acc/aha guidelines for the management of patients with stemi--2004 presenter: r5 李政翰 r5...
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ACC/AHA Guidelines for the Management of Patients With
STEMI--2004
Presenter: R5 李政翰 R5 李威廷
Circulation 2004;110:588-636
Management before STEMI
A. Identification of patients at risk of STEMI
Class I
1. Every 3-5 years, evaluate major risk factors
2. For ≧2 risk factors, calculate 10-year risk of CHD
3. For CHD risk equivalent (DM, CRI, or 10-year risk>20%), intensive risk intervention as CHD
Management before STEMI
B. Education for early recognition and response to STEMI
Class I
1. Patients with symptoms of ACS taken to ER by ambulance rather than by relatives
2. If NTG 1#SL does not relieve chest pain, recommend call EMS
<note> NTG--->NTG--->NTG--->EMS in 1999 guideline
Onset of STEMI
A. Out-of-hospital cardiac arrest
Class I
1. Early activation of EMS, early CPR, early defibrillation and early ACLS
2. For families of patients experiencing STEMI, they should take CPR training and familiarize AED
Prehospital Issues A. Emergency Medical Services Systems Class I EMS equipped to provide early defibrillation Public safety AEDS B. Prehospital Chest Pain Evaluation and Treatment Class I EMS give 162—325mg aspirin to suspecting ACS
Class IIa 9-1-1 dispatcher advice 162—325mg aspirin to suspecting ACS while waiting EMS ACLS provider perform 12-lead ECG ACLS provider review reperfusion checklists
Prehospital Fribrinolysis
Class IIa
under 1) physicians are in ambulance
2) well-organized EMS
(training in ECG reading, STEMI
treatment)
Prehospital destination Protocols
Class I1. STEMI/Killip IV and ≤75 y/o transfer to PCI and
CABG facilities if within 18hrs of shock2. STEMI with contraindications to thrombolysis tra
nsfer to PCI and CABG facilities (<30 mins departure)
Class IIa
1. STEMI/Killip IV and >75 y/o transfer to PCI and CABG facilities if within 18hrs of shock
2. STEMI with severe CHFtransfer to PCI and CABG facilities (<30 mins departure)
Initial Recognition and Management in the ED
A. Optimal strategiesClass I- establish protocol for STEMIB. Initial evaluationClass I Door to fibrinolysis <30 mins Door to balloon < 90 mins2. The choice of initial STEMI treatment ER physi
cian based on CV specialtist protocol
History
Class I
acquire whether the patient had prior stable, unstable angina, MI, CABG or PCI, CAD risk factors, possibility of aortic dissection, risk of bleeding and CNS disease
Physical Examination
Class I
1. Evaluate the extent, location and complications of STEMI
2. A brief NE for evidence of new or old neurologic deficits
ECG
Class I
1. ECG within 10 mins
2. Symptomatic non-diagnostic ECG serial ECG q5-10 mins follow-ups
3. Inferior STEMI, do right side ECG to rule out RV infarction
Laboratory Examinations
Class I1. Should be performed but should not delay the use of rep
erfusion therapyBiomarkers of cardiac damageClass I1. Troponins should be used for coexistent skeletal muscle i
njuryClass IIa
1. Serial biomarker can be used to evaluate the reperfusion after fibrinolysis within first 24 hrs
Class III1. Serial biomarkers should not be used to diagnose reinfar
ction within 18 hrs after STEMI
Imaging
Class I1. Portable chest x-ray, but do not delay reperfusion therap
y2. Portable chest x-ray, TTE or TEE, and contrast CT shoul
d be used to rule out aortic dissectionClass IIa
1. TTE to clarify the diagnosis of STEMI and risk stratification of patients with chest pain especially with LBBB or pacing or suspect posterior STEMI with anterior ST depression
Class III1. SPECT should not be performed under the diagnosis of
STEMI is evident on ECG
Management Oxygen Class I O2 supply when SaO2<90% Class IIa O2 supply to all patients with uncomplicated STEMI during the first 6 hrs NTG Class I 1. NTG (0.4mg) sublingual per 5 mins for total 3 doses, after which give IV form2. IV NTG ongoing chest pain, control HTN or pulmonary edema
Class III1. SBP<90mmHg or ≥30mmHg below baseline, HR
<50/min or >100/min or suspected RV infarction2. Take phosphodiesterase inhibitor within the last 24 hrs
(48hrs for tadalafil)
Management
Analgesia
Class I morphine (2-4mg with increments of 2-8mg per 5-15 mins) for chest pain
Aspirin
Class I 162-325mg be chewed for who have not taken it before STEMI
Management
B-blockers
Class I promptly given without contraindication irrespective of fibrinolysis or primary PCI
Class IIa IV form promptly to STEMI patients without contraindication, especially tachyarrhythmia or HTN
Reperfusion
Selection of reperfusion strategy Time from onset of symptoms1. Fibrinolytic therapy administered within the first 2
hours (especially the first hour) can occasionally abort MI and dramatically reduce mortality
2. Several reports claim no influence of time delay on mortality rates when PCI is performed after 2 to 3 hours of symptom duration
3. a target of medical contact–to-balloon or door-to-balloon time within 90 minutes
Reperfusion
Risk of STEMI mortality with fibrinolysis is extremely high, a
s cardiogenic shock, favors a PCI strategy
