1 / 40

STEMI VS Non STEMI COMPARISON IN ADMITTED MANAGEMENT

STEMI VS Non STEMI COMPARISON IN ADMITTED MANAGEMENT. 2004 ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction ACC/AHA 2002 Guideline Update for the Management of Patients With Unstable Angina and Non–ST-Segment Elevation Myocardial Infarction

happy
Download Presentation

STEMI VS Non STEMI COMPARISON IN ADMITTED MANAGEMENT

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. STEMI VS Non STEMICOMPARISON IN ADMITTED MANAGEMENT 2004 ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction ACC/AHA 2002 Guideline Update for the Management of Patients With Unstable Angina and Non–ST-Segment Elevation Myocardial Infarction Management of acute coronary syndromes: an Update, Heart 2004;90;698-706 Ri徐子茜/VS柯文哲

  2. Acute coronary syndrome

  3. First step-Triage • 1.a typical clinical syndrome + • 2.electrocardiographic changes+/- • 3.Markers of myocyte injury • Unstable angina • Non ST-elevation MI • ST-elevation MI • Decide whether or not to receive acute reperfusion therapy (thrombolytic agent, PCI, emergent CABG )

  4. General measures • pain relief • Adequate arterial oxygen concentration • relief of ischemia • assisted ventilation • reperfusion of critically ischemic myocardium • hemodynamic support (IABP) • control hypertension • treat acute heart failure and mechanical complications

  5. ACC/AHA guideline • Class I:有益之適應症 • Class II:使用效果有爭議 • Class IIa:證據偏向有效 • Class IIb:無有效之證據 • Class III:該處置無效,甚至有害

  6. ST-elevation MI

  7. Managementinitial therapy • a. Oxygen • For at least 2-3 hrs after presentation • b. Nitroglycerin • Class I : ongoing ischemic discomfort → sublingual nitroglycerin (0.4 mg) every 5 minutes for a total of 3 doses →consider iv nitroglycerin a.) relief of ongoing ischemic discomfort b.) control of hypertension c.) management of pulmonary congestion • Class III :SBP<90 mmHg HR<50 or >100 suspected RV infarction phosphodiesterase inhibitor for erectile dysfunction in the past 24 hrs

  8. Managementinitial therapy • c. Analgesia • Class I: Morphine sulfate 2 to 4 mg IV repeated at 5- to 15-minute intervals • d. Aspirin • Class I :chewed, 162 mg to 325 mg • e. Beta-Blockers • Class I : Oral beta-blocker should be administered promptly to those patients without a contraindication • Class IIa: IV beta-blockers promptly to STEMI patients without contraindications ,especially if a tachyarrhythmia or hypertension is present. • f. ACE Inhibitor

  9. Managementearly therapy • Reperfusion: as soon as possible • Thrombolytic therapy • Primary PCI • Emergent CABG • Refractory ischemia • Cardiogenic shock • The coronary vasculature is not amentable to PCI or the procedures has failed • Acute mechanical complications of MI(papillary muscle rupture, VSD, ventricular free wall rupture)

  10. Thrombolytic therapy • rapid administration • the risk of intracranial hemorrage • Sudden change in neurologic status • DC anticoagulatnt & thrombolytic agent • Head CT • FFP, platelet transfusion • whether the normal flow was restored in the infarct-related area • Within 90mins,induce clot lysis in 60-90% patients, but only 30-60% normal flow in the infarct-related area

  11. Thrombolytic therapy • Most effective if given within 12hrs, not beyond 24 hrs • Not indicated if the symptoms resolved or patients with ST-depression on EKG • 1.Recombinant tissue-plasminogen activator (rt-PA) • 2.Reteplase (r-PA) • 3.Tenecteplase (TNK) • 4.Streptokinase • TNK has a lower rate of non-cerebral bleeds and a lesser need for blood transfusion.

  12. Primary PCI • With experienced team (door-to-balloon time <90mins), superior to the fibrinolytic therapy • Immediate assessment LV function • Identification of other diseased vessel • Effective when the symptoms persist

  13. PCI combined with fibrinolysis • fibrinolytic agent is administered followed by PCI. • larger scale trials are awaited. • PCI combined with Gp IIb/IIIa (abciximab) • clear benefit in reducing MI when primary PCI is combined with abciximab. • Death or MI at 30 days was 3.2% (59/1843) with abciximab versus 4.8% (88/1823) without • modern reference standard

  14. Rescue PCI • PCI procedure performed in patients without evidence of a response to thrombolysis (,50% ST segment resolution) • No insufficient data to demonstrate the improvement in mortality or further MI

