STEMI resident survival guide: Difference between revisions
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===Pre-Hospital Care=== | ===Pre-Hospital Care=== | ||
Pre-hospital care can begin in the ambulance by [[Emergency Medical Services]] (EMS) personnel and it can decrease the delay in the management of [[STEMI]] patients. EMS services are staffed by either volunteers, fire fighters, or highly trained paramedics and their services depends on their level of training. Pre-hopital care is different among countries depending on the availability of EMS and highly trained paramedics. In the United States, volunteers and fire fighters are permitted to initiate emergency care prior to the arrival of highly trained paramedics by beginning [[CPR]] and if adequately trained, can defibrillate the patient using an automatic external defibrillator. Early access to EMS is promoted by a 9-1-1 system. | |||
{{Family tree/start}} | |||
{{familytree | A01 | | |A01= <div style="float: left; text-align: left; width: 30em; padding:1em;"> '''Prehospital Care'''<br> | |||
❑ Check the [[vital signs]] <br> | |||
❑ Order [[ECG|12 lead ECG]] and transmit it to the receiving hospital<br> | |||
❑ Establish [[Intravenous therapy|Peripheral IV lines|IV access]]<br> | |||
❑ Administer [[Oxygen]]<br> | |||
❑ Administer medications (depending on the level of training) | |||
:❑ Non-enteric coated [[aspirin]] | |||
:❑ [[Nitroglycerin|Sublingual nitroglycerin]] | |||
:❑ [[Clopidogrel]] | |||
:❑ [[Unfractionated heparin]] | |||
:❑ [[Glycoprtein IIb IIIa inhibitors]] | |||
:❑ [[Fibrinolytic therapy]] (especially in rural areas) | |||
❑ Activate the STEMI team | |||
❑ [[Resuscitation]] in case of cardiac arrest | |||
:❑ [[CPR]] | |||
:❑ [[Automated defibrillator]]</div> }} | |||
{{Family tree/end}} | |||
===Initial Care=== | ===Initial Care=== |
Revision as of 23:50, 12 March 2014
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Alejandro Lemor, M.D. [2]; Rim Halaby, M.D. [3]
Overview
ST elevation myocardial infarction (STEMI) is a syndrome characterized by the presence of symptoms of myocardial ischemia associated with persistent ST elevation on electrocardiogram and elevated cardiac enzymes. The management of STEMI should be initiated without delay and the following timelines should be minimized (the 4 D's):
Door to Data
If a patient presents with chest discomfort, an electrocardiogram must be obtained immediately and no later than 5-10 minutes after arrival. In the patient with chest discomfort, an electrocardiogram should be obtained prior to obtaining insurance / payment information.
Data to Decision
If the electrocardiogram shows ST segment elevation, ST segment depression consistent with posterior MI, or a new left bundle branch block, a decision must be made within 5 to 10 minutes as to whether to administer a fibrinolytic agent or to proceed to primary angioplasty.
Decision to Drug or Device
Once a decision is made to administer a fibrinolytic agent or to proceed to primary angioplasty this should be carried out within 30 minutes.
Causes
Life Threatening Causes
STEMI is a life-threatening condition and must be treated as such irrespective of the underlying cause.
Common Causes
- Aortic dissection with propagation to the right coronary artery
- Cocaine
- Plaque rupture
- Takotsubo cardiomyopathy (also known as broken heart syndrome or stress cardiomyopathy)
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]
Abbreviations: CABG: coronary artery bypass graft; ECG: electrocardiogram; LAD: left anterior descending; LBBB: left bundle branch block; MI: myocardial infraction; PCI: percutaneous coronary intervention
Characterize the symptoms: ❑ Chest pain or chest discomfort
❑ Dyspnea | |||||||||
Obtain a detailed history: ❑ Age
❑ List of medications Identify possible triggers: | |||||||||
Examine the patient: Vital signs
Pulses
Skin Heart
❑ Murmurs
❑ Pericardial friction rub (suggestive of pericarditis) Signs of Right Ventricular MI: Lungs | |||||||||
Rule out life threatening alternative diagnoses: ❑ Aortic dissection (suggestive signs and symptoms: vomiting, subcutaneous emphysema)( | |||||||||
❑ Characterize ECG changes consistent with STEMI
❑ Confirm the diagnosis based on an increase in troponin | |||||||||
Diagnostic Approach to Right Ventricular Myocardial Infarction
Consider right ventricular MI in case of:
❑ Hypotension | |||||||
❑ Do not delay the decision and initiation of PCI vs fibrinolytic therapy
❑ Increase the right ventricle load by volume expansion with normal saline preferably with invasive monitoring
| |||||||
If hypotension is not corrected with 1-2 L normal saline, administer inotropic agents such as dopamine:
❑ Initial dose 1-5 mcg/kg/min IV | |||||||
Pre-Hospital Care
Pre-hospital care can begin in the ambulance by Emergency Medical Services (EMS) personnel and it can decrease the delay in the management of STEMI patients. EMS services are staffed by either volunteers, fire fighters, or highly trained paramedics and their services depends on their level of training. Pre-hopital care is different among countries depending on the availability of EMS and highly trained paramedics. In the United States, volunteers and fire fighters are permitted to initiate emergency care prior to the arrival of highly trained paramedics by beginning CPR and if adequately trained, can defibrillate the patient using an automatic external defibrillator. Early access to EMS is promoted by a 9-1-1 system.
