STEMI-WRAP on Evidence-Based Management of STEMI: The Emergency Department Perspective

Charles V. Pollack, Jr., M.A., M.D., FACEP, FAHA

Professor and Chair, Emergency Medicine, Pennsylvania Hospital University of Pennsylvania Health System Philadelphia

STEMI



Accounts for 15-20% of cases of ACS seen in ED; UA/NSTEMI (collectively, NSTE ACS) account for majority



High-visibility diagnosis because of its high morbidity and mortality, patient and family fears and expectations, and intensity of monitoring by observers inside and outside the hospital —QI, payors, JCAHO, P4P

STEMI



Pathophys: STEMI is caused by complete obstruction of an epicardial vessel, which causes angina or anginal equivalent and diagnostic ECG changes of ST-segment elevation



Recognition of STEMI, which by GLs should occur within 10 minutes of ED arrival, launches the ED cardiology team on a fast-moving track that demands prompt stabilization, evidence-based medical management, and quick decisions regarding reperfusion therapy



Dx of STEMI is clinical + electrocardiographic and DOES NOT require assessment of cardiac markers

STEMI



STEMI typically result from fissure or frank rupture of an atherosclerotic plaque

  Stimulates local activation of: • platelets • coagulation cascade • complement Platelet aggregate forms over site of plaque injury and as it matures (fibrinogen →fibrin) causes complete obstruction of distal flow. To the extent that collateral flow downstream is lacking, ischemia quickly ensues and infarction starts to occur within minutes

STEMI



Pharmacologic therapy in STEMI is therefore directed at this triad of abnormal activity:

 Platelet activation —anti-activation and anti aggregation   • ASA and clopidogrel • GPIs Coagulation activation —anticoagulants Complement activation —anti-inflammatories . . . ? Statins  In preparation for reperfusion therapy by lysis or angiography and primary PCI

Guidelines for STEMI diagnosis and management



complex disease state with broad ranges of presentation and a multitude of therapeutic options



Many important and pertinent clinical studies



Information overload!



Need evidence-based guidelines to promote consistency of care and resulting better outcomes

Guidelines for STEMI management



ACC/AHA Joint Task Force: 1990, 1996, 1999



Last comprehensive update in 2004

   Widely read, lots of interest Clear evidence scoring, sensible recommendations, temporal sequencing • “soup to nuts” Recapitulation, interpretation, and promulgation for upstream providers in

Annals of Emergency Medicine

Guidelines for STEMI management



ACC/AHA Joint Task Force: presented “focused update” in December 2007

 “focus” (from upstream perspective) on reperfusion strategies and opportunities to minimize delays to reperfusion    Beta blockers Choices of anticoagulants New recommendations regarding clopidogrel

Class I

Benefit >>> Risk

Applying Classification of Recommendations

Class IIa Class IIb Class III

Benefit >> Risk Additional studies with focused objectives needed

Procedure/ Treatment SHOULD be performed/ administered IT IS REASONABLE to perform procedure/administer treatment

Benefit ≥ Risk Additional studies with broad objectives needed; Additional registry data would be helpful

Procedure/Treatment MAY BE CONSIDERED

Risk ≥ Benefit No additional studies needed

Procedure/Treatment should NOT be per formed/administered SINCE IT IS NOT HELPFUL AND MAY BE HARMFUL

should is recommended is indicated is useful/effective/ beneficial is reasonable can be useful/effective/ beneficial is probably recommended or indicated may/might be considered may/might be reasonable usefulness/effectiveness is unknown /unclear/uncertain or not well established is not recommended is not indicated should not is not useful/effective/ beneficial may be harmful

“The Guidelines”

Weighing the Evidence



Weight of evidence grades:

= Data from many large, randomized trials = Data from fewer, smaller randomized trials, careful analyses of nonrandomized studies, observational registries = Expert consensus

Time Delays and 30 Day Outcome in STEMI

40 30 20 3000 14,000 12,000 9000 Loss of benefit per hour of delay 1.6

±0.6 lives per 1000 patients 45,000 patients in placebo controlled lytic trials.

10 7000 0 0 6 12 18 Hours from onset of symptoms to randomization Collins. NEJM. 1997;336:847.

24

Time Delays and 30 Day Outcome in STEMI: Primary PCI (NRMI-2)

Cannon C, et al.