Risk of bleeding the higher the patient’s risk of bleeding with f
ibrinolytic therapy, the more strongly the decision should favor PCI
Reperfusion
Time required for transport to skilled PCI If time delay for PCI > 60mins than immediat
e fibrinolysis, no extra benefit of primary
Determine whether fibrinolysis or primary PCI is preferred
If onset < 3hrs, there is no preferrence. Prefer fibrinolysis if1. Early onset (<3 hrs) and delay to primary P
CI2. Primary PCI is unavailable, vascular acces
s difficulties, lack of skilled PCI lab.3. Delay to primary PCI prolonged transpor
t, TPCI-Tfibrinolysis>1 hr, door-to-balloon > 90mins
Skilled lab operator: >75 primary PCI per year; team experience>36 PCI per year
Determine whether fibrinolysis or primary PCI is preferred
Primary PCI is preferred if1. Skilled PCI Lab available with surgical bac
k-up2. High risk Killip ≥33. Contraindications to fibrinolysis, include inc
reased risk of bleeding and ICH4. Late presentation > 3hrs5. Diagnosis of STEMI is in doubt
Lancet 2003;361:13-20
Lancet 2003;361:13-20
Absolute contraindications of fibrinolysis
Any prior ICH Known structural cerebral vascular lesion Known malignant intracranial neoplasm (primary or metastatic) Ischemic stroke within 3 months EXCEPT acute ischemic stroke within 3 hours Suspected aortic dissection Active bleeding or bleeding diathesis (excluding menses) Significant closed head or facial trauma within 3 months
Relative contraindications of fibrinolysis
History of chronic severe, poorly controlled hypertension Severe uncontrolled hypertension on presentation (> 180/110mmHg) History of prior ischemic stroke greater than 3 months, dementia,
or known intracranial pathology not covered in contraindications Traumatic or prolonged (greater than 10 minutes) CPR or major surger
y (less than 3 weeks) Recent (within 2 to 4 weeks) internal bleeding Noncompressible vascular punctures For streptokinase/anistreplase: prior exposure (more than 5 days ago)
or prior allergic reaction to these agents Pregnancy Active peptic ulcer Current use of anticoagulants: the higher the INR, the higher the risk of
bleeding
Indications for fibrinolysis
Class I1. Onset< 12hrs, ST elevation> 0.1mv in at least 2 contiguo
us precordial leads or at least 2 adjacent limb leads or new LBBB and no contraindications.
Class IIa
1. Onset< 12hrs, no contraindications with posterior MI ECG change
2. Onset 12-24 hrs, ongoing chest pain with ST elevation> 0.1mv in at least 2 contiguous precordial leads or at least 2 adjacent limb leads and no contraindications
Class III1. Asymptomatic patients with onset >24hrs2. ST depression except posterior MI
Complications of fibrinolysis
Class I1. Conscious change during or after reperfusi
on, particularly within 24 hrs after therapy stop antiplatelete, fribrinolysis and anticoagulant until brain imaging
2. Consult neurologiest or neurosurgeon when suspecting ICH
3. If ICH (+), give cryo, FFP, protamine and platelets
Complications of fibrinolysis
Class IIa
In patients with ICH optimize BP and sugar, reduce IICP with mannitol, hyperventilation and consider neurosurgical evacuation.
Combination therapy with Gp IIb/IIIa inhibitor
Class IIb
1. If patients with anterior MI, <75yrs and no risk of bleeding, half dose of reteplase or tenecteplase with abciximab may prevent reinfarction; however, no survival benefit at either 30 days or 1 year
2. If patients with anterior MI, <75yrs and no risk of bleeding, half dose of reteplase or tenecteplase with abciximab were given for early referral for primary PCI
Class III
combination therapy is given to age >75ys
PCI
Coronary angiographyClass I1. Candidates for primary PCI or rescue PCI2. Cardiogenic shock who are candidates for revasculizatio
n3. Candidates for surgical repair of VSD or severe MR relat
ed AMI4. Persistent hemodynamic or electrical instabilityClass IIIExtensive comorbidities in which risk outweighbenefit
Primary PCI
Class I1. General considerations: primary PCI
should be performed in patients with STEMI within 12 hours, (balloon inflation within 90 minutes of presentation) by persons skilled in the procedure
Primary PCI Class I2. Specific considerations:
a. door-to-balloon time of within 90 minutes.
b. If symptom within 3 hours and the expected door-to-balloon time minus the expected door-to-needle time is: i) within 1 hour, primary PCI is generally preferred.
ii) greater than 1 hour, favor fibrinolytic therapy (fibrin-specific agents) c. If symptom duration is greater than 3 hours, primary PCI is generally prefe
rred.
d. Primary PCI for patients < 75 yrs who develop shock within 36 hours of MI and are suitable for revascularization that can be performed within 18 hours of shock.
e. Patients with at least Killip III and onset of symptoms within 12 hours.
Primary PCI
Class IIa 1. Primary PCI for selected patients >75 yrs who develop shoc
k within 36 hours of MI and revascularization that can be performed within 18 hours of shock. Patients with good prior functional status who are suitable for revascularization.
