STEMI resident survival guide: Difference between revisions

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===Therapeutic Apporach===
===Therapeutic Apporach===
Shown below is an algorithm depicting the therapeutic approach to STEMI based on the 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction.<ref name="O'GaraKushner2013">{{cite journal|last1=O'Gara|first1=Patrick T.|last2=Kushner|first2=Frederick G.|last3=Ascheim|first3=Deborah D.|last4=Casey|first4=Donald E.|last5=Chung|first5=Mina K.|last6=de Lemos|first6=James A.|last7=Ettinger|first7=Steven M.|last8=Fang|first8=James C.|last9=Fesmire|first9=Francis M.|last10=Franklin|first10=Barry A.|last11=Granger|first11=Christopher B.|last12=Krumholz|first12=Harlan M.|last13=Linderbaum|first13=Jane A.|last14=Morrow|first14=David A.|last15=Newby|first15=L. Kristin|last16=Ornato|first16=Joseph P.|last17=Ou|first17=Narith|last18=Radford|first18=Martha J.|last19=Tamis-Holland|first19=Jacqueline E.|last20=Tommaso|first20=Carl L.|last21=Tracy|first21=Cynthia M.|last22=Woo|first22=Y. Joseph|last23=Zhao|first23=David X.|title=2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction|journal=Journal of the American College of Cardiology|volume=61|issue=4|year=2013|pages=e78–e140|issn=07351097|doi=10.1016/j.jacc.2012.11.019}}</ref>
Shown below is an algorithm depicting the therapeutic approach to STEMI based on the 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction.<ref name="O'GaraKushner2013">{{cite journal|last1=O'Gara|first1=Patrick T.|last2=Kushner|first2=Frederick G.|last3=Ascheim|first3=Deborah D.|last4=Casey|first4=Donald E.|last5=Chung|first5=Mina K.|last6=de Lemos|first6=James A.|last7=Ettinger|first7=Steven M.|last8=Fang|first8=James C.|last9=Fesmire|first9=Francis M.|last10=Franklin|first10=Barry A.|last11=Granger|first11=Christopher B.|last12=Krumholz|first12=Harlan M.|last13=Linderbaum|first13=Jane A.|last14=Morrow|first14=David A.|last15=Newby|first15=L. Kristin|last16=Ornato|first16=Joseph P.|last17=Ou|first17=Narith|last18=Radford|first18=Martha J.|last19=Tamis-Holland|first19=Jacqueline E.|last20=Tommaso|first20=Carl L.|last21=Tracy|first21=Cynthia M.|last22=Woo|first22=Y. Joseph|last23=Zhao|first23=David X.|title=2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction|journal=Journal of the American College of Cardiology|volume=61|issue=4|year=2013|pages=e78–e140|issn=07351097|doi=10.1016/j.jacc.2012.11.019}}</ref>
{{Family tree/start}}
{{Family tree/start}}
{{familytree  | | | | | | | A01 | | | | | | A01= '''Initial Treatment'''<br> <div style="float: left; text-align: left; width: 20em; padding:1em;"> ❑ Administer 300 mg [[aspirin]]<ref name="pmid18574276">{{cite journal| author=Harrington RA, Becker RC, Cannon CP, Gutterman D, Lincoff AM, Popma JJ et al.| title=Antithrombotic therapy for non-ST-segment elevation acute coronary syndromes: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). | journal=Chest | year= 2008 | volume= 133 | issue= 6 Suppl | pages= 670S-707S | pmid=18574276 | doi=10.1378/chest.08-0691 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18574276  }} </ref> <br>
{{familytree  | | | | | | | A01 | | | | | | A01= '''Initial Treatment'''<br> <div style="float: left; text-align: left; width: 30em; padding:1em;"> ❑ Administer 300 mg [[aspirin]]<ref name="pmid18574276">{{cite journal| author=Harrington RA, Becker RC, Cannon CP, Gutterman D, Lincoff AM, Popma JJ et al.| title=Antithrombotic therapy for non-ST-segment elevation acute coronary syndromes: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). | journal=Chest | year= 2008 | volume= 133 | issue= 6 Suppl | pages= 670S-707S | pmid=18574276 | doi=10.1378/chest.08-0691 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18574276  }} </ref> <br>
❑ Administer [[oxygen]] in patients with saturation <90%<ref name="pmid23554440">{{cite journal| author=Shuvy M, Atar D, Gabriel Steg P, Halvorsen S, Jolly S, Yusuf S et al.| title=Oxygen therapy in acute coronary syndrome: are the benefits worth the risk? | journal=Eur Heart J | year= 2013 | volume= 34 | issue= 22 | pages= 1630-5 | pmid=23554440 | doi=10.1093/eurheartj/eht110 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23554440  }} </ref><br>
