Reperfusion Strategies for the STEMI Patient - PCI versus Thrombolysis

Transcription

1 Reperfusion Strategies for the STEMI Patient - PCI versus Thrombolysis Scott Mikesell, DO, FACC, FSCAI, FSVM STEMI Program Director Cardiac Catheterization Laboratory Director St. Luke s Hospital, Duluth, Minnesota

2 Disclosures Disclosures: I have no financial relationships or other conflict of interests to disclose, and I will not discuss off label use and/or investigational use in my presentation

3 Terminology STEMI = ST Elevation Myocardial Infarction PCI = Percutaneous coronary intervention PTCA = Percutaneous transluminal coronary angioplasty ACS = Acute coronary syndrome Thrombolysis = Fibrinolysis

4 Outline 1. STEMI Case 2. Epidemiology 3. Fibrinolysis 4. PCI

5 CASE

6 MZ 44 yo male with minimal past medical history presents with chest pain.

7 MZ After the diagnosis he was given 81mg aspirin x 4 600mg clopidogrel 5000 units of unfractionated heparin Morphine sulfate

8 MZ He was emergently transferred to the cardiac catheterization laboratory.

9 MZ

10 MZ

11 MZ PCI was performed with one drug eluting stent placed.

12 MZ

13 EPIDEMIOLOGY

14 Epidemiology 680,300 patients were discharged from US hospitals with the diagnosis of ACS. STEMI comprises 25-40% of myocardial infarctions in the US. 30% of STEMI patients are women in the US. 23% of STEMI patients have diabetes mellitus in the US.