Prehospital Care ❑ Check the vital signs
❑ Activate the STEMI team ❑ Resuscitation in case of cardiac arrest | |||||||||
Initial Care
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 162 - 325 mg of non enteric aspirin
❑ Administer 2-4 L/min via nasal cannula oxygen when saturation <90%
❑ Administer beta-blockers (unless contraindicated)
❑ Administer sublingual nitroglycerin 0.4 mg every 5 minutes for a total of 3 doses
❑ Administer 80 mg atorvastatin | |||||||||||||||||||||||
❑ Determine if PCI is available | |||||||||||||||||||||||
PCI is available | PCI is not available | ||||||||||||||||||||||
First medical contact to device ≥ 120 min | First medical contact to device time ≤ 120 min | ||||||||||||||||||||||
❑ Primary PCI within 90 minutes | ❑ Fibrinolytic therapy within 30 min | ❑ Transfer for primary PCI | |||||||||||||||||||||
Confirm that the patient has one of the following indications: ❑ Symptoms of ischemia <12 hours (Class I, level of evidence A) | ❑ Confirm that the patient has one of the following indications:
❑ Confirm that the patient has no contraindications for fibrinolytics | ||||||||||||||||||||||
Administer ONE of the following antiplatelet agents (before or at the time of PCI):
❑ IV GP IIb/IIIa inhibitors
Administer ONE of the following anticoagulant therapy:
| Administer ONE of the following fibrinolytic therapy ❑ Tenecteplase single IV bolus
❑ Reteplase 10 units IV boluses every 30 min
❑ Streptokinase 1.5 million units IV administered over 30-60 min Administer a P12Y2 inhibitor
Administer ONE of the following anticoagulant therapy
❑ Enoxaparin (for up to 8 days or until revascularization)
| ||||||||||||||||||||||
Consider urgent CABG if the coronary anatomy is not amenable to PCI and one of the following: ❑ Ongoing and recurrent ischemia | Transfer to a PCI-Capable hospital for non primary PCI, if there is: ❑ Cardiogenic shock (Class I, level of evidence B) | ||||||||||||||||||||||
Contraindications to Fibrinolytic Therapy
Shown below is a table summarizing the absolute and relative contraindications for fibrinolytic therapy among STEMI patients.
Absolute contraindications | Relative contraindications |
❑ Prior intracranial hemorrhage ❑ Ischemic stroke within the last 3 months (Unless within 4.5 hours) |
❑ Oral anticoagulation therapy ❑ Pregnancy |
Pre-Discharge Care
Long Term Management
Administer the following medications in patients without contraindications: ❑ Aspirin 81-325 mg (indefinitely)
❑ ACE inhibitor in case of anterior MI, ejection fraction ≤ 40% or heart failure
❑ Atorvastatin 80 mg daily Administer antiplatelet therapy For patients who underwent PCI, for one year Educate the patient about:
❑ Management of comorbidities Manage complications of STEMI
❑ Temporary pacing for asymptomatic bradycardia refractory to medical therapy (Class I, level of evidence C) | |||||||||
Do's
- Pre-hospital ECG is recommended. If STEMI is diagnosed the PCI team should be activated while the patient is en route to the hospital.
- Administer reperfusion therapy for all patients presenting with STEMI within 12 hours of the beginning of the symptoms (Class I, level of evidence A).
- Administer a loading dose followed by a maintenance dose of clopidogrel, ticagrelor or prasugrel (if PCI is planned) as initial treatment instead of aspirin among patients with gastrointestinal intolerance or hypersensitivity reaction to aspirin.
- Administer sublingual nitroglycerin in patients with ischemic chest pain; however, administer IV nitroglycerin among patients with persistent chest pain after three sublingual nitroglycerins.[4]
- Discontinue non-steroidal anti-inflamatory drugs immediately.[5][6]
- Rule out any contraindications for fibrinolytic therapy before its administration. If contraindications to fibrinolytics are present, the patient should be transferred to another hospital where PCI is available.
- Initiate therapeutic hypothermia among comatose patients with STEMI (Class I, level of evidence B).
- Perform immediate angiography and PCI among STEMI patients who underwent resuscitation for cardiac arrest (Class I, level of evidence B).