❑ Administer [[oxygen]] in patients with saturation <90%<ref name="pmid23554440">{{cite journal| author=Shuvy M, Atar D, Gabriel Steg P, Halvorsen S, Jolly S, Yusuf S et al.| title=Oxygen therapy in acute coronary syndrome: are the benefits worth the risk? | journal=Eur Heart J | year= 2013 | volume= 34 | issue= 22 | pages= 1630-5 | pmid=23554440 | doi=10.1093/eurheartj/eht110 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23554440  }} </ref><br>
❑ Administer sublingual [[nitroglycerine]], (0.4-0.8 mg)<ref name="pmid10704160">{{cite journal| author=Doucet S, Malekianpour M, Théroux P, Bilodeau L, Côté G, de Guise P et al.| title=Randomized trial comparing intravenous nitroglycerin and heparin for treatment of unstable angina secondary to restenosis after coronary artery angioplasty. | journal=Circulation | year= 2000 | volume= 101 | issue= 9 | pages= 955-61 | pmid=10704160 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10704160  }} </ref> <br>
❑ Administer sublingual [[nitroglycerine]], (0.4-0.8 mg)<ref name="pmid10704160">{{cite journal| author=Doucet S, Malekianpour M, Théroux P, Bilodeau L, Côté G, de Guise P et al.| title=Randomized trial comparing intravenous nitroglycerin and heparin for treatment of unstable angina secondary to restenosis after coronary artery angioplasty. | journal=Circulation | year= 2000 | volume= 101 | issue= 9 | pages= 955-61 | pmid=10704160 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10704160  }} </ref> <br>
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:❑ [[UFH]] in case of [[renal failure]]<ref name="pmid16537663">{{cite journal| author=Fifth Organization to Assess Strategies in Acute Ischemic Syndromes Investigators. Yusuf S, Mehta SR, Chrolavicius S, Afzal R, Pogue J et al.| title=Comparison of fondaparinux and enoxaparin in acute coronary syndromes. | journal=N Engl J Med | year= 2006 | volume= 354 | issue= 14 | pages= 1464-76 | pmid=16537663 | doi=10.1056/NEJMoa055443 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16537663  }}  [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16944851 Review in: ACP J Club. 2006 Sep-Oct;145(2):30-1] </ref>  </div>}}
:❑ [[UFH]] in case of [[renal failure]]<ref name="pmid16537663">{{cite journal| author=Fifth Organization to Assess Strategies in Acute Ischemic Syndromes Investigators. Yusuf S, Mehta SR, Chrolavicius S, Afzal R, Pogue J et al.| title=Comparison of fondaparinux and enoxaparin in acute coronary syndromes. | journal=N Engl J Med | year= 2006 | volume= 354 | issue= 14 | pages= 1464-76 | pmid=16537663 | doi=10.1056/NEJMoa055443 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16537663  }}  [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16944851 Review in: ACP J Club. 2006 Sep-Oct;145(2):30-1] </ref>  </div>}}
{{familytree  | | | | | | | |!| | | | | | | }}
{{familytree  | | | | | | | |!| | | | | | | }}
{{familytree  | | | | | | | B01 | | | | | | B01= <div style="float: left; text-align: left; width: 20em; padding:1em;">'''Determine the risk of [[adverse coronary event]]:''' <br>
{{familytree  | | | | | | | B01 | | | | | | B01= <div style="float: left; text-align: left; width: 30em; padding:1em;">'''Determine the risk of [[adverse coronary event]]:''' <br>
❑[[Unstable angina resident survival guide#Thrombolysis in Myocardial Infarction (TIMI) Risk Score|TIMI Score]], or <br>
❑[[Unstable angina resident survival guide#Thrombolysis in Myocardial Infarction (TIMI) Risk Score|TIMI Score]], or <br>
❑[[Unstable angina resident survival guide#HEART Risk Score|HEART Risk Score]], or <br>
❑[[Unstable angina resident survival guide#HEART Risk Score|HEART Risk Score]], or <br>
❑[[Unstable angina resident survival guide#GRACE Risk Score|GRACE Risk Score]]</div>}}
❑[[Unstable angina resident survival guide#GRACE Risk Score|GRACE Risk Score]]</div>}}
{{familytree/end}}