  15. Non ST-elevation MI

  16. Risk profile • 1.TIMI score • Age>65 y/o • >= 3 coronary risk factor • Angiographically documented prior CAD • >2 angina episodes within 24 hrs • ST deviation on the EKG • Aspirin use within in 7 days • Elevated cardiac enzymes

  17. Management • 1.antiischemia therapy • Bed rest • O2 • Morphine Sulfate • Nitroglyceride • Beta-Blockers • 2.antiplatelet therapy

  18. Management • 3.antithrombic treatment • 4.early conservative VS early invasive strategy • 5.Coronary revascularization • PCI • CABG

  19. Antiplatelet therapy • highly significant reduction in the risk of MI/ stroke/vascular death • ASA • Thienopyridine (ADP antagonist) • GP IIb/IIIa antagonist

  20. Antiplatelet therapy • Class I • 1.ASA should be administered as soon as possible after presentation and continued indefinitely. • 2.Clopidogrel should be administered to hospitalized patients who are unable to take ASA • * 3.early noninterventional approach is planned, clopidogrel should be added to ASA as soon as possible on admission and administered for at least 1 month and for up to 9 months. • * 4.A platelet GP IIb/IIIa antagonist should be administered, in addition to ASA and heparin, to patients in whom catheterization and PCI are planned. The GP IIb/IIIa antagonist may also be administered just prior to PCI.

  21. Antiplatelet therapy • Class I • * 5.In patients for whom a PCI is planned and who are not at high risk for bleeding, clopidogrel should be started and continued for at least 1 month and for up to 9 months. • * 6.In patients taking clopidogrel in whom elective CABG is planned, the drug should be withheld for 5 to 7 days • Class IIa • * 1. Eptifibatide or tirofiban should be administered, in addition to ASA and LMWH or UFH, to patients with continuing ischemia, an elevated troponin, or with other high-risk features in whom an invasive management strategy is not planned.

  22. Antiplatelet therapy • Class IIa • * 2.A platelet GP IIb/IIIa antagonist should be administered to patients already receiving heparin, ASA, and clopidogrel in whom catheterization and PCI are planned. The GP IIb/IIIa antagonist may also be administered just prior to PCI. • Class IIb • *1. Eptifibatide or tirofiban, in addition to ASA and LMWH or UFH, to patients without continuing ischemia who have no other high-risk features and in whom PCI is not planned.

  23. Antiplatelet therapy • Class III • 1. Intravenous fibrinolytic therapy in patients without acute ST-segment elevation, a true posterior MI, or a presumed new left bundle-branch block. • *2. Abciximabadministration in patients in whom PCI is not planned.

  24. Anticoagulation treatment • Enoxaperin (LMWH) • UFH (unfractionated heparin)

  25. Anticoagulant Therapy • Class I • *1. Anticoagulation with subcutaneous LMWH or iv UFH should be added to antiplatelet therapy with ASA and/or clopidogrel.

  26. Early Conservative vs EarlyInvasive Strategies • 1.medium- and high-risk patients : • troponin T> 0.01 ng/mL or troponin I > 0.1ng/mL, the presence of ST-segment deviation, or a TIMI risk>=3 • The beneficial effects : I>C • 2.low-risk patients: • outcomes I=C • Rates of major bleeding were similar, and lengths of hospital stay were reduced in patients assigned to the invasive strategy.

  27. Class I • †1. An early invasive strategy in patients with UA/ NSTEMI without serious comorbidity and who have any of the following high-risk indicators: • *(a) Recurrent angina/ischemia at rest or with low-level activities despite intensive anti-ischemictherapy. • *(b) Elevated TnT or TnI • *(c) New or presumably new ST-segment depression • (d) Recurrent angina/ischemia with CHF symptoms, an S3 gallop, pulmonary edema, worsening rales, or new or worsening MR

  28. (e) High-risk findings on noninvasive stress testing • (f) Depressed LV systolic function (eg, EF <0.40 on noninvasive study) • (g) Hemodynamic instability • (h) Sustained ventricular tachycardia • (i) PCI within 6 months • (j) Prior CABG • 2. In the absence of any of these findings, either an early conservative or an early invasive strategy may be offered in hospitalized patients without contraindications for revascularization.

  29. Coronary revascularization • PCI • CABG • Significant left main CAD • 3 vessel disease and abnormal LV function (LVEF<50%) • 2 vessel disease with a significant proximal left ant. descending artery stenosis and abnormal LV function • DM and multivessel disease

  30. Coronary revascularization

  31. Coronary revascularization

  32. Comparison of different revascularization stragies • Lack of long term outcome • PCI • Coronary stenting • The adjuvant use of platelet inhibitors • CABG • Refinement of surgical management with right internal mammary artery grafts, radial artery grafts • less invasive methodology

  33. Take home message

  34. THANK YOU FOR YOUR ATTENEION!!

More Related