- Consider bare-metal stent among STEMI patients with any of the following (Class I, level of evidence C):
- High bleeding risk
- Lack of compliance for a one year regimen of dual antiplatelet therapy
- Surgery or invasive procedure within the next year
- Achieve the following therapeutic activated clotting time when administering UFH:
- 200 to 250 seconds with the concomitant administration of GPIIbIIIa receptor inhibitor
- 250 to 300 seconds (HemoTec device) without the concomitant administration of a GPIIbIIIa receptor inhibitor
- 300 to 350 seconds (Hemochron device) without the concomitant administration of a GPIIbIIIa receptor inhibitor
- Make sure the dose of P2Y12 receptor inhibitors is appropriate among patients undergoing PCI after fibrinolytic therapy:
- Patients who already received a loading dose of clopidogrel: No loading dose, clopidogrel daily
- Patients who did not receive a loading dose of clopidogrel and PCI is performed ≤ 24 hours after fibrinolytic therapy: loading dose of 300 mg clopidogrel
- Patients who did not receive a loading dose of clopidogrel and PCI is performed > 24 hours after fibrinolytic therapy: loading dose of 600 mg clopidogrel
- Patients who did not receive a loading dose of clopidogrel and PCI is performed >24 hours after therapy with fibrin specific agent, or >48 hours after therapy with a non-fibrin-specific agent: prasugrel 60 mg
- Prepare the patient for urgent CABG when indicated by discontinuing the following:
- Clopidogrel or ticagrelor at least 24 hours prior to CABG
- Eptifibatide or tirofiban at least 2 to 4 hours prior to CABG
- Abciximab 12 hours prior to CABG
- Consider using a mechanical circulatory support among hemodynamically unstable patients with STEMI requiring an urgent CABG (Class IIa, level of evidence C).
- Recommend a long term maintenance dose of 81 mg of aspirin when the patient is administered ticagrelor.
- Include aldosterone antagonist in the discharge medication list among patients who are already on ACE inhibitors and beta-blockers with a left ventricular ejection fraction <40% or diabetes or heart failure.[1]
Don'ts
- Do not administer IV beta-blockers among patients with elevated risk for cardiogenic shock, signs of heart failure, low ouput state, prolonged PR interval more than 0.24 seconds, second or third degree block or asthma (Class I, level of evidence B).
- Do not administer IV GP IIb/IIIa inhibitors to patients with low risk of ischemic events or at high risk of bleeding and who are already on aspirin and P2Y12 receptor inhibitors therapy.
- Do not administer nitroglycerine to patients with systolic BP < 90 mm Hg or ≥ to 30 mm Hg below baseline, severe bradycardia (< 50 bpm), tachycardia (> 100 bpm), or suspected right ventricular infarction.
- Do not delay the time for reperfusion.
- Do not administer prasugrel among patients with any of the following:
- Prior history of strokes or TIAs (Class III, Level of evidence B)
- Active pathological bleeding
- Age ≥75 years of age, (except in high-risk patients such as diabetes or prior MI, where its use may be considered)
- Urgent coronary artery bypass graft surgery (CABG) is likely
- Presence of additional risk factors for bleeding such as body weight <60 kg, propensity to bleed, concomitant use of medications that increase the risk of bleeding[7]
- Do not administer fibrinolytic therapy to patients with known cerebral arteriovenous malformation or to patients with suspected aortic dissection.
- Do not withhold aspirin among patients who are planned to undergo urgent CABG (Class I, level of evidence C).[1]
References
- ↑ 1.0 1.1 1.2 1.3 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.
- ↑ Inohara T, Kohsaka S, Fukuda K, Menon V (2013). "The challenges in the management of right ventricular infarction". Eur Heart J Acute Cardiovasc Care. 2 (3): 226–34. doi:10.1177/2048872613490122. PMC 3821821. PMID 24222834.
- ↑ Epstein AE, Dimarco JP, Ellenbogen KA, Estes NA, Freedman RA, Gettes LS; et al. (2008). "ACC/AHA/HRS 2008 guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities: executive summary". Heart Rhythm. 5 (6): 934–55. doi:10.1016/j.hrthm.2008.04.015. PMID 18534377.
- ↑ Kaplan K, Davison R, Parker M, Przybylek J, Teagarden JR, Lesch M (1983). "Intravenous nitroglycerin for the treatment of angina at rest unresponsive to standard nitrate therapy". Am J Cardiol. 51 (5): 694–8. PMID 6402912.
- ↑ Trelle S, Reichenbach S, Wandel S, Hildebrand P, Tschannen B, Villiger PM; et al. (2011). "Cardiovascular safety of non-steroidal anti-inflammatory drugs: network meta-analysis". BMJ. 342: c7086. doi:10.1136/bmj.c7086. PMC 3019238. PMID 21224324. Review in: Evid Based Med. 2011 Oct;16(5):142-3
- ↑ Coxib and traditional NSAID Trialists' (CNT) Collaboration. Bhala N, Emberson J, Merhi A, Abramson S, Arber N; et al. (2013). "Vascular and upper gastrointestinal effects of non-steroidal anti-inflammatory drugs: meta-analyses of individual participant data from randomised trials". Lancet. 382 (9894): 769–79. doi:10.1016/S0140-6736(13)60900-9. PMC 3778977. PMID 23726390. Review in: Ann Intern Med. 2013 Oct 15;159(8):JC12
- ↑ "http://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=5fe9c118-c44b-48d7-a142-9668ae3df0c6". Retrieved 6 February 2014. External link in
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