==References==
==References==

Revision as of 19:28, 3 March 2014


Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Alejandro Lemor, M.D. [2]

Definition

ST elevation myocardial infarction (STEMI) is a syndrome defined by symptoms of myocardial ischemia (sudden chest pain and pressure, shortness of breath) associated with persistent ECG ST elevation and subsequent release of cardiac enzymes.

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated. STEMI is a life-threatening condition and must be treated as such irrespective of the causes.

Common Causes

Management

Diagnostic Approach

Shown below is an algorithm summarizing the diagnostic approach to STEMI based on the 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction[1]


 
 
 
 
 
Characterize the symptoms:

❑ Chest pain

❑ Sudden onset
❑ Described as a sensation of tightness, pressure, or squeezing
❑ Radiation to the jaw or left arm
❑ No relief with medications or rest
❑ Worse with time
❑ Shortness of breath (Dyspnea)

❑ Diaphoresis
❑ Light-headedness

❑ Nausea and/or vomiting
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Obtain a detailed history:

❑ Age
❑ Previous MI
❑ Previous PCI or CABG
❑ Cardiac risk factors:

❑ Hypertension
❑ Diabetes
❑ Hypercholesterolemia
❑ Smoking
❑ Obesity
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Examine the patient:

❑ Measure the blood pressure
❑ Measure the heart rate
❑ Auscultate the heart searching for murmurs
❑ Search for signs of CHF

❑ Decreased air entry in the lungs
❑ Edema in the extremities
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Rule out life threatening alternative diagnoses:

❑ Aortic dissection
❑ Pulmonary embolism
❑ Cardiac tamponade
❑ Tension pneumothorax

❑ Esophageal rupture
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Order labs and tests:
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
EKG
❑ New 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 (0.1 mV) in other contiguous chest leads or the limb leads
❑ For EKG examples click here
 
Cardiac Enzymes
❑ Troponin I (preferred biomarker)
❑ CK-MB
 
Other labs:

❑ Creatinine
❑ Glucose

❑ Hemoglobin
 
 

Therapeutic Apporach

Shown below is an algorithm depicting the therapeutic approach to STEMI based on the 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction.[1]

 
 
 
 
 
 
Initial Treatment
❑ Administer 300 mg aspirin[2]

❑ Administer oxygen in patients with saturation <90%[3]
❑ Administer sublingual nitroglycerine, (0.4-0.8 mg)[4]
❑ Administer morphine IV (initial dose 2-4 mg with increments of 2-8 mg every 5 to 15 minutes)
❑ Administer beta-blockers (unless contraindicated)[5] [6]
❑ Administer statins (atorvastatin, 80 mg)[7]
❑ Administer antithrombotic treatment