15 STEMI PROTOCOL

16 TIME

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18 Clinical Course

19 The Protocol Minnesota STEMI GUIDELINE! Minnesota Mission: Lifeline Statewide STEMI Interfacility Transfer Guideline! IDENTIFY / CONFIRM STEMI Signs & Symptoms suspect for AMI (Acute Myocardial Infarction) Duration > 15 minutes < 12 hours ST Elevation as defined by diagnostic criteria on pg. 2 Pre-Hospital STEMI confirmed by 12 L ECG trained ALS EMS recognize ST segment elevation of 1 mm in 2 contiguous leads, Confirmed Interpretation of STEMI transmitted, or ECG Monitor interpretative statement infers: Acute Myocardial Infarction with pt. signs & symptoms suspect of AMI Estimated FMC to PCI 120 minutes Or FMC > 120 minutes, and one of the following: Fibrinolytic Ineligible Resuscitated out-of-hospital cardiac arrest patients whose initial ECG shows STEMI Evidence of either Cardiogenic Shock or Acute Severe CHF Top Patient Care Priorities: Establish DNR / Resuscitation Status Obtain vital signs and assess pain level on scale of 1-10 Cardiac Monitor & attach hands-free defibrillator pads Establish Saline Lock - large bore needle (left arm preferred) Oxygen PRN at 2 L/min and titrate to SpO2 > 90% Assess Allergies (Note if reaction to IV Contrast?) Notes:! **Do NOT give Lytic/TNK! All: Aspirin 81 mg x4 chewed (*Dose to achieve 324 mg) Heparin IV Bolus 60 Units/kg, max 4,000 Units (No IV Heparin Drip) Ticagrelor 180 mg PO (If Ticagrelor not available, then give Clopidogrel 600 mg PO) ACTIVATE TRANSPORT Establish availability and ETA of Air or Ground ALS EMS for Interfacility Transfer to PCI Hospital Estimate FMC (first medical contact) to Potential PCI: (Allow approx. 20 min after arrival to PCI capable hospital Estimated FMC to PCI minutes Establish if Fibrinolytic appropriate (See page 2 for contraindications) Goal: Door to Needle < 30 minutes 1. For all ages transferring not utilizing Pharmaco-invasive strategy proceed to Full Dose Fibrinolytic Strategy 2. For patients transferring to Abbott NW/MHI utilizing Pharmaco-invasive strategy, administer HALF-Dose TNK IV and transfer for PCI (Dosing table pg. 2) 3. For patients transferring to CentraCare St Cloud Consult Cardiologist prior to implementing >120 minute protocol All: Aspirin 81 mg x4 chewed (*Dose to achieve 324 mg) Heparin IV Bolus 60 Units/kg, max 4,000 Units (No IV Heparin Drip) Clopidogrel 600 mg PO TNK HALF Dose IV ACTIVATE CODE STEMI / STEMI ALERT AT PCI HOSPITAL (See Page 2 for phone #, or follow your regional STEMI protocol) TRANSPORT PATIENT AS SOON AS POSSIBLE! Fax or Transmit ECG and other pertinent records (EMS reports, allergies, past medical history, etc.) Patient Care When Time Allows: ACTIVATE YOUR INTERNAL STEMI ALERT Alert appropriate provider(s) and team members ESTABLISH KEY TIMES: Symptom Onset: First Medical Contact: ETA to PCI Hospital:! Estimated FMC to PCI >120 minutes Establish if Fibrinolytic appropriate (See page 2 for contraindications) Goal: Door to Needle < 30 minutes **For all ages transferred with an estimated FMC to PCI > 180 minutes All: Aspirin 81 mg x 4 chewed (*Dose to achieve 324 mg) Heparin IV Bolus 60 Units/kg, max 4,000 Units Heparin IV Drip 12 Units/kg/hr, max 1,000 Units/hr For AGE 75 years old: Clopidogrel 300 mg PO TNK FULL-Dose IV* For AGE > 75 years old Clopidogrel 75 mg PO TNK HALF Dose IV Establish 2 nd large bore IV with Normal ( Left arm preferred) Obtain Appropriate Labs: Troponin, CBC, Potassium, Creatinine, PT/ INR, aptt Nitroglycerin 0.4 mg SL every 5 min or Nitropaste PRN for chest pain (hold for SBP < 90) Evaluate if erectile dysfunction or pulmonary hypertension medications taken in the past 48 hours including: Sildenafil (Viagra, Revatio), Vardenafil (Levitra, Staxyn), Avanafil (Stendra), or Tadalafil (Cialis, Adcirca), and if so, hold nitrates for 48 hours! Minnesota STEMI GUIDELINE! Mission: Lifeline Statewide STEMI Interfacility Transfer Guideline!! RELATIVE CONTRAINDICATIONS FOR FIBRINOLYSIS Chest Pain / Symptom Onset > 6 hours Current use of oral anticoagulants (Warfarin, Dabigatran, Rivaroxaban, Apixaban, etc.) Uncontrolled hypertension on presentation (SBP > 180 or DBP > 90 mmhg) History of ischemic stroke more than 3 months, dementia, or known intracranial pathology not covered in contraindications Traumatic or prolonged CPR (over 10 minutes) Major surgery within last 3 weeks Recent internal bleeding (within last 2-4 weeks) Minnesota STEMI (ST Elevation Myocardial Infarction) Diagnostic Criteria: 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 (0.1mV) in other contiguous chest leads or the limb leads Signs & symptoms of discomfort suspect for AMI (Acute Myocardial Infarction) or STEMI with a duration > 15 minutes < 12 hours Although new, or presumably new, LBBB at presentation occurs infrequently and may interfere with ST-elevation analysis, care should be exercised in not considering this an acute myocardial infarction (MI) in isolation...if in doubt, immediate consultation with PCI receiving center is recommended ECG demonstrates evidence of ST depression suspect of a Posterior MI consult with PCI receiving center If initial ECG is not diagnostic but suspicion is high for STEMI, obtain serial 12 Lead ECG s at 5-10 minute intervals ABSOLUTE CONTRAINDICATIONS FOR FIBRINOLYSIS Chest Pain / Symptom Onset > 12 hours Suspected aortic dissection Any prior intracranial hemorrhage Structural cerebral vascular lesion or malignant intracranial neoplasm Any active bleeding (excluding menses) Ischemic stroke within 3 months Significant closed-head or facial trauma within 3 months Pregnancy Notes:!! AHA Mission: Lifeline STEMI Recommendations: FMC (First Medical Contact)-to-First ECG time < 10 minutes unless pre-hospital ECG obtained All eligible STEMI patients receiving a Reperfusion Therapy (Primary PCI or fibrinolysis) Fibrinolytic eligible STEMI patients with Door-to-Needle time < 30 minutes Primary PCI eligible patients transferred to a PCI receiving center with referring center Door in- Door out (Length of Stay) < 45 min Referring Center ED or Pre-Hospital First Medical Contact-to-PCI time < 120 minutes (including transport time) All STEMI patients without a contraindication receiving Aspirin prior to referring center ED discharge! Page 2 of 2 Final Approved Destination! CITY! Primary!PCI!Receiving! Hospital! STEMI! Activation! Phone!#:! Fax!#!for! Records:! Bemidji MN Sanford Health Coon Rapids MN Mercy Hospital Duluth MN St. Luke's Health Duluth MN Essentia St. Mary's Edina MN Fairview Southdale Fargo ND Essentia Health Fargo ND Sanford Health or Eau Claire WI Mayo Clinic Health Eau Claire WI Sacred Heart Hospital Grand Forks ND Altru Health System or La Crosse WI Gundersen Mankato MN Mayo Clinic Health Hospital EMS Minneapolis MN Abbott NW / MHI Minneapolis MN Hennepin County or or Minneapolis MN U of MN. - Fairview Robinsdale MN North Memorial Rochester MN Mayo St. Mary's St. Cloud MN CentraCare Health St. Louis Park MN Methodist St. Paul MN Regions St. Paul MN St. Joseph's Health East St. Paul MN United Hospital Sioux Falls SD Avera Heart Hospital Sioux Falls SD Avera McKennan Sioux Falls SD Sanford Health or Watertown SD Prairie Lakes Health (Other) (Other)!!

