ST elevation myocardial infarction reperfusion therapy: Difference between revisions
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{{Infobox_Disease | | {{Infobox_Disease | | ||
Name = Myocardial infarction| | Name = Myocardial infarction| | ||
Image = | Image = | | ||
Caption = | Caption = | | ||
DiseasesDB = 8664 | | DiseasesDB = 8664 | | ||
ICD10 = {{ICD10|I|21||i|20}}-{{ICD10|I|22||i|20}} | | ICD10 = {{ICD10|I|21||i|20}}-{{ICD10|I|22||i|20}} | | ||
Revision as of 12:15, 27 May 2009
| Myocardial infarction | |
| ICD-10 | I21-I22 |
|---|---|
| ICD-9 | 410 |
| DiseasesDB | 8664 |
| MedlinePlus | 000195 |
| eMedicine | med/1567 emerg/327 ped/2520 |
| Cardiology Network |
 Discuss ST elevation myocardial infarction reperfusion therapy further in the WikiDoc Cardiology Network |
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]
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Reperfusion
Regardless of the mode of reperfusion, the overarching concept is to minimize total ischemic time, which is defined as the time from onset of symptoms of STEMI to initiation of reperfusion therapy.
It is increasingly clear that 2 types of hospital systems provide reperfusion therapy:
- Hospitals with percutaneous coronary intervention (PCI) capability
- Hospitals without PCI capability.
When PCI capability is available, the best outcomes are achieved by offering this strategy 24 hours per day, 7 days per week.[1]
The concept of reperfusion has become so central to the modern treatment of acute myocardial infarction, that we are said to be in the reperfusion era.[2][3] Patients who present with suspected acute myocardial infarction and ST segment elevation (STEMI) or new bundle branch block on the 12 lead ECG are presumed to have an occlusive thrombosis in an epicardial coronary artery. They are therefore candidates for immediate reperfusion, either with thrombolytic therapy, percutaneous coronary intervention (PCI) or when these therapies are unsuccessful, bypass surgery.
Individuals without ST segment elevation are presumed to be experiencing either unstable angina (UA) or non-ST segment elevation myocardial infarction (NSTEMI). They receive many of the same initial therapies and are often stabilized with antiplatelet drugs and anticoagulated. If their condition remains (hemodynamically) stable, they can be offered either late coronary angiography with subsequent restoration of blood flow (revascularization), or non-invasive stress testing to determine if there is significant ischemia that would benefit from revascularization. If hemodynamic instability develops in individuals with NSTEMIs, they may undergo urgent coronary angiography and subsequent revascularization. The use of thrombolytic agents is contraindicated in this patient subset, however.[4][5][6][7][8][9][10][11][12]
The basis for this distinction in treatment regimens is that ST segment elevations on an ECG are typically due to complete occlusion of a coronary artery. On the other hand, in NSTEMIs there is typically a sudden narrowing of a coronary artery with preserved (but diminished) flow to the distal myocardium. Anticoagulation and antiplatelet agents are given to prevent the narrowed artery from occluding.
At least 10% of patients with STEMI don't develop myocardial necrosis (as evidenced by a rise in cardiac markers) and subsequent q waves on EKG after reperfusion therapy. Such a successful restoration of flow to the infarct-related artery during an acute myocardial infarction is known as "aborting" the myocardial infarction. If treated within the hour, about 25% of STEMIs can be aborted.[13]
The emphasis on primary PCI should not obscure the importance of fibrinolytic therapy. Many hospital systems in North America do not have the capability of meeting the time goal for primary PCI. Therefore, because of the critical importance of time to treatment from onset of symptoms of STEMI in reducing morbidity and mortality, fibrinolytic therapy is preferred. In these settings, transfer protocols need to be in place for arranging rescue PCI when clinically indicated.[11][12][14]
For fibrinolytic therapy, the system goal is to deliver the drug within 30 minutes of the time that the patient presents to the hospital. The focus for primary PCI is from first medical contact because in regionalization strategies, extra time may be taken to transport patients to a center that performs the procedure. Consequently, it is important to consider the time from first medical contact.
Clinical Trial Data
Side Effects
Guidelines (DO NOT EDIT)
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Class I1. All STEMI patients should undergo rapid evaluation for reperfusion therapy and have a reperfusion strategy implemented promptly after contact with the medical system. (Level of Evidence: A)[15] STEMI patients presenting to a facility without the capability for expert, prompt intervention with primary PCI within 90 minutes of first medical contact should undergo fibrinolysis unless contraindicated. (Level of Evidence: A)[16] |
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Sources
- The 2004 ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction [17]
- The 2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients with ST-Elevation Myocardial Infarction [16]
References
- ↑ Antman EM. Manual for ACC/AHA Guideline Writing Committees: Methodologies and Policies from the ACC/AHA Task Force on Practice Guidelines. 2004. Available at: http://www.acc.org/qualityandscience/clinical/manual/pdfs/methodology.pdf Accessed September 24, 2007.