2. It is reasonable to perform primary PCI for patients with onset of symptoms within the prior 12 to 24 hours and 1 or more of the following:
a. Severe CHF
b. Hemodynamic or electrical instability c. Persistent ischemic symptoms.
“SHOCK” trial absolute 9% reduction in mortality with primary PCI
Primary PCI Class IIb The benefit of primary PCI eligible for fibrinolysis is not well est
ablished when performed by an operator who performs fewer than 75 PCI procedures per year.
Class III
PCI should not be performed in a noninfarct artery at the time of primary PCI in patients without hemodynamic compromise.
Primary PCI should not be performed in asymptomatic patients more than 12 hours after onset of STEMI if they are hemodynamically and electrically stable.
The goal of the interventional cardiologists
1. Door-to-balloon times less than 90 minutes
2. TIMI 2/3 flow rates obtained in more than 90% of patients
3. Emergency CABG rate less than 2%
4. Actual performance of PCI in a high percentage of patients (85%) brought to the laboratory
5. Risk-adjusted in-hospital mortality rate less than 7% in patients without cardiogenic shock
Primary PCI in fibrinolyitc-ineligible patients
Class I: onset s/s < 12 hours Class IIa: onset s/s 12--24 hours and
CHF
Hemodynamic instability
Persistent ischemic s/s
Primary PCI without CVS back-up
Class IIb: STEMI / new LBBB
rapid transport to OR
door-to-balloon time < 90 minutes
operator > 75 PCIs per year
hospital > 36 primary PCIs per year
(direct transport the patient to the CPI centers)
Class III: others
Facilitated PCI
Class IIb: PCI is not available in the first time
receiving initial pharmacological Tx
bleeding risk is low
(facilitated PCI: planned immediate PCI after an initial pharmacological regimen)
(increase bleeding in >75y/o, and added cost)
Rescue PCI
Class I: < 75 y/o develop shock within MI 36 hours revascularization within 18 hours of shock
Class I: Killip III s/s onset <12 hours
(Rescue PCI: PCI within 12 hours after failed fibrinolysis for patients with continuing or recurrent myocardial ischemia)
Rescue PCI
Class IIa: > 75 y/o
develop shock within MI 36 hours
revascularization within 18 hours of shock
hemodynamic or electrical instability
persistent ischemic s/s
PCI for cardiogenic shock
Class I: < 75 y/o
develop shock within MI 36 hours
revascularization within 18 hours of shock
(level of evidence: A)
Class IIa: > 75 y/o
develop shock within MI 36 hours
revascularization within 18 hours of shock
PCI after fibrinolysis
Class I: recurrent MI post –AMI angina cardiogenic shock, unstable hemodynamics Class IIa: CHF LVEF <40% serious ventricular arrhythmias Calss IIb: routine PCI after fibrinolysis
(no benefit of routine PCI immediate after fibrinolytic therapy)(not salvage myocardium, not improve LV, not prevent
re-infarction, not prevent death)(increase adverse events)
Acute surgical intervention (CABG)
Class I: failed PCI with persistent pain or unstable hemodynamics
persistent or recurrent or refractory ischemia and contra-
incandicated for PCI or fibrinolytic therapy
surgical repair of post-MI ventricular septal rupture or
mitral insufficiency
life-threatening ventricular arrhythmia and L’t main / 3-V-D
<75 y/o, Lt’ main or multi-vessels, shock <36h MI, and
surgery < 18h shock onset (level of evidence: A)
Acute surgical intervention (CABG)
Class IIa: >75 y/o, Lt’ main or multi-vessels, shock
<36h post-MI, and surgery < 18h
shock-onset
<6—12 hour onset, not candidate for PCI
or fibrinolysis
(especially L’t main or multi-vessels)
Class III: persistent angina but hemodynamic stable
or successful epicardial reperfusion but
unsuccessful microvascular reperfusion
Assessment of reperfusion
Class IIa:
monitor rhythm ST elevation, rhythm, and s/s over 60—180 minutes after initial fibrinolytic therapy
relief s/s, stable hemodynamics, reduction of at least 50% of the initial ST elevation means successful noninvasive evaluation of reperfusion
Heparin
Class I: perform PCI or CABG combine thrombolytic therapy (streptokinase: IIb) combine thrombolytic therapy at high risk for systemic emboli (large or anterior MI, Af, previous embolus, known LV embolus) (streptokinase: IIa)
60U/kg bolus (<= 4000U), then 12U/kg/hour (<= 1000U)
keep APTT: 1.5—2.0X (50—70s), and follow PLT count qd Class IIb: for DVT prophylaxis (7500—12500U bid)
Low-Molecular-Weight Heparin (LMWH)
Class IIb: <75y/o, receiving fibrinolytic therapy
(especially )
Cr < 2.5 in male and <2.0 in female (Enoxaparin 30mg bolus, then 1.0mg/kg q12h s.c. till discharge)
prophylaxis for DVT Class III: >75y/o, receiving fibrinolytic therapy
<75y/o, but with poor renal function
Direct anti-thrombins (bivalirudin)
Heparin-induced thrombocytopenia Combine Streptokinase Class IIa: 0.25mg/kg bolus
then 0.5mg/kg for 12 hours
then 0.25mg/kg for 36 hours