20 Initial Evaluation Minnesota STEMI GUIDELINE! IDENTIFY / CONFIRM! Minnesota Mission: STEMI Lifeline Statewide STEMI Interfacility Transfer ACTIVATE Guideline TRANSPORT Signs & Symptoms suspect for AMI (Acute Myocardial Establish availability and! Infarction) IDENTIFY Duration / CONFIRM > 15 STEMI minutes < 12 hours ACTIVATE ETA of Air TRANSPORT or Ground ALS ST Elevation Signs as & defined Symptoms by diagnostic suspect for criteria AMI (Acute on pg. Myocardial Establish EMS for availability Interfacility and 2 Infarction) Duration > 15 minutes < 12 hours ETA Transfer of Air or to Ground PCI Hospital ALS Pre-Hospital STEMI confirmed by 12 L ECG trained ALS EMS for Interfacility ST Elevation as defined by diagnostic criteria on pg. 2 EMS recognize ST segment elevation of 1 mm in 2 Transfer Estimate to PCI FMC Hospital Pre-Hospital STEMI confirmed by 12 L ECG trained ALS (first contiguous EMS leads, recognize Confirmed ST segment Interpretation elevation of of 1 mm STEMI in 2 Estimate medical FMC contact) (first to transmitted, contiguous or ECG leads, Monitor Confirmed interpretative Interpretation statement of infers: STEMI medical Potential contact) PCI: to Acute Myocardial transmitted, or Infarction ECG Monitor with interpretative pt. signs statement & symptoms infers: Potential (Allow approx. PCI: 20 min after suspect of Acute AMI Myocardial Infarction with pt. signs & symptoms (Allow approx. 20 min after suspect of AMI arrival to PCI capable hospital arrival to PCI capable hospital ACTIVATE YOUR! INTERNAL STEMI ALERT ACTIVATE Alert YOUR appropriate provider(s) INTERNAL and STEMI team members ALERT Alert appropriate provider(s) and team members ESTABLISH KEY TIMES: ESTABLISH Symptom KEY TIMES: Onset: Symptom First Onset: Medical Contact: First Medical ETA to Contact: PCI Hospital: ETA to PCI Hospital: Estimated Estimated FMC to PCI FMC to 120 PCI minutes 120 minutes Estimated FMC to to PCI minutes! Estimated Estimated FMC to FMC PCI >120 to PCI minutes >120 minutes Or FMC > Or 120 FMC minutes, > 120 minutes, and one and of one the of the Establish if if Fibrinolytic appropriate (See (See following: following: page page 2 for 2 for contraindications) Establish Establish if Fibrinolytic if Fibrinolytic appropriate appropriate (See page 2 for contraindications) Goal: Door to Needle < 30 minutes (See page 2 for contraindications) Fibrinolytic Ineligible Goal: Door to Needle 30 minutes Goal: Door to Needle < 30 minutes Fibrinolytic Resuscitated Ineligible out-of-hospital cardiac Goal: Door to Needle < 30 minutes 1. For all ages transferring not utilizing Resuscitated arrest out-of-hospital patients whose cardiac initial ECG 1. For Pharmaco-invasive all ages transferring strategy not proceed utilizing to **For all ages transferred with an arrest patients shows whose STEMI initial ECG Pharmaco-invasive Full Dose Fibrinolytic strategy Strategy proceed to estimated **For FMC all ages to PCI transferred > 180 minutes with an shows STEMI Evidence of either Cardiogenic Shock Full Dose Fibrinolytic Strategy estimated FMC to PCI > 180 minutes or Acute Severe CHF 2. For patients transferring to Abbott All: Evidence of either Cardiogenic Shock NW/MHI utilizing Pharmaco-invasive or Acute Severe CHF 2. For patients transferring to Abbott Aspirin 81 mg x 4 chewed All: **Do NOT give Lytic/TNK! strategy, administer HALF-Dose TNK IV NW/MHI utilizing Pharmaco-invasive (*Dose to achieve 324 mg) and transfer for PCI (Dosing table pg. 2) Heparin Aspirin IV Bolus mg Units/kg, x 4 chewed **Do NOT give Lytic/TNK! strategy, administer HALF-Dose TNK IV 3. For patients transferring to CentraCare max 4,000 (*Dose Units to achieve 324 mg) All: and transfer for PCI (Dosing table pg. 2) St Cloud Consult Cardiologist prior to Heparin Heparin IV Drip IV 12 Bolus Units/kg/hr, 60 Units/kg, Aspirin 81 mg x4 chewed 3. For implementing patients transferring >120 minute to protocol max 1,000 CentraCare max 4,000 Units/hr Units (*Dose to achieve 324 mg) All: St Cloud Consult Cardiologist prior to Heparin IV Drip 12 Units/kg/hr, Heparin IV Bolus 60 Units/kg, Aspirin 81 mg x4 chewed All: For AGE 75 years old: max 4,000 Units (No IV Heparin Drip) implementing >120 minute protocol max 1,000 Units/hr Aspirin 81 mg x4 chewed Clopidogrel 300 mg PO (*Dose to achieve Ticagrelor mg) PO (*Dose to achieve 324 mg) TNK FULL-Dose IV* Heparin IV (If Bolus Ticagrelor 60 Units/kg, not available, then give All: Heparin IV Bolus 60 Units/kg, For AGE 75 years old: max 4,000 Clopidogrel Units (No 600 IV mg Heparin PO) Drip) Aspirin max 4, mg Units x4 chewed (No IV Heparin Drip) For AGE Clopidogrel > 75 years old 300 mg PO Ticagrelor 180 mg PO Clopidogrel 600 mg PO Clopidogrel (*Dose to achieve 324 mg) TNK FULL-Dose 75 mg PO IV* (If Ticagrelor not available, then give TNK HALF Dose IV TNK HALF Dose IV Heparin IV Bolus 60 Units/kg, Clopidogrel 600 mg PO) max 4,000 Units (No IV Heparin Drip) For AGE > 75 years old Clopidogrel 600 mg PO Clopidogrel 75 mg PO ACTIVATE CODE STEMI / STEMI ALERT AT PCI HOSPITAL TNK HALF Dose IV TNK HALF Dose IV (See Page 2 for phone #, or follow your regional STEMI protocol)

