amgen fournier clinical trial-lipitor janssen mariner clinical trial- xarelto
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DOOR 2 DOOR MANAGEMENT OF
STEMI
Disclosure
Amgen FOURNIER Clinical Trial-Lipitor Janssen MARINER Clinical Trial- Xarelto
Acute Myocardial Infarction remains a leading cause of morbidity and mortality world wide.
450,000 die in the U. S. yearly
95% survival rate in the U. S. for hospitalized patients. This is related to the EMS response times and
in field treatment. Advanced treatment strategies like the D2B
initiative.
Myocardial Infarction Categories
Trans mural Ischemic necrosis
of the full thickness of the heart muscle distal to the obstruction. Endocardium Myocardium Epicardium
Myocardial Infarction Categories
Non Trans mural Ischemia usually
limited to the endocardium
Universal Definition of
Myocardial Infarction
Type 1- spontaneous MI related to ischemia from a primary plaque rupture.
Type 2- ischemia from supply/demand mismatch. Ao stenosis Anemia Vasospasm Low Cardiac Output States
Type 3- MI resulting in sudden cardiac death Type 4a- MI associated with PCI Type 4b- MI associated with stent thrombosis Type 5 – MI associated with CABG
EKGClassification of MI
STEMI
NSTEMI
TIME
STEMI
Immediate reperfusion
PCI Thrombolytic therapy
30% of the patients in the U.S. with STEMI never receive treatment!
90 minutes40%
“You can not know where you are going,until you know where you have been.”
Unknown
Antonio Egas Moniz1874-1955
Portuguese physician who developed the technique of angiography
1927 –first cerebral angiogram
Won the Nobel Prize for physiology and medicine
Werner Forssman1904-1979
German physician inserted a rubber catheter into his own antecubital vein, walked to the xray machine and guided it into his right heart.
1929 – first heart catheterization
Nobel Prize for physiology and medicine.
Mason Sones1918-1985
The most important contributor to modern invasive cardiology.
Coronary angiography is born!
1958 in the angiography lab at CCF
Dr. Sones unintentionally engaged the RCA while doing an aortic angiogram. The RCA was injected before the cath could be pulled back……
Vae Lucile Van Derwyst
RN present during the first coronary angiogram.
World’s first cath lab nurse.
She was in charge of a 40 nurse staff that traveled the world to speak and teach.
Rene Favaloro1923-2000
Pioneer in Cardiothoracic Surgery
1967- first CABG at CCF
Saphenous Vein Graft
Heart Catheterization Lab
Before the 1970’s coronary angiography was diagnostic
1977 balloon angioplasty
1986 angioplasty with stents
Treatment of MI D2B is born
Door to Balloon Initiative
Launched November 2006
ACC/AHA guidelines recommend a D2B of 90 min. (JCAHO core quality measurement)
Time starts when an EKG showing STEMI is obtained and analyzed.
Time ends when the catheter crosses the lesion and the balloon is inflated.
Evidence Based Strategies to Reduce D2B Times
ED or Prehospital EKG is obtained within 10 minutes of patient encounter (1B)
ED Physician activates the Cath Lab Single-call activation system activates
the cath lab team. Cath lab team arrives within 20-30 min. Prompt data feedback Senior Management commitment Team Approach/Community Leaders
Team Effort
All communities should create and maintain a regional system of STEMI care. (1B) Door to EKG time EKG to Lab time Lab to Device time
EMS >98% of the US
population is covered by 9-1-1 service
2011 ACTION Registry 60% of 37K STEMI
patients used EMS Older surveys
EMS activation 23-53% with substantial geographic variability
EKG
EKG
GOOD BAD
EKG
GOOD BAD
EKG
STEMI Location
One More
Primary PCI in STEMI.
WRITING COMMITTEE MEMBERS* et al. Circulation. 2013;127:e362-e425
Copyright © American Heart Association, Inc. All rights reserved.