(reduction of the infusion rate in the first 12 hours if APTT >75s)
Aspirin
Class I: 162—325mg bolus,
75—162mg maintain dose
(level of evidence: A)
Thienpyridines (Plavix)
Class I: 1-month for bare stent
3-month for Sirolimus (Cypher)
6-month for Taclitaxel (Taxus)
stop 5—7 days before CABG
Class IIa: aspirin intolerance
Glycoprotein IIb/IIIa inhibitors
Class IIa: abciximab in primary PCI
(level of evidence: B)
Class IIb: tirofiban (Aggrastat) in promary PCI
cetifibatide in primary PCI
(level of evidence: C)
Beta-blocker
Class I: within 24 hours without adverse effects
start in early convalescent phase if
no use in the first 24 hours
(level of evidence: A)
re-evaluate in the patients with contra-
indicated in the first 24 hours
(level of evidence: C)
Nitroglycerin
Class I: <48 hours on persistent ischemia, CHF,
or hypertension
>48 hour on recurrent angina, CHF Class IIb: >24—48 hours without s/s
Class III: hypotension, severe bradycardia,
tachycardia, or RV infarction
ACEI & ARB
Class I: < 24 hours
anterior infarction, pulmonary congestion,
LVEF<0.4 without hypotension
Long-term use if no significant renal diseases
(Cr<2.5 in men and Cr<2.0 in women)
(level of evidence: A)
ARB for ACEI intolerance (Diovan, Blopress) (SBP <100mmHg or >30mmHg below baseline)
ACEI & ARB
Class IIa: no LVEF<0.4, no anterior infarction,
no pulmonary congestion
(Valsartan, Candesartan)
Class III: intravensou ACEI in the first 24 hours
Metabolic modulation of the glucose-insulin axis
Class I: insulin infusion in complicated course
Class IIa: uncomplicated, only hyperglycemia
control sugar after acute phase
Magnesium
Class IIa: correct hypomagnesemia (esp in diuretics)
torsade de pointes-type VT with long-QT
with trying 1-2g, bolus over 5 minutes
Class III: give Mg without the above condition
Calcium channel blocker
Class IIa: Verapamil / Dildiazed in beta-blocker
ineffective or contraindication
no CHF, no low LVEF, no AV block
Class III: Verapamil / Dildiazed in LV dysfunction
Nifedipine (immediate-release form) is
contraindicated
Hospital management
EKG, pulse oximeter, hemodynamic monitor Aspirin,, beta-blocker, or nitroglycerin Oxygenation for at least 6 hours to keep SpO2 >90
% Monitor to detect ST deviation, axis shift, conductio
n defect, and dysrhythmias Admission to step-down unit when low risk STEMI s
/p successful PCI Transfer to step-down unit after 12—24 hour stabilit
y at CCU course
Hospital management
IIa: beside activity after 12-24 hours on hymodynamic instability patients
III: beside activity after 12-24 hours on symptoms/ signs free patients
Analgesia / anxiolytics: IIa
Estimate for infarction size
EKG: at 24 hours and at discharge
CK / CKMB Radionucleotide image Echocardiography MRI
Hemodynamic Disturbances
1. Hemodynamic AssessmentClass I PA catheter monitoring for A. progressive hypotension, when unreponsive t
o fluid or contraindication of fluid supply B. Suspected mechanical complications ( VSR, p
apillary muscle rupture, or free wall rupture with pericardial tamponade) if unavailable echocardiogram
Hemodynamic Disturbances
Class I
A-line monitoring Hypotension (SBP<80mmHg) Receiving vasopressor/inotropic agents Cardiogenic shock
Hemodynamic Disturbances
Class IIa
1. PA catheter monitoring: A. hypotension without pul. Congestion and unresponsive to initial
fluid B. Cardiogenic shock C. Severe CHF or pul. Edema that do not respond rapidly to therapy D. Persistent signs of hypoperfusion without hypotension or pul congestion E. receiving vasopressor/inotropic agents
2. A-line monitoring receiving IV nitroprusside or other potent vasodilator
Hemodynamic Disturbances
Class IIb
A-line monitoring might be considered in patients receiving
intravenous inotropic agents
Class III1. PA catheter not recommended without evidence of hemo
dynamic instability or respiratory compromise
2. A-line not recommended without pulmonary congestion and have adequate tissue perfusion without use of circulatory support measures
Hypotension
Class I1. Rapid volume loading administered without clinical evidence for
volume overload.
2. Correct rhythm disturbances or conduction abnormalities
3. IABP performed not respond to other interventions
4. Vasopressor support for hypotension that does not resolve after volume loading.
5. Echocardiography evaluate mechanical complications unless these are assessed by invasive measures.
Low-Output State
Class I1. Echocardiography for LV function and mechanical complication if these hav
e not been evaluated by invasive measures
2. Recommended treatments for low-output states include:
A. Inotropic support
B. Intra-aortic counterpulsation
C. Mechanical reperfusion with PCI or CABG
D. Surgical correction of mechanical complications
Class III1. BB or CCB should not be administered to patients in a low-output state due to pu
mp failure.
