ST elevation myocardial infarction oxygen therapy: Difference between revisions

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{{Infobox_Disease |
{{ST elevation myocardial infarction}}
  Name          = Myocardial infarction|
Editors-In-Chief: [[C. Michael Gibson]], M.S., M.D. [mailto:charlesmichaelgibson@gmail.com] and Tom Quinn, FRCN, FESC [mailto:T.Quinn@surrey.ac.uk]
  Image          = |
  Caption        = |
  DiseasesDB    = 8664 |
  ICD10          = {{ICD10|I|21||i|20}}-{{ICD10|I|22||i|20}} |
  ICD9          = {{ICD9|410}} |
  ICDO          = |
  OMIM          = |
  MedlinePlus    = 000195 |
  eMedicineSubj  = med |
  eMedicineTopic = 1567 |
  eMedicine_mult = {{eMedicine2|emerg|327}} {{eMedicine2|ped|2520}} |
  MeshID        = |
}}
{{SI}}
{{WikiDoc Cardiology Network Infobox}}
{{CMG}}


'''Associate Editor:''' {{CZ}}
==Overview==
 
Oxygen therapy is commonly used within the STEMI patient population. Theoretical models suggest that the usage of oxygen therapy can influence the ventilation perfusion mismatch which occurs early on in the patient's course of disease. Randomized clinical data to support this therapy is still lacking.
{{Editor Join}}
 
==Oxygen==


==Oxygen Therapy==
===Mechanism of Benefit===
===Mechanism of Benefit===
[[Oxygen]] is administered to the vast majority (98%) of patients with [[ST elevation myocardial infarction]] ([[STEMI]]). There is limited data to suggest that supplemental oxygen improves ST segment resolution (a surrogate endpoint)<ref name="pmid1253359">{{cite journal |author=Madias JE, Hood WB |title=Reduction of precordial ST-segment elevation in patients with anterior myocardial infarction by oxygen breathing |journal=Circulation |volume=53 |issue=3 Suppl |pages=I198–200 |year=1976 |month=March |pmid=1253359 |doi= |url=}}</ref> The theoretical basis for oxygen administration is also based on the fact that there may be ventilation perfusion mismatch early in the patient's course<ref name="pmid5444451">{{cite journal |author=Fillmore SJ, Shapiro M, Killip T |title=Arterial oxygen tension in acute myocardial infarction. Serial analysis of clinical state and blood gas changes |journal=Am. Heart J. |volume=79 |issue=5 |pages=620–9 |year=1970 |month=May |pmid=5444451 |doi= |url=}}</ref>


[[Oxygen]] is administered to the vast majority of patients with [[ST elevation myocardial infarction]] ([[STEMI]]). There is limited data to suggest that supplemental [[oxygen]] improves ST segment resolution (a surrogate endpoint)<ref name="pmid1253359">{{cite journal |author=Madias JE, Hood WB |title=Reduction of precordial ST-segment elevation in patients with anterior myocardial infarction by oxygen breathing |journal=Circulation |volume=53 |issue=3 Suppl |pages=I198–200 |year=1976 |month=March |pmid=1253359 |doi= |url=}}</ref>  
===Clinical Trial Data===
Large scale randomized clinical trial data is lacking regarding its impact on mortality or other hard clinical endpoints.  A recent review of available trial data indicated no benefit of supplemental oxygen, and in fact there was signs of a hazard <ref> Cabello JB, Burls A, Emparanza JI, et al. Oxygen therapy for acute myocardial infarction. Cochrane Database Syst Rev 2010; 6: CD007160. DOI: 10.1002/14651858.CD007160.pub2. Available at: http://www.cochrane.org/cochrane-reviews </ref>.  Three randomized trial have enrolled a total of 387 patients. There were 14 deaths.  Oxygen administration was associated with non-significant 2.88 fold increase in mortality (95% CI 0.88-9.39). It should be emphasized that given the small numbers of deaths in the trials, the trend toward a hazard associated with oxygen could represent a play of chance, and was not statistically significant.  Large randomized trials would be necessary to evaluate the risks and benefits of oxygen. Current guideline recommendations are based upon expert consensus, and not clinical trial data.


The theoretical basis for [[oxygen]] administration is also based on the fact that there may be ventilation perfusion mismatch early in the patient's course<ref name="pmid5444451">{{cite journal |author=Fillmore SJ, Shapiro M, Killip T |title=Arterial oxygen tension in acute myocardial infarction. Serial analysis of clinical state and blood gas changes |journal=Am. Heart J. |volume=79 |issue=5 |pages=620–9 |year=1970 |month=May |pmid=5444451 |doi= |url=}}</ref>
===Dosing===
In general [[oxygen]] is administered via nasal canula or face mask to patients with an uncomplicated course to maintain an [[oxygen saturation]] greater than 90%. However, endotracheal intubation may be required in those patients with a clinical course complicated by severe [[pulmonary edema]], [[cardiogenic shock]] or mechanical complications (e.g. [[papillary muscle rupture]], [[free wall rupture]], or [[acquired ventricular septal defect]]).