21 Initial Evaluation!! STEMI (ST Elevation Myocardial Infarction) Diagnostic Criteria: 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 (0.1mV) in other contiguous chest leads or the limb leads Signs & symptoms of discomfort suspect for AMI (Acute Myocardial Infarction) or STEMI with a duration > 15 minutes < 12 hours Although new, or presumably new, LBBB at presentation occurs infrequently and may interfere with ST-elevation analysis, care should be exercised in not considering this an acute myocardial infarction (MI) in isolation...if in doubt, immediate consultation with PCI receiving center is recommended ECG demonstrates evidence of ST depression suspect of a Posterior MI consult with PCI receiving center If initial ECG is not diagnostic but suspicion is high for STEMI, obtain serial 12 Lead ECG s at 5-10 minute intervals Chest Pain / Symptom Onset > 12 hours Suspected aortic dissection Any prior intracranial hemorrhage Structural cerebral vascular lesion or malignant intracranial neoplasm Any active bleeding (excluding menses) Ischemic stroke within 3 months Significant closed-head or facial trauma within 3 months Pregnancy Destination! CITY Primary!PCI!Receiving! Hospital Activation! Records:! Chest Pain / Symptom Onset > 6 hours Current use of oral anticoagulants (Warfarin, Dabigatran, Rivaroxaban, Apixaban, etc.) Uncontrolled hypertension on presentation (SBP > 180 or DBP > 90 mmhg) Mankato MN Mayo Clinic Health