❑ Fondaparinux, or
❑ UFH in case of renal failure[8]
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Determine the risk of adverse coronary event:

❑TIMI Score, or
❑HEART Risk Score, or

❑GRACE Risk Score
 
 
 
 
 

References

  1. ↑ 1.0 1.1 O'Gara, Patrick T.; Kushner, Frederick G.; Ascheim, Deborah D.; Casey, Donald E.; Chung, Mina K.; de Lemos, James A.; Ettinger, Steven M.; Fang, James C.; Fesmire, Francis M.; Franklin, Barry A.; Granger, Christopher B.; Krumholz, Harlan M.; Linderbaum, Jane A.; Morrow, David A.; Newby, L. Kristin; Ornato, Joseph P.; Ou, Narith; Radford, Martha J.; Tamis-Holland, Jacqueline E.; Tommaso, Carl L.; Tracy, Cynthia M.; Woo, Y. Joseph; Zhao, David X. (2013). "2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction". Journal of the American College of Cardiology. 61 (4): e78–e140. doi:10.1016/j.jacc.2012.11.019. ISSN 0735-1097.
  2. ↑ Harrington RA, Becker RC, Cannon CP, Gutterman D, Lincoff AM, Popma JJ; et al. (2008). "Antithrombotic therapy for non-ST-segment elevation acute coronary syndromes: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition)". Chest. 133 (6 Suppl): 670S–707S. doi:10.1378/chest.08-0691. PMID 18574276.
  3. ↑ Shuvy M, Atar D, Gabriel Steg P, Halvorsen S, Jolly S, Yusuf S; et al. (2013). "Oxygen therapy in acute coronary syndrome: are the benefits worth the risk?". Eur Heart J. 34 (22): 1630–5. doi:10.1093/eurheartj/eht110. PMID 23554440.
  4. ↑ Doucet S, Malekianpour M, Théroux P, Bilodeau L, Côté G, de Guise P; et al. (2000). "Randomized trial comparing intravenous nitroglycerin and heparin for treatment of unstable angina secondary to restenosis after coronary artery angioplasty". Circulation. 101 (9): 955–61. PMID 10704160.
  5. ↑ Rosendorff C, Black HR, Cannon CP, Gersh BJ, Gore J, Izzo JL; et al. (2007). "Treatment of hypertension in the prevention and management of ischemic heart disease: a scientific statement from the American Heart Association Council for High Blood Pressure Research and the Councils on Clinical Cardiology and Epidemiology and Prevention". Circulation. 115 (21): 2761–88. doi:10.1161/CIRCULATIONAHA.107.183885. PMID 17502569.
  6. ↑ López-Sendón J, Swedberg K, McMurray J, Tamargo J, Maggioni AP, Dargie H; et al. (2004). "Expert consensus document on beta-adrenergic receptor blockers". Eur Heart J. 25 (15): 1341–62. doi:10.1016/j.ehj.2004.06.002. PMID 15288162.
  7. ↑ Cannon CP, Braunwald E, McCabe CH, Rader DJ, Rouleau JL, Belder R; et al. (2004). "Intensive versus moderate lipid lowering with statins after acute coronary syndromes". N Engl J Med. 350 (15): 1495–504. doi:10.1056/NEJMoa040583. PMID 15007110. Review in: ACP J Club. 2004 Sep-Oct;141(2):33
  8. ↑ Fifth Organization to Assess Strategies in Acute Ischemic Syndromes Investigators. Yusuf S, Mehta SR, Chrolavicius S, Afzal R, Pogue J; et al. (2006). "Comparison of fondaparinux and enoxaparin in acute coronary syndromes". N Engl J Med. 354 (14): 1464–76. doi:10.1056/NEJMoa055443. PMID 16537663. Review in: ACP J Club. 2006 Sep-Oct;145(2):30-1


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