JAMA

2000;283:2941-2947

Time Delays and 30 Day Outcome in STEMI: Primary PCI (NRMI-2)

Cannon C, et al.

JAMA

2000;283:2941-2947

Prehospital Issues

 EMS  Emphasis on early defibrillation; AEDs; 911 dispatchers training & use of national protocols; 12-lead ECGs  Chest Pain Evaluation & Treatment  Emphasis on giving chewable ASA, unless contraindicated & prehospital ECG & checklist  Prehospital Fibrinolysis  Upgraded to a Class IIa (Level B) Recommendation • although not particularly likely in most systems  Prehospital Destination Protocols   Where to transport STEMI patients: a plan must be in place Special considerations • Cardiogenic Shock • Fibrinolytic contraindicated

Patients Transported by EMS After Calling 9-1-1

Onset of STEMI Symptoms

Goals

Patient 5’ after sx onset 9-1-1 EMS Dispatch EMS on-scene • Encourage 12-lead ECG • Consider prehospital fibrinolytic

if capable

and EMS-to-needle < 30 min Dispatch 1 min EMS on scene Within 8 min Hospital Fibrinolysis: Door-to-needle within<30 min Not PCI Capable Hospital PPCI: Door-to-balloon within<90 min PCI Capable Hospital EMS transport

EMS transport:EMS to Balloon within 90 min Patient self-transport: Hospital Door-to-Balloon within 90 min

Total ischemic time: Within 120 min*

ACC/AHA 2007 STEMI Focused Update: Acute Medical Therapy General treatment measures

 Aspirin, nitrates, oxygen, analgesics a (morphine)

Infarct size limitation

 β-blockers (not for acute use in patients with evidence of heart failure)

Reperfusion Anticoagulant and antiplatelet therapy

 Thrombolysis (within 30 min) or primary PCI (within 90 min)  UFH or enoxaparin or fondaparinux b  Clopidogrel 75 mg/d added to aspirin for patients undergoing fibrinolysis; 300 mg loading dose for patients <75 y who receive fibrinolytic therapy or who do not receive reperfusion therapy  If PCI: clopidogrel, GP IIb/IIIa inhibitors a Patients routinely taking NSAIDs (except for aspirin), both nonselective as well as COX-2 selective agents, before STEMI should have those agents discontinued at the time of presentation with STEMI because of the increased risk of mortality, reinfarction, hypertension, heart failure, and myocardial rupture associated with their use.

b Because of the risk of catheter thrombosis, fondaparinux should not be used as the sole anticoagulant to support PCI. An additional anticoagulant with anti-IIa activity should be administered. Antman E, et al.

J Am Coll Cardiol.

doi:10.1016/j.jacc.2007.10.001.

2007 ACC/AHA STEMI Focused Update

Reperfusion Therapy for STEMI

Class I Modified Recommendations

  STEMI patients presenting to a hospital with PCI capability should be treated with primary PCI within 90 minutes of first medical contact as a systems goal (

Level of Evidence: A

) STEMI patients presenting to a hospital without PCI capability and who cannot be transferred to a PCI center and undergo PCI within 90 minutes of first medical contact should be treated with fibrinolytic therapy within 30 minutes of hospital presentation as a systems goal unless fibrinolytic therapy is contraindicated (

Level of Evidence: B

) Antman E, et al.

J Am Coll Cardiol.

doi:10.1016/j.jacc.2007.10.001.

Determine Whether Fibrinolysis or PCI Is Preferred

No Preference for Either Strategy If Presentation Is  3 hr and There Is No Delay in Invasive Strategy

However, fibrinolysis generally preferred when

 

Invasive strategy not an option

– Vascular access difficulties – No access to skilled PCI lab

Delay to invasive strategy

– – – Prolonged transport Door-to-balloon time >90 min >1 hr vs fibrinolysis (fibrin-specific agent) now Adapted with permission from Antman EM, et al.

J Am Coll Cardiol

. 2004;44:671-719.

Photo courtesy of ACC/AHA guidelines for STEMI slide set. http://www.cardiosource.com/srch/results.asp?searchterm=STEMI+PowerPoint+ Slides&parsedquery+&x+10&y=5. Accessed January 10, 2008.

Determine Whether Fibrinolysis or PCI Is Preferred (cont.)