- ↑ Lee KL, Woodlief LH, Topol EJ; et al. (1995). "Predictors of 30-day mortality in the era of reperfusion for acute myocardial infarction. Results from an international trial of 41,021 patients. GUSTO-I Investigators". Circulation. 91 (6): 1659–68. PMID 7882472. Unknown parameter
|month=ignored (help) - ↑ Wang K, Asinger RW, Marriott HJ (2003). "ST-segment elevation in conditions other than acute myocardial infarction". N. Engl. J. Med. 349 (22): 2128–35. doi:10.1056/NEJMra022580. PMID 14645641. Unknown parameter
|month=ignored (help) - ↑ "Indications for fibrinolytic therapy in suspected acute myocardial infarction: collaborative overview of early mortality and major morbidity results from all randomised trials of more than 1000 patients. Fibrinolytic Therapy Trialists' (FTT) Collaborative Group". Lancet. 343 (8893): 311–22. 1994. PMID 7905143. Unknown parameter
|month=ignored (help) - ↑ Jacobs AK, Antman EM, Faxon DP, Gregory T, Solis P (2007). "Development of systems of care for ST-elevation myocardial infarction patients: executive summary". Circulation. 116 (2): 217–30. doi:10.1161/CIRCULATIONAHA.107.184043. PMID 17538045. Unknown parameter
|month=ignored (help) - ↑ Bradley EH, Herrin J, Wang Y; et al. (2006). "Strategies for reducing the door-to-balloon time in acute myocardial infarction". N. Engl. J. Med. 355 (22): 2308–20. doi:10.1056/NEJMsa063117. PMID 17101617. Unknown parameter
|month=ignored (help) - ↑ Dalby M, Bouzamondo A, Lechat P, Montalescot G (2003). "Transfer for primary angioplasty versus immediate thrombolysis in acute myocardial infarction: a meta-analysis". Circulation. 108 (15): 1809–14. doi:10.1161/01.CIR.0000091088.63921.8C. PMID 14530206. Unknown parameter
|month=ignored (help) - ↑ Henry TD, Unger BT, Sharkey SW; et al. (2005). "Design of a standardized system for transfer of patients with ST-elevation myocardial infarction for percutaneous coronary intervention". Am. Heart J. 150 (3): 373–84. doi:10.1016/j.ahj.2005.01.059. PMID 16169311. Unknown parameter
|month=ignored (help) - ↑ Garvey JL, MacLeod BA, Sopko G, Hand MM (2006). "Pre-hospital 12-lead electrocardiography programs: a call for implementation by emergency medical services systems providing advanced life support--National Heart Attack Alert Program (NHAAP) Coordinating Committee; National Heart, Lung, and Blood Institute (NHLBI); National Institutes of Health". J. Am. Coll. Cardiol. 47 (3): 485–91. doi:10.1016/j.jacc.2005.08.072. PMID 16458125. Unknown parameter
|month=ignored (help) - ↑ Curtis JP, Portnay EL, Wang Y; et al. (2006). "The pre-hospital electrocardiogram and time to reperfusion in patients with acute myocardial infarction, 2000-2002: findings from the National Registry of Myocardial Infarction-4". J. Am. Coll. Cardiol. 47 (8): 1544–52. doi:10.1016/j.jacc.2005.10.077. PMID 16630989. Unknown parameter
|month=ignored (help) - ↑ 11.0 11.1 Nallamothu BK, Bates ER, Herrin J, Wang Y, Bradley EH, Krumholz HM (2005). "Times to treatment in transfer patients undergoing primary percutaneous coronary intervention in the United States: National Registry of Myocardial Infarction (NRMI)-3/4 analysis". Circulation. 111 (6): 761–7. doi:10.1161/01.CIR.0000155258.44268.F8. PMID 15699253. Unknown parameter
|month=ignored (help) - ↑ 12.0 12.1 Pinto DS, Kirtane AJ, Nallamothu BK; et al. (2006). "Hospital delays in reperfusion for ST-elevation myocardial infarction: implications when selecting a reperfusion strategy". Circulation. 114 (19): 2019–25. doi:10.1161/CIRCULATIONAHA.106.638353. PMID 17075010. Unknown parameter
|month=ignored (help) - ↑ Verheugt FW, Gersh BJ, Armstrong PW (2006). "Aborted myocardial infarction: a new target for reperfusion therapy". Eur. Heart J. 27 (8): 901–4. doi:10.1093/eurheartj/ehi829. PMID 16543251. Unknown parameter
|month=ignored (help) - ↑ Sinno MC, Khanal S, Al-Mallah MH, Arida M, Weaver WD (2007). "The efficacy and safety of combination glycoprotein IIbIIIa inhibitors and reduced-dose thrombolytic therapy-facilitated percutaneous coronary intervention for ST-elevation myocardial infarction: a meta-analysis of randomized clinical trials". Am. Heart J. 153 (4): 579–86. doi:10.1016/j.ahj.2006.12.024. PMID 17383297. Unknown parameter
|month=ignored (help) - ↑ Antman EM, Anbe DT, Armstrong PW; 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. Unknown parameter
|month=ignored (help) - ↑ 16.0 16.1 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) - ↑ 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)