22 Fibrinolytic Ineligible Resuscitated out-of-hospital cardiac arrest patients whose initial ECG shows STEMI Evidence of either Cardiogenic Shock or Acute Severe CHF Think Backwards **Do NOT give Lytic/TNK! All: Aspirin 81 mg x4 chewed (*Dose to achieve 324 mg) Heparin IV Bolus 60 Units/kg, max 4,000 Units (No IV Heparin Drip) Ticagrelor 180 mg PO (If Ticagrelor not available, then give Clopidogrel 600 mg PO) 1. For all ages transferring not utilizing Pharmaco-invasive strategy proceed to Full Dose Fibrinolytic Strategy 2. For patients transferring to Abbott NW/MHI utilizing Pharmaco-invasive strategy, administer HALF-Dose TNK IV and transfer for PCI (Dosing table pg. 2) All: Aspirin 81 mg x4 chewed (*Dose to achieve 324 mg) Heparin IV Bolus 60 Units/kg, max 4,000 Units (No IV Heparin Drip) Clopidogrel 600 mg PO TNK HALF Dose IV! Goal: Door to Needle < 30 minutes **For all ages transferred with an estimated FMC to PCI > 180 minutes All: Aspirin 81 mg x 4 chewed (*Dose to achieve 324 mg) Heparin IV Bolus 60 Units/kg, max 4,000 Units Heparin IV Drip 12 Units/kg/hr, max 1,000 Units/hr For AGE 75 years old: Clopidogrel 300 mg PO TNK FULL-Dose IV* For AGE > 75 years old Clopidogrel 75 mg PO TNK HALF Dose IV ACTIVATE CODE STEMI / STEMI ALERT AT PCI HOSPITAL (See Page 2 for phone #, or follow your regional STEMI protocol) TRANSPORT PATIENT AS SOON AS POSSIBLE! Fax or Transmit ECG and other pertinent records (EMS reports, allergies, past medical history, etc.) Establish DNR / Resuscitation Status Obtain vital signs and assess pain level on scale of 1-10 Cardiac Monitor & attach hands-free defibrillator pads Establish Saline Lock - large bore needle (left arm preferred) Oxygen PRN at 2 L/min and titrate to SpO2 > 90% Assess Allergies (Note if reaction to IV Contrast?) Establish 2 nd large bore IV with Normal ( Left arm preferred) Obtain Appropriate Labs: Troponin, CBC, Potassium, Creatinine, PT/ INR, aptt Nitroglycerin 0.4 mg SL every 5 min or Nitropaste PRN for chest pain (hold for SBP < 90) Evaluate if erectile dysfunction or pulmonary hypertension medications taken in the past 48 hours including: Sildenafil (Viagra, Revatio), Vardenafil (Levitra, Staxyn), Avanafil (Stendra),

23 THROMBOLYSIS

24 Coagulation Cascade

25 Fibrinolysis

26 Fibrinolysis

27 Fibrinolysis Pitfalls Arterial thrombi are rich in platelets and relatively resistant to fibrinolysis. Initial reperfusion fails in ~20% of patients. Doubled mortality rates. 5-8% of patients experience reocclusion during the index hospitalization.