No Preference for Either Strategy If Presentation Is  3 hr and There Is No Delay in Invasive Strategy However, invasive strategy generally preferred when  Skilled PCI lab is available with surgical backup – Door-to-balloon time <90 min   High risk from STEMI – Cardiogenic shock*, Killip class ≥III Contraindications to fibrinolysis, including increased risk of bleeding and ICH  Late presentation – >3 hr from symptom onset  Diagnosis of STEMI is in doubt *PCI strongly preferred, but if immediate PCI not available/transfer for PCI delayed and presentation ≤3 hours, treat with fibrinolytic therapy and transfer to a skilled PCI lab.

Adapted from Antman EM, et al.

J Am Coll Cardiol

. 2004;44:671-719.

Photo courtesy of ACC/AHA guidelines for STEMI slide set. http://www.cardiosource.com/srch/results.asp?searchterm=STEMI+PowerPoint+ Slides&parsedquery+&x+10&y=5. Accessed January 10, 2008.

Primary PCI vs Thrombolysis in STEMI: Quantitative Analysis (23 RCTs*, N=7739)

25 20 Short-term outcomes (4 –6 wk) P<.0001

PCI Thrombolytic therapy P<.0001

15 P=.0002

P<.0001

P=.032

10 5 P<.0001

0 Death Nonfatal MI Recurrent Ischemia Hemor rhagic Stroke

*The criterion for time to treatment was 6 h or less in 9 of the trials, 12 h in 13 trials, and up to 36 h in the SHOCK trial.

Adapted with permission from Keeley EC, et al.

Lancet

. 2003;361:13-20.

Major Bleed Death, Nonfatal Reinfarction, or Stroke

NRMI: Advantage of PCI Compared With Fibrinolysis Decreases as PCI-Related Delay Increases 2.0

1.5

1.25

1.0

0.8

0.5

60 75 90 105 114 135 150 165 PCI-Related Delay (door-to-balloon –door-to-needle time), min 180

Adapted with permission from Pinto DS, et al.

Circulation

. 2006;114:2019-2025.

Door to Balloon (D2B): An Alliance for Quality Campaign

 Door to Balloon (D2B) Campaign —joint program of ACC, AHA, and other health organizations  Aims to increase percentage of AMI patients who receive primary angioplasty within 90 minutes of hospital presentation to 75%; current figures indicate only 35% achieve this goal  D2B implementation kit contains 6 evidence based strategies for reducing door-to-balloon times December 27, 2007.

Door to Balloon (D2B): An Alliance for Quality Campaign Strategies Associated With a Significant Reduction in DTB Time Strategy Mean reduction in door-to-balloon time (min)*

Having emergency medicine physicians activate the cath lab 8.2

Having a single call to a central page operator activate the cath lab Having the ED activate the cath lab while patient is still en route Expecting staff to arrive at the cath lab within 20 minutes after page 13.8

15.4

19.3

14.6

Having an attending cardiologist always on site Having staff in the ED and cath lab use and receive real-time feedback *

P

<.05 for all.

Bradley EH, et al.

N Engl J Med.

2006;355:2308-2320.

8.6

2007 ACC/AHA STEMI Focused Update

Anticoagulants as Ancillary Therapy to Reperfusion Therapy

●

New Class I Recommendation

Patients undergoing reperfusion with fibrinolytics should receive anticoagulant therapy for a minimum of 48 hours and preferably for the duration of the index hospitalization, up to 8 days (regimens other than UFH are recommended if anticoagulant therapy is given for more than 48 hours because of the risk of heparin-induced thrombocytopenia with prolonged UFH treatment) ● Anticoagulants regimens with established efficacy include: ● UFH ● Enoxaparin ● Fondaparinux Antman E, et al.

J Am Coll Cardiol.

doi:10.1016/j.jacc.2007.10.001.

2007 ACC/AHA STEMI Focused Update

Anticoagulants

●

Modified Class IIa Recommendation

It is reasonable for patients with STEMI who do not undergo reperfusion therapy to be treated with anticoagulant therapy (non-UFH regimen) for the duration of the index hospitalization, up to 8 days (

Level of Evidence: B

). Convenient strategies that can be used include those with LMWH (Level of Evidence: C) or fondaparinux (

Level of Evidence: B

) using the same dosing regimens as for patients who receive fibrinolytic therapy Antman E, et al.

J Am Coll Cardiol.

doi:10.1016/j.jacc.2007.10.001.