Pulmonary Congestion
Class I1. O2 for SaO2>90% with pulmonary congestion
2. Morphine for pulmonary congestion
3. ACE inhibitors, beginning with titration of a short-acting ACE inhibitor with a low initial dose unless SBP< 100 mm Hg or more than 30 mm Hg below baseline. Pulmonary congestion and marginal or low blood pressure often need inotropic and vasopressor agents and/or IABP
4. Nitrates for pulmonary congestion unless the SBP< 100 mm Hg or more than 30 mm Hg below baseline.
Pulmonary Congestion
Class I5 Diuretic for pulmonary congestion if there is volume overload.
Caution is advised for patients who have not received volume expansion
6. Beta-blockade should be initiated before discharge for secondary prevention. For active heart failure, low doses should be initiated, with gradual titration on an outpatient basis.
7. Long-term aldosterone blockade for post-STEMI without significant renal dysfunction (creatinine <= 2.5 mg/dL in men and <= 2.0 in women) or hyperkalemia (K<= 5.0 mEq/L) already receiving ACE inhibitor, have an LVEF<= 0.40, and have either symptomatic heart failure or diabetes
8. Echocardiography urgently to estimate LV and RV function and exclude a mechanical complication
Pulmonary Congestion
Class IIb
IABP for refractory pulmonary congestion
Class III
BB or CCB should not be administered acutely to STEMI patients with frank cardiac failure or signs of a low-output state.
Cardiogenic Shock
Class I1. IABP for cardiogenic shock is not quickly reversed with pharma
cological therapy. The IABP is a stabilizing measure for angiography and prompt revascularization
2. A-line for cardiogenic shock
3. Early revascularization, either PCI or CABG, for < 75 years old with ST elevation or LBBB who develop shock within 36 hours of MI and are suitable for revascularization that can be performed within 18 hours of shock
4. Fibrinolytic therapy for cardiogenic shock who are unsuitable for further invasive care and no contraindications to fibrinolysis
5. Echocardiography should be used to evaluate mechanical complications unless these are assessed by invasive measure
Cardiogenic Shock
Class IIa1. PA catheter monitoring for cardiogenic shock
2. Early revascularization, either PCI or CABG, is reasonable for >= 75 years who develop shock within 36 hours of MI and are suitable for revascularization that can be performed within 18 hours of shock. Patients with good prior functional status who agree to invasive care may be selected for such an invasive strategy
RV Infarction Class I1. Inferior STEMI and hemodynamic compromise shoul
d be assessed with a right precordial V4R lead and an echocardiogram2. The following principles for STEMI and RV infar
ction and ischemic dysfunction:
Early reperfusion Achieve AV synchrony and correct bradycardia
Optimize RV preload Optimize RV afterload
Inotropic support for hemodynamic instability not responsive to fluid
Class IIaReasonable to delay CABG surgery for 4 weeks
Mechanical Causes of CHF/Low-output Syndrome
the presence of a new cardiac murmur
indicates the possibility of either a VSR or MR
Mitral regurgitationClass I1. Acute papillary muscle rupture should be considered
for urgent cardiac surgical repair2. CABG surgery should be undertaken at the same
time as mitral valve surgery
Mechanical Causes of CHF/Low-output Syndrome
Ventricular septal rupture after STEMI
Class I
1. Urgent surgical repair
2. CABG at the same time
Mechanical Causes of CHF/Low-output Syndrome
LV free wall rupture
Class I
1. Urgent surgical repair
2. CABG at the same time
Mechanical Causes of CHF/Low-output Syndrome
LV aneurysm
Class IIa
If associated with intractable VT/Vf and/or
pump failure which unresponsive to medical
and catheter-based therapy, consider
aneurectomy and CABG
Mechanical Causes of CHF/Low-output Syndrome
IABP Class I1. Hypotension (SBP< 90 mm Hg or 30 mm Hg below ba
seline) who do not respond to other interventions
2. Low-output state
3. Cardiogenic shock is not quickly reversed with pharmacological therapy. IABP is a stabilizing measure for angiography and prompt revascularization
4. Recurrent angina and signs of hemodynamic instability, poor LV function, or a large area of myocardium at risk
IABP
Class IIa
Refractory polymorphic VT Class IIb
Refractory pulmonary congestion
Arrhythmias after STEMI VfClass I
VF or pulseless VT unsynchronized electric shock with an initial monophasic shock energy of 200 J 200 to 300 J 360 J
Class IIa amiodarone (300 mg or 5 mg/kg, IV bolus) followed by a repeat unsynch
ronized electric shock. For refractory eletrical shock
Keep potassium >4.0 mEq/L and magnesium > 2.0 mg/dL)