PCI vs Fibrinolytic Therapy
Higher rates of infarct artery patency Lower rates of
Recurrent ischemia Re-infarction Emergency repeat revascularization
procedures Intracranial hemorrhage death
ED to CATH LAB
Platelet Clotting Cascade
BMS or DES
Class 1 Stent Recommendations
Placement of a DES or BMS in STEMI (1A)
BMS (1C) High bleeding risk Inability to comply
with 1 year of dual antiplatelet therapy (DAPT)
Anticipated surgery within one year
Stent Class 3:Harm
DES should not be used if the patient can not comply with one year of dual antiplatelet therapy because of increased risk of stent thrombosis. (3B)
Stent Delivery
Antiplatelet Therapy
Aspirin 162 to 325mg should be given before PCI (1B)
After PCI should be continued indefinitely (1A)
81mg maintenance does is preferred after PCI (2aB)
P2Y12 Receptor Inhibitors
A loading dose should be given as early as possible or at the time of PCI to patients with STEMI (1B)
DAPT should be given for one year for patients with STEMI who receive DES or BMS (1B)
Effient (Prasugrel) should not be given to patients with a history of prior stroke or TIA (3B)
P2Y12 Receptor Inhibitors
Problems with Plavix
PPI and Plavix
Interferes with Plavix metabolism diminishing the antiplatelet effect.
At this time it does not appear this effect has lead to worse clinical outcomes
Take Home
DO NOT STOP antiplatelet medication unless cleared by patient’s interventional cardiologist.
Monitor your patient’s compliance with DAPT
Medical Management
Beta Blockers
Oral beta blockers should be initiated in the first 24 hours in patients with STEMI who do not have any of the following: signs of HF, evidence of a low output state, increased risk for cardiogenic shock,* or other contraindications to use of oral beta blockers (PR interval >0.24 seconds, second- or third-degree heart block, active asthma, or reactive airways disease).
Beta blockers should be continued during and after hospitalization for all patients with STEMI and with no contraindications to their use.
I IIa IIb III
I IIa IIb III
*Risk factors for cardiogenic shock (the greater the number of risk factors present, the higher the risk of developing cardiogenic shock) are age >70 years, systolic BP <120 mm Hg, sinus tachycardia >110 bpm or heart rate <60 bpm, and increased time since onset of symptoms of STEMI.
Beta Blockers
Patients with initial contraindications to the use of beta blockers in the first 24 hours after STEMI should be reevaluated to determine their subsequent eligibility.
It is reasonable to administer intravenous beta blockers at the time of presentation to patients with STEMI and no contraindications to their use who are hypertensive or have ongoing ischemia.
I IIa IIb III
I IIa IIb III
Renin-Angiotensin-Aldosterone System Inhibitors
An ACE inhibitor should be administered within the first 24 hours to all patients with STEMI with anterior location, HF, or EF less than or equal to 0.40, unless contraindicated.
An ARB should be given to patients with STEMI who have indications for but are intolerant of ACE inhibitors.
I IIa IIb III
I IIa IIb III
Renin-Angiotensin-Aldosterone System Inhibitors
An aldosterone antagonist should be given to patients with STEMI and no contraindications who are already receiving an ACE inhibitor and beta blocker and who have an EF less than or equal to 0.40 and either symptomatic HF or diabetes mellitus.
ACE inhibitors are reasonable for all patients with STEMI and no contraindications to their use.
I IIa IIb III
I IIa IIb III
Lipid Management
High-intensity statin therapy should be initiated or continued in all patients with STEMI and no contraindications to its use.
It is reasonable to obtain a fasting lipid profile in patients with STEMI, preferably within 24 hours of presentation.
I IIa IIb III
I IIa IIb III
Risk Assessment
DELAYS TO TREATMENT SHORTER TREATMENT TIME
Women African Americans Elderly Medicaid-only
Medicare, when compared to privately insured patients
Patients taken directly to the hospital by EMS
Risk Management
Post Hospitalization Plan of Care
A clear, detailed, and evidence-based plan of care that promotes medication adherence, timely follow-up with the healthcare team, appropriate dietary and physical activities, and compliance with interventions for secondary prevention should be provided to patients with STEMI.
Encouragement and advice to stop smoking and to avoid secondhand smoke should be provided to patients with STEMI.
I IIa IIb III
I IIa IIb III
Post Hospitalization Plan of Care
Post hospital systems of care designed to prevent hospital readmissions should be used to facilitate the transition to effective, coordinated outpatient care for all patients with STEMI.
I IIa IIb III
Exercise-based cardiac rehabilitation/secondary prevention programs are recommended for patients with STEMI.
I IIa IIb III
Risk ManagementNew Hypertensive Guidelines
>60 yrs., treat to goal <150/90 <60 yrs., treat to goal <140/80 Diabetes or CKD, treat to goal <140/80
(23% STEMI have DM, 75% of DM deaths are from CAD)
Report from Panel Members Appointed to Eighth Joint National Committee (JNC8)
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