Main Results From ExTRACT –TIMI 25

% 12 9 6 3 0 0 Primary End Point: Death or nonfatal re-MI by 30 days

RR=0.83

P

<.001

UFH 12.0

ENOX 9.9

15 12 9 % 6 Main Secondary End Point: Death, nonfatal re-MI, or urgent revascularization by 30 days UFH 14.5

RR=0.81

P

<.001

ENOX 11.7

3

RR=0.88

P

=.02

5 10 15 Days 20 25 30 0 0 5 10 15 Days 20 25 30

•

Major bleeding at 30 days: 1.4% with UFH vs 2.1% with enoxaparin (P<.001)

•

ICH: 0.7% for UFH vs 0.8% for enoxaparin (P=.14)

Adapted with permission from Antman EM, et al.

N Engl J Med

. 2006;354:1477-1488.

ExTRACT –TIMI 25: For Every 1000 Patients Treated With Enoxaparin vs UFH

5 4 0 -5 -10 -7 -15 -20 -15 Nonfatal reMI Urgent Revasc.

Antman EM, et al.

N Engl J Med

. 2006;354:1477-1488.

Adapted with permission from clinicaltrialresults.org.

-6 Death (No increase in nonfatal ICH) Nonfatal TIMI Major Bleed

OASIS-6 Trial: Study Design

12,092 patients presenting with STEMI within 24 hours of symptom onset (shortened to 12 hours of symptom onset midway through trial)

Randomized. Blinded. Factorial.

28% female; mean age, 62 years; mean follow-up, 3-6 months

Stratum 1 (No UFH) n=5658 Stratum 2 (UFH) n=6434 Fondaparinux n=2823

2.5 mg/day for up to 8 days or hospital discharge

Placebo n=2835 Fondaparinux n=3213

2.5 mg/day for up to 8 days or hospital discharge

UFH n=3221

 

Primary end point: composite of death or reinfarction at 30 days Secondary end point: composite of death or reinfarction at 9 days and at final follow up

Yusuf S, et al.

JAMA.

2006;295:1519-1530.

Adapted with permission from www.clinicaltrialresults.org.

15% 12% 9% 6% 3% 0%

All cases

OASIS-6 Trial: Results Primary End Point: Death/Reinfarction (%) 11.2% 13.4% 14.8% 14% 12% 10% 8% 6% Reduction in Death/MI at 30 days: Stratum 1 (No UFH Indicated) P<.05

14% 11.2% 9.7% 7.4% 8.9% 4% 2% 0% P=.008

30 days Severe Bleeding at 9 Days P=.003

9 days Fondaparinux (n=6036 ) Fonda -

1.0%

P=.008

3-6 months Control (n=6056) Placebo/U FH

1.3%

HR

0.77

P

.13

14% 12% 10% 8% 6% 4% 2% 0% Fondaparinux Reduction in Death/MI: Stratum 2 (UFH Indicated) P=NS 8.3% Placebo 8.7%

p=0.9

7

Fondaparinux UFH

Stratum 1 vs placebo Stratum 2 vs UFH 1.0% 1.1% 1.6% 1.1% 0.63

0.95

.06

.82

Yusuf S, et al.

JAMA

. 2006;295:1519-1530.

Adapted with permission from clinicaltrialresults.org.

8% 6% 4% 2%

OASIS-6: PCI Substudy at 30 Days

Primary End Point of Death or MI in Primary PCI Cohort (%) P=.04

6.0% 4.9% 0% Fondaparinux Control

Yusuf S, et al.

JAMA

. 2006;295:1519-1530.

Adapted with permission from www.clinicaltrialresults.org.

 Guiding catheter thrombosis in the primary PCI cohort occurred more often with fondaparinux compared with control (n=22 vs n=0,

P

<.001)

20 15 HORIZONS AMI: Bivalirudin vs Heparin + GP IIb/IIIa for Primary PCI in STEMI Heparin + GP IIb/IIIa inhibitor (n=1802) Bivalirudin monotherapy (n=1800) Diff = -2.9% [-4.9, -0.8] RR = 0.76 [0.63, 0.92]

P

NI

P

sup ≤ .0001

= .006

Diff = -3.3% [-5.0, -1.6] RR = 0.60 [0.46, 0.77]

P

NI

P

sup ≤ .0001

≤ .0001

Diff = 0.0% [-1.6, 1.5] RR = 0.99 [0.76, 1.30]

P

sup = 1.00

10 12.1

9.2

8.3

5 1



end point 4.9

1



end point 5.5

0 Net adverse clinical events Major bleeding a

a Not related to CABG; b MACE = All-cause death, reinfarction, ischemic TVR or stroke.