Class IIb
boluses of intravenous procainamide for refractory eletrical shock
Class III Prophylactic administration of antiarrhythmic therapy
VT Class I
1 Sustained polymorphic VT or hemodynamic collapse unsynchronized shock with 200 J 200 to 300 J 360 J.
2. Sustained monomorphic VT associated with angina, pulmonary edema, or hypotension (blood pressure less than 90 mm Hg) synchronized electric shock of 100 J
3. Sustained monomorphic VT not associated with angina, pulmonary edema, or hypotension :
a. Amiodarone: 150 mg infused over 10 minutes (alternative dose 5 mg/kg); repeat 150 mg every 10 to 15 minutes as needed. Alternative infusion: 360 mg over 6 hours (1 mg/min), then 540 mg over the next 18 hours (0.5 mg/min). The total cumulative dose, including additional doses given during cardiac arrest, must not exceed 2.2 g over 24 hours
b. Synchronized electrical cardioversion 50 J
Class IIa 1. It is reasonable to manage refractory polymorphic VT by:
a. Reduce myocardial ischemia and adrenergic stimulation, including therapies such as beta-adrenoceptor blockade, IABP use, and consideration of emergency PCI/CABG surgery
b. potassium to greater than 4.0 mEq/L and of magnesium to greater than 2.0 mg/dL.
c. bradycardia to HR< 60/min or long QTc, temporary pacing at a higher rate may be instituted
VT Class IIb
1. sustained monomorphic VT not associated with angina, pulmonary edema, or hypotension (blood pressure less than 90 mm Hg) with a procainamide bolus and infusion.
Class III
1. routine prophylactic antiarrhythmic drugs for VPCs, couplets, runs of AIVR, or nonsustained VT
2. routine prophylactic antiarrhythmic therapy when fibrinolytic agents are administered
VPCs
Class III Treatment of isolated ventricular prematur
e beats, couplets, and nonsustained VT is not recommended unless they lead to hemodynamic compromise
AIVR and accelerated junctional rhythm
Class IIIAntiarrhythmic therapy is not indicated for AIVR and accelerated junctional rhythm
ICD for post-STEMI Class I
1. VF or hemodynamically significant sustained VT more than 2 days after STEMI, provided the arrhythmia is not judged to be due to transient or reversible ischemia or reinfarction
2. patients without spontaneous VF or sustained VT more than 48 hours after STEMI whose STEMI occurred at least 1 month previously, who have an LVEF between 0.31 and 0.40, demonstrate additional evidence of electrical instability (eg, nonsustained VT), and have inducible VF or sustained VT on electrophysiological testing
Class IIa
1. If there is reduced LVEF (0.30 or less), at least 1 month after STEMI and 3 months after
coronary artery revascularization, it is reasonable to implant an ICD in post STEMI patients without spontaneous VF or sustained VT more than 48 hours after STEMI.
ICD for post-STEMI
Class IIb
1. not well established in STEMI patients without spontaneous VF or sustained VT more than 48 hours after STEMI who have a reduced LVEF (0.31 to 0.40) at least 1 month after STEMI but who have no additional evidence of electrical instability (eg, nonsustained VT).
2. not well established in STEMI patients without spontaneous VF or sustained VT more than 48 hours after STEMI who have a reduced LVEF (0.31 to 0.40) at least 1 month after STEMI and additional evidence of electrical instability (eg, nonsustained VT) but who do not have inducible VF or sustained VT on electrophysiological testing
Class III
1. not indicated in STEMI patients who do not experience spontaneous VF or sustained VT more than 48 hours after STEMI and in whom the LVEF is greater than 0.40 at least 1 month after STEMI
Supraventricular arrhythmias/Af
Class ISustained Af/AF with hemodynamic compromise or ongoing ischemia:
a. Synchronized cardioversion with an initial monophasic shock of 200 J for
atrial fibrillation and 50 J for flutter
b. Af that do not respond to electrical cardioversion or recur after a brief period of sinus rhythm
i. Intravenous amiodarone.
ii. Intravenous digoxin for rate control principally for patients with severe LV dysfunction and heart failure.
Supraventricular arrhythmias/Af
Class ISustained Af/AF with ongoing ischemia but without hemodynamic co
mpromise
a. Beta-adrenergic blockade is preferred, unless contraindicated.
b. Intravenous diltiazem or verapamil.
c. Synchronized cardioversion with an initial monophasic shock of 200 J for atrial fibrillation and 50 J for flutter
3. For sustained Af/AF without hemodynamic compromise or ischemia, rate control is indicated. anticoagulant therapy. Consideration of cardioversion to sinus rhythm with a history of Af or AF prior to STEMI
Supraventricular arrhythmias/Af
Class IReentrant paroxysmal supraventricular tachycardia should be treated with the following in the sequence shown:
a. Carotid sinus massage. b. Intravenous adenosine (6 mg 12 mg 12mg c. Intravenous metoprolol (2.5 to 5.0 mg every 2 to 5 minutes to a total of 15 mg over 10 to 15 minutes) or atenolol (2.5 to 5.0 mg over 2 minutes to a total of 10 mg in 10 to 15 minutes). d. Intravenous diltiazem (20 mg [0.25 mg/kg]) over 2 minutes followed by an infusion of 10 mg/h) e. Intravenous digoxin( a delay of at least 1 hour before effects appear) (8 to 15 mcg/kg [0.6 to 1.0 mg in a person weighing 70 kg])
Class III Treatment of APCs is not indicated
Bradyarrhythmia
Ventricular asystole
Class I
Prompt resuscitative measures, including
chest compressions, atropine, vasopressin,
epinephrine, and temporary pacing
The requirement for temporary pacing in STEMI does not by itself constitute an indication
for permanent pacing
Use of permanent pacemaker
Class I persistent 2nd AV block in the His-Purkinje syste
m with bilateral BBB or 3rd AV block within or below the His-Purkinje system after STEMI.
transient advanced 2nd or 3rd infranodal AV block and associated BBB. If the site of block is uncertain, an EPS may be necessary.
persistent and symptomatic 2nd or 3rd AV block
Use of permanent pacemaker Class IIb
persistent 2nd or 3rd AV block at the AV node level.