28 Addition of Clopidogrel to Fibrinolysis

29 Addition of Clopidogrel to Fibrinolysis

30 Addition of Clopidogrel to Fibrinolysis

31 farction) Duration > 15 minutes < 12 hours T Elevation as defined by diagnostic criteria on pg. 2 Establish availability and ETA of Air or Ground ALS EMS for Interfacility Transfer Times >120 Minutes Symptom Onset: medical contact) to Potential PCI: (Allow approx. 20 min after FMC > 120 minutes, and one of the following: ibrinolytic Ineligible esuscitated out-of-hospital cardiac rrest patients whose initial ECG hows STEMI vidence of either Cardiogenic Shock r Acute Severe CHF **Do NOT give Lytic/TNK! spirin 81 mg x4 chewed Dose to achieve 324 mg) eparin IV Bolus 60 Units/kg, ax 4,000 Units (No IV Heparin Drip) icagrelor 180 mg PO f Ticagrelor not available, then give lopidogrel 600 mg PO) Estimated FMC to PCI minutes Establish if Fibrinolytic appropriate (See page 2 for contraindications) Goal: Door to Needle < 30 minutes 1. For all ages transferring not utilizing Pharmaco-invasive strategy proceed to Full Dose Fibrinolytic Strategy 2. For patients transferring to Abbott NW/MHI utilizing Pharmaco-invasive strategy, administer HALF-Dose TNK IV and transfer for PCI (Dosing table pg. 2) All: Aspirin 81 mg x4 chewed (*Dose to achieve 324 mg) Heparin IV Bolus 60 Units/kg, max 4,000 Units (No IV Heparin Drip) Clopidogrel 600 mg PO TNK HALF Dose IV!! Estimated FMC to PCI >120 minutes Establish if Fibrinolytic appropriate (See page 2 for contraindications) Goal: Door to Needle < 30 minutes **For all ages transferred with an estimated FMC to PCI > 180 minutes All: Aspirin 81 mg x 4 chewed (*Dose to achieve 324 mg) Heparin IV Bolus 60 Units/kg, max 4,000 Units Heparin IV Drip 12 Units/kg/hr, max 1,000 Units/hr For AGE 75 years old: Clopidogrel 300 mg PO TNK FULL-Dose IV* For AGE > 75 years old Clopidogrel 75 mg PO TNK HALF Dose IV Fax or Transmit ECG and other pertinent records

32 !! Patient Based Considerations ST elevation the J point in least 2 contiguous leads of 2 mm (0.2 mv) in men or 1.5 mm (0.15 mv) in wome and/or of 1 mm (0.1mV) in other contiguous chest leads or the limb leads Signs & symptoms of discomfort suspect for AMI (Acute Myocardial Infarction) or STEMI with a duration > 15 minute Although new, or presumably new, LBBB at presentation occurs infrequently and may interfere with ST-elevation an be exercised in not considering this an acute myocardial infarction (MI) in isolation...if in doubt, immediate consultat receiving center is recommended ECG demonstrates evidence of ST depression suspect of a Posterior MI consult with PCI receiving center ABSOLUTE CONTRAINDICATIONS FOR FIBRINOLYSIS Chest Pain / Symptom Onset > 12 hours Suspected aortic dissection Any prior intracranial hemorrhage Structural cerebral vascular lesion or malignant intracranial neoplasm Any active bleeding (excluding menses) Ischemic stroke within 3 months Significant closed-head or facial trauma within 3 months Pregnancy Destination! CITY Primary!PCI!Receiving! Hospital Activatio! RELATIVE CONTRAINDICATIONS FOR FIBRINOLYSIS Chest Pain / Symptom Onset > 6 hours Current use of oral anticoagulants (Warfarin, Dabigatran, Rivaroxaban, Apixaban, etc.) Uncontrolled hypertension on presentation (SBP > 180 or DBP > 90 mmhg) History of ischemic stroke more than 3 months, dementia, or known intracranial pathology not covered in contraindications Traumatic or prolonged CPR (over 10 minutes) Major surgery within last 3 weeks Recent internal bleeding (within last 2-4 weeks) Mankato MN Mayo Clinic Health EMS Minneapolis MN Abbott NW / MHI Minneapolis MN Hennepin County Minneapolis MN U of MN. - Fairview Robinsdale MN North Memorial Rochester MN Mayo St. Mary's St. Cloud MN CentraCare Health St. Louis Park MN Methodist St. Paul MN Regions St. Paul MN St. Joseph's Health East St. Paul MN United Hospital Sioux Falls SD Avera Heart Hospital Sioux Falls SD Avera McKennan