==Clinical Trial Data==
===Side Effects===


Large scale randomized clinical trial data is lacking regarding its impact on mortality or other hard clinical endpoints.
While the majority of patients may benefit from supplemental oxygen administration, excess oxygen administration may be harmful to those patients with [[chronic obstructive pulmonary disease]]. Administration of oxygen to these patients should be judicious and guided by periodic [[arterial blood gas]] values.


===Dosing===
==2004 ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction (DO NOT EDIT) <ref name="pmid15289388">{{cite journal| author=Antman EM, Anbe DT, Armstrong PW, Bates ER, Green LA, Hand M et al.| title=ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction--executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1999 Guidelines for the Management of Patients With Acute Myocardial Infarction). | journal=Circulation | year= 2004 | volume= 110 | issue= 5 | pages= 588-636 | pmid=15289388 | doi=10.1161/01.CIR.0000134791.68010.FA | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15289388  }} </ref>==


In general [[oxygen]] is administered via nasal canula or face mask to patients with an uncomplicated course to maintain an [[oxygen saturation]] greater than 90%. However, endotracheal intubation may be required in those patients with a clinical course complicated by severe [[pulmonary edema]], [[cardiogenic shock]] or mechanical complications (e.g. [[papillary muscle rupture]], free wall rupture, or [[ventricular septal defect]]).
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' Supplemental [[oxygen]] should be administered to patients with arterial [[oxygen]] desaturation (SaO2 less than 90%). ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' <nowiki>"</nowiki>
|}


===Side Effects===
{|class="wikitable"
 
|-
While the majority of patients may benefit from supplemental [[oxygen]] administration, excess [[oxygen]] administration may be harmful to those patients with [[chronic obstructive pulmonary disease]]. Administration of [[oxygen]] to these patients should be judicious and guided by periodic [[arterial blood gas]] values.
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
 
|-
==Guidelines (DO NOT EDIT)==
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' It is reasonable to administer supplemental oxygen to all patients with uncomplicated [[STEMI]] during the first 6 hours. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
|}


===Class I===
==Sources==
Supplemental [[oxygen]] should be administered to patients with arterial [[oxygen]] desaturation (SaO2 less than 90%). (Level of Evidence: B)
*The 2004 ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction <ref name="pmid15339869">{{cite journal |author=Antman EM, Anbe DT, Armstrong PW, Bates ER, Green LA, Hand M, Hochman JS, Krumholz HM, Kushner FG, Lamas GA, Mullany CJ, Ornato JP, Pearle DL, Sloan MA, Smith SC, Alpert JS, Anderson JL, Faxon DP, Fuster V, Gibbons RJ, Gregoratos G, Halperin JL, Hiratzka LF, Hunt SA, Jacobs AK |title=ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of Patients with Acute Myocardial Infarction) |journal=Circulation |volume=110 |issue=9 |pages=e82–292 |year=2004 |month=August |pmid=15339869 |doi= |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=15339869}}</ref>


===Class IIa===
*The 2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients with ST-Elevation Myocardial Infarction <ref name="pmid18071078">{{cite journal |author=Antman EM, Hand M, Armstrong PW, ''et al'' |title=2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines: developed in collaboration With the Canadian Cardiovascular Society endorsed by the American Academy of Family Physicians: 2007 Writing Group to Review New Evidence and Update the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction, Writing on Behalf of the 2004 Writing Committee |journal=Circulation |volume=117 |issue=2 |pages=296–329 |year=2008 |month=January |pmid=18071078 |doi=10.1161/CIRCULATIONAHA.107.188209 |url=}}</ref>
It is reasonable to administer supplemental oxygen to all patients with uncomplicated [[STEMI]] during the first 6 hours. (Level of Evidence: C)<ref name="pmid18071078">{{cite journal |author=Antman EM, Hand M, Armstrong PW, ''et al'' |title=2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines: developed in collaboration With the Canadian Cardiovascular Society endorsed by the American Academy of Family Physicians: 2007 Writing Group to Review New Evidence and Update the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction, Writing on Behalf of the 2004 Writing Committee |journal=Circulation |volume=117 |issue=2 |pages=296–329 |year=2008 |month=January |pmid=18071078 |doi=10.1161/CIRCULATIONAHA.107.188209 |url=}}</ref>


==References==
==References==
{{reflist|2}}
{{reflist|2}}


{{STEMI}}
[[Category:Disease]]
 
[[Category:Cardiology]]
[[Category:Cardiology]]
[[Category:Ischemic heart diseases]]
[[Category:Intensive care medicine]]
[[Category:Emergency medicine]]
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Latest revision as of 00:01, 23 January 2013

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Editors-In-Chief: C. Michael Gibson, M.S., M.D. [1] and Tom Quinn, FRCN, FESC [2]

Overview

Oxygen therapy is commonly used within the STEMI patient population. Theoretical models suggest that the usage of oxygen therapy can influence the ventilation perfusion mismatch which occurs early on in the patient's course of disease. Randomized clinical data to support this therapy is still lacking.