Class III
not recommended for transient AV block in the absence of IVCD
not recommended for transient AV block in the presence of isolated LAFB
is not recommended for acquired LAFB in the absence of AV block
not recommended for persistent 1st AV block in the presence of BBB that is old or of indeterminate age.
Sinus node dysfunction after STEMI
Class ISymptomatic sinus bradycardia, sinus pauses greater than 3 seconds, or sinus bradycardia with a heart rate less than 40 bpm and associated hypotension or signs of systemic hemodynamic compromise atropine 0.6 to 1.0 mg. If bradycardia is persistent and maximal (2 mg) doses of atropine have been used, transcutaneous or transvenous (preferably atrial) temporary pacing should be instituted
Pacing mode selection in STEMI
Class I indication for permanent pacing after STEMI shoul
d be evaluated for ICD indications.
Class IIa
implant a permanent dual-chamber pacing system in STEMI patients who need permanent pacing and are in sinus rhythm. patients in permanent atrial fibrillation or flutter receive a single-chamber ventricular device.
evaluate all patients who have an indication for permanent pacing after STEMI for CRT
Recurrent chest pain after STEMI Pericarditis
Class I Aspirin as high as 650 mg orally (enteric) every 4 to 6 hours may
be needed.
Anticoagulation should be immediately discontinued if pericardial effusion develops or increases.
Class IIa
not adequately controlled with aspirin, administer 1 or more of the following: a. Colchicine 0.6 mg q12h. b. Acetaminophen 500 mg q6h
Class IIb
NSAIDs should not be used for extended periods because of their continuous effect on platelet function, an increased risk of myocardial scar thinning, and infarct expansion.
Corticosteroids a last resort refractory to aspirin or nonsteroidal drugs. associated with an increased risk of scar thinning and myocardial rupture
Class III
Ibuprofen should not be used for pain relief
Recurrent ischemia/infarction Class I
nitrates and beta-blockers . anticoagulation if not already accomplished.
signs of hemodynamic instability, poor LV function, or a large area of myocardium at risk urgently for revascularization as needed. Insertion of an IABP should also be considered.
candidates for revascularization should undergo PCI or CABG as dictated by coronary anatomy.
Class IIa
readminister fibrinolytic therapy with recurrent ST elevation not considered candidates for revascularization or for whom coronary angiography and PCI cannot be rapidly (ideally within 60 minutes from the onset of recurrent discomfort) implemented.
Class III
Streptokinase should not be given who received a non–fibrin-specific fibrinolytic agent more than 5 days previously
Tea time
Other complications – ischemic stroke
Class I: consult neurologist
cardiac echo, neuroimaging, vascular image
Warfarin (APTT-INR= 2-3x ) in Af patients
Warfarin (APTT-INR= 2-3x ) in suspect
embolism patients (LV mural thrombus
or akinetic segment: 3 months; persistent
Af: indefinitely)
Other complications – ischemic stroke
Class IIa: supportive care in non-fatal acute ischemic
stroke to minimize complications
Class IIb: carotid angioplasty / stenting
STEMI with high surgical risk
Acute stroke due to carotid a. > 50% stenosis
perform 4—6 weeks after stroke
Other complications – DVT and pulmonary embolism
Class IIa: full-dose LMWH >= 5 days,
low dose heparin prophylaxis (prefer
LMWH): in prolonged hospitalization,
unable to ambulate, high risk groups)
Warfarin (PT-INR= 2-3x)
CABG after STEMI: timing
Class IIa: increased in the first 3-7 days
benefit vs. risk
CABG after STEMI: arterial grafting
Class I: internal mammary artery graft in
significant LAD lesions
CABG after STEMI: recurrent ischemia
Class I: urgent CABG when the anatomy is
unsuitable for PCI
CABG after STEMI: elective
Class I: significant L’t main with stable angina
equivalent L’t main, significant LAD-P,
significant LCX-P with stable angina
3-V-D with stable angina (esp. LVEF<50%)
1- or 2-V-D with high risk group or large
viable tissue under perfusion image
2-V-D, significant LAD-P, LVEF <50%,
with stable angina
CABG after STEMI: antiplatelet agents
Class I: aspirin should not be withheld before op
aspirin use as soon as possible after op
(75—325mg qd)
Plavix should be withheld 5—7 days
before op
Exercise testing
Class I: refuse cath, high risk group
echocardiography or myocardial perfusion
image for the baseline abnormalities that
compromise EKG interpretation
Class IIb: evaluate coronary function after cath Class III: within MI 2-3 days without successful
reperfusion
post-MI angina, decompensated CHF, life-
threatening arrhythmia, exercise limiting
patient agree cath