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38 PCI

39 ! PCI Arm (<120 minutes transfer time) Infarction) Duration > 15 minutes < 12 hours ST Elevation as defined by diagnostic criteria on pg. 2 Establish availability and ETA of Air or Ground ALS EMS for Interfacility medical contact) to Potential PCI: (Allow approx. 20 min after Estimated FMC to PCI 120 minutes Estimated F Or FMC > 120 minutes, and one of the following: Fibrinolytic Ineligible Resuscitated out-of-hospital cardiac arrest patients whose initial ECG shows STEMI Evidence of either Cardiogenic Shock or Acute Severe CHF **Do NOT give Lytic/TNK! All: Aspirin 81 mg x4 chewed (*Dose to achieve 324 mg) Heparin IV Bolus 60 Units/kg, max 4,000 Units (No IV Heparin Drip) Ticagrelor 180 mg PO (If Ticagrelor not available, then give Clopidogrel 600 mg PO) Establish if Fibrinolytic appropriate (See page 2 for contraindications) Goal: Door to Needle < 30 minutes 1. For all ages transferring not utilizing Pharmaco-invasive strategy proceed to Full Dose Fibrinolytic Strategy 2. For patients transferring to Abbott NW/MHI utilizing Pharmaco-invasive strategy, administer HALF-Dose TNK IV and transfer for PCI (Dosing table pg. 2) ents transferring to CentraCare St Cloud Consult Cardiologist prior to implementing >120 minute protocol All: Aspirin 81 mg x4 chewed (*Dose to achieve 324 mg) Heparin IV Bolus 60 Units/kg, max 4,000 Units (No IV Heparin Drip) Clopidogrel 600 mg PO TNK HALF Dose IV Establis (See pa Goal: D **For all age estimated F All: Aspirin (*Dose Heparin max 4,0 Heparin max 1,0 For AGE Clopido TNK F For AGE > Clopido TNK H Fax or Transmit ECG and other pertinent records

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42 ANCILLARY CONSIDERATIONS

43 Aspirin 81 mg x4 chewed (*Dose to achieve 324 mg) Heparin IV Bolus 60 Units/kg, max 4,000 Units (No IV Heparin Drip) Ticagrelor 180 mg PO (If Ticagrelor not available, then give Clopidogrel 600 mg PO) All: Aspirin 81 mg x4 chewed (*Dose to achieve 324 mg) Heparin IV Bolus 60 Units/kg, max 4,000 Units (No IV Heparin Drip) Clopidogrel 600 mg PO TNK HALF Dose IV Other Priorities! Heparin IV Drip 12 Units/kg/hr, max 1,000 Units/hr For AGE 75 years old: Clopidogrel 300 mg PO TNK FULL-Dose IV* For AGE > 75 years old Clopidogrel 75 mg PO TNK HALF Dose IV Fax or Transmit ECG and other pertinent records Top Patient Care Priorities: Establish DNR / Resuscitation Status Obtain vital signs and assess pain level on scale of 1-10 Cardiac Monitor & attach hands-free defibrillator pads Establish Saline Lock - large bore needle (left arm preferred) Oxygen PRN at 2 L/min and titrate to SpO2 > 90% Assess Allergies (Note if reaction to IV Contrast?) Notes:! Patient Care When Time Allows: Establish 2 nd large bore IV with Normal ( Left arm preferred) Obtain Appropriate Labs: Troponin, CBC, Potassium, Creatinine, PT/ INR, aptt Nitroglycerin 0.4 mg SL every 5 min or Nitropaste PRN for chest pain (hold for SBP < 90) Evaluate if erectile dysfunction or pulmonary hypertension medications taken in the past 48 hours including: Sildenafil (Viagra, Revatio), Vardenafil (Levitra, Staxyn), Avanafil (Stendra), or Tadalafil (Cialis, Adcirca), and if so, hold nitrates for 48 hours

44 or Minneapolis MN U of MN. - Fairview Robinsdale MN North Memorial Rochester MN Mayo St. Mary's St. Cloud MN CentraCare Health STEMI Recommendations St. Louis Park MN Methodist St. Paul MN Regions St. Paul MN St. Joseph's Health East St. Paul MN United Hospital Sioux Falls SD Avera Heart Hospital Sioux Falls SD Avera McKennan Sioux Falls SD Sanford Health or Watertown SD Prairie Lakes Health (Other) (Other)!! AHA Mission: Lifeline STEMI Recommendations: FMC (First Medical Contact)-to-First ECG time < 10 minutes unless pre-hospital ECG obtained All eligible STEMI patients receiving a Reperfusion Therapy (Primary PCI or fibrinolysis) Fibrinolytic eligible STEMI patients with Door-to-Needle time < 30 minutes Primary PCI eligible patients transferred to a PCI receiving center with referring center Door in- Door out (Length of Stay) < 45 min Referring Center ED or Pre-Hospital First Medical Contact-to-PCI time < 120 minutes (including transport time) All STEMI patients without a contraindication receiving Aspirin prior to referring center ED discharge

45 THANK YOU