dose of LMWH was given >8 hours previously. What is 0.3mg/kg? (Class I, Level B)

21 3 - $500 This is the appropriate time to give a Prasugrel to patients who did not receive Clopidogrel with their thrombolytics. What is 24 hours after fibrin-specific thrombolytic and 48 hours after non-fibrinspecific thrombolytic? (Class Iia, Level B)

22 4 - $100 This is the favored anticoagulant in patients undergoing primary PCI who are at high bleeding risk. What is Bivalirudin over UFH and GP2B3A? (Class IIa, Level B)

23 4 - $200 This is the goal for FMC to balloon time. What is 90 minutes? (Class I, Level A)

24 4 - $300 These are the two indications for non-infarct vessel PCI during the index hospitalization. What are intermediate to high risk findings on non-invasive testing (Class IIa, Level B) and symptoms of myocardial ischemia (post MI angina)? (Class I, Level C)

25 4 - $400 What three questions should be asked to every patient prior to PCI to determine what type of stent to use. Do you have any planned surgical or invasive procedures? Do you have any problems getting your medicines or taking them every day? Do you have any bleeding problems? (Class I, Level C)

26 4 - $500 PCI is indicated after >24 hours in a STEMI in this clinical scenario. What is cardiogenic shock or acute systolic CHF? (Class I, Level B)

27 5 - $100 This is the approved treatment for post MI pericarditis. What is aspirin? (Class I, Level B)

28 5 - $200 PCI within a minimum of this many hours of thrombolytics in a stable patient. What is 3 hours? (Class IIa, Level B)

29 5 - $300 The shortest length of time to give dual antiplatelet therapy with Clopidogrel and aspirin post thrombolytic therapy. What is 14 days? (Class I, Level A)

30 5 - $400 The maximum duration of LMWH vs UFH after thrombolytics. What is 8 days (Class I, Level A) vs 48 hours (or until revascularization) (Class I, Level C)?

31 5 - $500 The guidelines based therapy for a patient with a new left bundle branch block and ischemic type chest pain. Who knows? (Not addressed directly in current guidelines)

32 This patient is a healthy 91 year old female with distant history of stroke who is having chest pain at Miners Colfax hospital in Raton. The optimal management is Final Jeopardy Heparin (Class I, Level C), Clopidogrel (Class I, Level B), Aspirin (Class I, Level B), rapid transfer for primary PCI. (Class I, Level B)