Echocardiography
Class I: evaluate LV in patients refusing cath
(especially unstable hemodynamic)
inferior wall MI and suspect RV invlove
post-MI complications (MR, cardiogenic
shock, VSR, intracardiac thrombus,
pericardioal effusion)
stress cardioechography
Echocardiography
Class IIa: re-evaluate LVEF during recovery
Dobutamine echocardiography (or perfusion)
for 4 or more days after AMI to define
revascularzation efficacy
assess LVEF after revascularzation without
contrast echocardiography Class III: re-evaluate LV in patients without clinical
revascularzation (30—90 days is better)
Myocardial perfusion image
Class I: induce ischemia in patients refusing cath
and unable to exercise (persantin or
adenosine) Class IIa: for 4 or more days after AMI to define
revascularzation efficacy
Invasive evaluation
Class I: post-MI angina
intermediate or high-risk in non-invasive
testing
stable condition before definite therapy of
mechanical complications
persistent unstable hemodynamics
transient heart failure with recovered LV
Invasive evaluation
Class IIa: not thrombotic AMI,
routine in DM, LVEF<40%, CHF, prior
revascularization, life-threatening
ventricular arrhythmia Class IIb: routine Class III: not candidate in PCI
Assessment of ventricular arrhythmia
Class IIb: EKG monitor, Holter, heart-rate
variability, T-wave variability
Secondary prevention: education
Class I: lifestyle
NTG
119 if angina progression or no improve 5
minutes after NTG 1# sl use
AED, CPR
Secondary prevention: lipid management
Class I: low saturated fat (<7% total calories)
cholesterol (<200mg/d)
fasted, within 24-hour admission
statin use in LDL>100 mg/dL
non-pharmacological Tx in non-HDL>130
and HDL<40 Class IIa: statin in non-HDL>130
statin in LDL<100, non-HDL>130, HDL>40
niacin or fibrate in trigleceride >500 (goal:
non-HDL<130)
Secondary prevention: weight management
Class I: body mass index: from 18.5 to 24.9 kg/m2
evaluate metabolic syndrome in
M>40 in. waist circumstance or
F>35 in. waist circumstance
physical activity + cardiac rehabilitation
Secondary prevention: smoking cessation
Class I: avoid secondhand smoke
assess for history of smoking in all patients
Secondary prevention: antipletelet agents
Class I: aspirin 75—162mg qd
Plavix 75mg qd or Ticlopidine 250mg bid
in aspirin allergy
Warfarin (INR: 2.5—3.5x) in <75y/o,
low bleeding risk, aspirin allergy Class III: ibuprofen because it blocks the
antiplatelet effects of aspirin
Secondary prevention: ACEI and ARB
Class I: all patients at discharge P’t without significant renal dysfunction or
hyperkalemia, LVEF<40%, CHF, DM
long-term use
valsartan or candesartan in ACEI intolerance
Class IIa: direct ARB use in ACEI tolerance Class IIb: ACEI + ARB in symptomatic CHF and
LVEF<40%
Secondary prevention: beta-blocker
Class I: all patients except low risk (normal LVEF,
successful reperfusion, absence of
significant ventricular arrhythmia) or
contraindication
titrate dose in moderate or severe CHF Class IIa: low risk patients without contraindication
Secondary prevention: BP control
Class I: 140/90 and 130/80 (DM, chronic kidney
disease)
lifestyle modification Class IIb: 120/80mmHg Class III: short-term dihydropyridine CCB
Secondary prevention: sugar control
Class I: HbA1C <7% Class III: thiazolidinediones (Avandia, Actos) in CHF
Fc III or IV
Secondary prevention: hormone therapy
Class III: new prescription estrogen + progestin
should not be given in postmenopausal
women for secondary prevention
women already took estrogen + progestin
should not continue hormone therapy
bed-rest in the hospital
Benefit and risk evaluation in the women more than
1-2 years initiation of hormone therapy and
wish to continue
Secondary prevention: Coumadin
Class I: For aspirin allergy
stent (+): INR= 2.0—3.0 + Plavix 75mg/d
stent (-): INR= 2.5—3.5, no Plavix
No aspirin allergy, combine anticoagulation
stent (-): INR= 2.0—3.0 + Aspirin
INR= 2.5—3.5 alone
Persistent or paroxysmal Af , INR= 2.0—3.0
LV thrombus post-MI: >= 3 months
Secondary prevention: Coumadin
Class IIa: No aspirin allergy, no anticoagulation indication
<75 y/o: INR= 2.0—3.0 + Aspirin
INR= 2.5—3.5 alone LV dysfunction and extensive regional wall-
motion abnormalities Class IIb: severe LV dysfunction, with or without CHF
Secondary prevention: physical activity
Class I: exercise >=30 minutes, 3-4 times / week
cardiac rehabilitation
Secondary prevention: antioxidant
Class III: vitamin C or E
Long term management
Psychosocial impact: Class I: depression, anxiety, sleep disorder po
st MI Class IIa: SSRI for depression patients post MI
Cardiac rehabilitation Class IIa: multiple modificable risk factors,
moderate to high-risk group