Oxygen Therapy

Mechanism of Benefit

Oxygen is administered to the vast majority (98%) of patients with ST elevation myocardial infarction (STEMI). There is limited data to suggest that supplemental oxygen improves ST segment resolution (a surrogate endpoint)[1] The theoretical basis for oxygen administration is also based on the fact that there may be ventilation perfusion mismatch early in the patient's course[2]

Clinical Trial Data

Large scale randomized clinical trial data is lacking regarding its impact on mortality or other hard clinical endpoints. A recent review of available trial data indicated no benefit of supplemental oxygen, and in fact there was signs of a hazard [3]. Three randomized trial have enrolled a total of 387 patients. There were 14 deaths. Oxygen administration was associated with non-significant 2.88 fold increase in mortality (95% CI 0.88-9.39). It should be emphasized that given the small numbers of deaths in the trials, the trend toward a hazard associated with oxygen could represent a play of chance, and was not statistically significant. Large randomized trials would be necessary to evaluate the risks and benefits of oxygen. Current guideline recommendations are based upon expert consensus, and not clinical trial data.

Dosing

In general oxygen is administered via nasal canula or face mask to patients with an uncomplicated course to maintain an oxygen saturation greater than 90%. However, endotracheal intubation may be required in those patients with a clinical course complicated by severe pulmonary edema, cardiogenic shock or mechanical complications (e.g. papillary muscle rupture, free wall rupture, or acquired ventricular septal defect).

Side Effects

While the majority of patients may benefit from supplemental oxygen administration, excess oxygen administration may be harmful to those patients with chronic obstructive pulmonary disease. Administration of oxygen to these patients should be judicious and guided by periodic arterial blood gas values.

2004 ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction (DO NOT EDIT) [4]

Class I
"1. Supplemental oxygen should be administered to patients with arterial oxygen desaturation (SaO2 less than 90%). (Level of Evidence: B) "
Class IIa
"1. It is reasonable to administer supplemental oxygen to all patients with uncomplicated STEMI during the first 6 hours. (Level of Evidence: C) "

Sources

  • The 2004 ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction [5]
  • The 2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients with ST-Elevation Myocardial Infarction [6]

References

  1. ↑ Madias JE, Hood WB (1976). "Reduction of precordial ST-segment elevation in patients with anterior myocardial infarction by oxygen breathing". Circulation. 53 (3 Suppl): I198–200. PMID 1253359. Unknown parameter |month= ignored (help)
  2. ↑ Fillmore SJ, Shapiro M, Killip T (1970). "Arterial oxygen tension in acute myocardial infarction. Serial analysis of clinical state and blood gas changes". Am. Heart J. 79 (5): 620–9. PMID 5444451. Unknown parameter |month= ignored (help)
  3. ↑ Cabello JB, Burls A, Emparanza JI, et al. Oxygen therapy for acute myocardial infarction. Cochrane Database Syst Rev 2010; 6: CD007160. DOI: 10.1002/14651858.CD007160.pub2. Available at: http://www.cochrane.org/cochrane-reviews
  4. ↑ Antman EM, Anbe DT, Armstrong PW, Bates ER, Green LA, Hand M; et al. (2004). "ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction--executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1999 Guidelines for the Management of Patients With Acute Myocardial Infarction)". Circulation. 110 (5): 588–636. doi:10.1161/01.CIR.0000134791.68010.FA. PMID 15289388.
  5. ↑ Antman EM, Anbe DT, Armstrong PW, Bates ER, Green LA, Hand M, Hochman JS, Krumholz HM, Kushner FG, Lamas GA, Mullany CJ, Ornato JP, Pearle DL, Sloan MA, Smith SC, Alpert JS, Anderson JL, Faxon DP, Fuster V, Gibbons RJ, Gregoratos G, Halperin JL, Hiratzka LF, Hunt SA, Jacobs AK (2004). "ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of Patients with Acute Myocardial Infarction)". Circulation. 110 (9): e82–292. PMID 15339869. Unknown parameter |month= ignored (help)
  6. ↑ Antman EM, Hand M, Armstrong PW; et al. (2008). "2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines: developed in collaboration With the Canadian Cardiovascular Society endorsed by the American Academy of Family Physicians: 2007 Writing Group to Review New Evidence and Update the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction, Writing on Behalf of the 2004 Writing Committee". Circulation. 117 (2): 296–329. doi:10.1161/CIRCULATIONAHA.107.188209. PMID 18071078. Unknown parameter |month= ignored (help)


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