ST Elevated Myocardial Infarction- Latest AHA recommendations

Transcription

1 ST Elevated Myocardial Infarction- Latest AHA recommendations Sherry Turner, DO, MPH, FACOEP Medical Director Emergency Services Wesley Medical Center

2 The Problem 250,000 Americans each year 30% fail to receive percutaneous coronary intervention (PCI) or thrombolytic therapy Those who receive PCI- only 40% are treated within the door to balloon timeframe of 90 minutes as recommended Those treated with thrombolytic therapy, less than 50% are treated within door-to-needle timeframe of 30 minutes 70% of those patients who aren t eligible for thrombolytic therapy fail to receive PCI Care_UCM_439065_SubHomePage.jsp

3 Age- and sex-adjusted incidence rates of acute MI, 1999 to 2008.

4 Reperfusion therapy for patients with STEMI. The bold arrows and boxes are the preferred strategies.

5 Indications for Fibrinolytic Therapy When There Is a >120-Minute Delay From FMC to Primary PCI (Figure 2).

6 Reperfusion therapy for patients with STEMI. The bold arrows and boxes are the preferred strategies.

7 Adjunctive Antithrombotic Therapy to Support Reperfusion With Primary PCI.

8 Adjunctive Antithrombotic Therapy to Support Reperfusion With Fibrinolytic Therapy.

9 Absolute contraindications Any prior ICH Known structural cerebral vascular lesion (eg, arterio-venous malformation) Known malignant intracranial neoplasm (primary or metastatic) Ischemic stroke within 3 mo EXCEPT acute ischemic stroke within 4.5 h Suspected aortic dissection Active bleeding or bleeding diathesis (excluding menses) Significant closed-head or facial trauma within 3 mo Intracranial or intraspinal surgery within 2 mo Severe uncontrolled hypertension (unresponsive to emergency therapy) For streptokinase, prior treatment within the previous 6 mo

10 Relative contraindications History of chronic, severe, poorly controlled hypertension Significant hypertension on presentation (SBP >180 mm Hg or DBP >110 mm Hg) History of prior ischemic stroke >3 mo Dementia Known intracranial pathology not covered in absolute contraindications Traumatic or prolonged (>10 min) CPR Major surgery (<3 wk) Recent (within 2 to 4 wk) internal bleeding Non-compressible vascular punctures Pregnancy Active peptic ulcer Oral anticoagulant therapy

11 Adjusted risk of nonfatal and fatal bleeding in patients treated with aspirin, clopidogrel, and/or vitamin K antagonists after first MI. Compared with aspirin alone, triple therapy is associated with a 3- to 4-fold increased risk of fatal and nonfatal bleeding.

12 Adjunctive Antithrombotic Therapy to Support Reperfusion With Fibrinolytic Therapy.

13 Indications for Transfer for Angiography After Fibrinolytic Therapy.

14 Primary outcome of trials of routine versus ischemia-driven (or delayed) catheterization and PCI after fibrinolytic therapy.

15 Indications for Coronary Angiography in Patients Who Were Managed With Fibrinolytic Therapy or Who Did Not Receive Reperfusion Therapy.

16 Indications for PCI of an Infarct Artery in Patients Who Were Managed With Fibrinolytic Therapy or Who Did Not Receive Reperfusion Therapy.

17 Review

18 Pearls Know who you are working with- What do the Cardiologist what Load with clopidegril or not Know your transfer plan EMS numbers Field Activation numbers Fax the EKG to receiving facility when possible Train your office staff to preform this actions

19 References ACCF/AHA 2013 Guideline for the Management of ST- Elevation Myocardial Infarction: A report of the American College of Cardiology Foundation/ American Heart Association Task Force on Practice Guidelines. Circulation 2013:127; e362-e425. J Am Coll Cardiol. 2013;61(4):e78-e140. doi: /j.jacc AHA STEMI Systems of Care accessed at age/learnaboutmissionlifeline/stemi-systems-of- Care_UCM_439065_SubHomePage.jsp