Stone GW, et al. Presented at: Transcatheter Cardiovascular Therapeutics 2007; October 20-25, 2007; Washington, DC.

MACE b 5.4

2007 ACC/AHA STEMI Focused Update

Thienopyridines

New Class I Recommendation

● Clopidogrel 75 mg per day orally should be added to aspirin in patients with STEMI regardless of whether they undergo reperfusion with fibrinolytic therapy or do not receive reperfusion therapy. Treatment with clopidogrel should continue for at least 14 days

2004 Class I Recommendation (remains current)

● In patients taking clopidogrel in whom CABG is planned, the drug should be withheld for at least 5 days, and preferably for 7 days, unless the urgency for revascularization outweighs the risks of excess bleeding Antman E, et al.

J Am Coll Cardiol.

doi:10.1016/j.jacc.2007.10.001.

2007 ACC/AHA STEMI Focused Update

Thienopyridines (cont.)

New Class IIa Recommendations

● In patients less than 75 years of age who receive fibrinolytic therapy or who do not receive reperfusion therapy, it is reasonable to administer an oral loading dose of clopidogrel 300 mg (No data are available to guide decision making regarding an oral loading dose in patients 75 years of age or older) ● Long-term maintenance therapy (eg, 1 year) with clopidogrel (75 mg per day orally) is reasonable in STEMI patients regardless of whether they undergo reperfusion with fibrinolytic therapy or do not receive reperfusion therapy Antman E, et al.

J Am Coll Cardiol.

doi:10.1016/j.jacc.2007.10.001.

CLARITY- TIMI 28 Trial: Study Design

Double-blind, randomized, placebo-controlled trial in 3491 patients, aged 18-75 yrs, with STEMI <12 hours Fibrinolytic, ASA, Heparin

Randomized

Clopidogrel 300 mg + 75 mg qd Placebo Study Drug Coronary Angiogram (2-8 days) Open-label clopidogrel per MD in both groups 30-day clinical follow-up

Sabatine MS, et al.

N Engl J Med

. 2005;352:1179-1189.

Primary end point: Occluded artery (TIMI flow grade 0/1) or death/MI by time of angio

CLARITY –TIMI 28: Clopidogrel 300 mg/75 mg qd vs Placebo With Thrombolysis for STEMI (n = 3491) Primary End Point: Occluded Artery (or Death/MI Through Angio/HD) CV Death, MI, RI



Urg Revasc 25 36% Odds Reduction 20 15.0

15 21.7

15 Placebo 10 Clopidogrel 10 5 5 Odds Ratio: 0.80

(95% CI, 0.65-0.97) P=.03

0 n=1752 Clopidogrel P <.001

n=1739 Placebo 0 0 5 10 15 Days 20

Adapted with permission from Sabatine MS, et al.

N Engl J Med

. 2005;352:1179-1189.

25 30 20%

COMMIT/CCS-2: Effect of Clopidogrel 75 mg qd vs Placebo (n = 45,852) Death, Re-MI, or Stroke Death in the Hospital Placebo + ASA: 2310 events (10.1%) Placebo + ASA: 1845 deaths (8.1%) 9 8 7 6 5 Clopidogrel + ASA: 2121 events (9.2%) 9% (SE 3) relative risk reduction (P=.002) 4 3 2 1 0 0 7 14 21 28 Days Since Randomization (up to 28 days) 7 6 5 4 3 2 1 Clopidogrel + ASA: 1726 deaths (7.5%) 7% (SE 3) relative risk reduction (P=.03) 0 0 7 14 21 28 Days Since Randomization (up to 28 days)

a All patients received aspirin 162 mg/d.

SE = standard error.

Adapted with permission from COMMIT Collaborative Group.

Lancet

. 2005;366:1607-1621.

CLARITY –TIMI 28 and COMMIT/CCS-2:

Intracranial Hemorrhage and Major Bleeding CLARITY –TIMI 28

1 ICH Major Bleeding 30-day Major Bleeding

COMMIT-CCS-2

ICH Major Bleeding 2 Clopidogrel n=1733 (%) 8 (0.5) 23 (1.3) 33 (1.9) Clopidogrel n=22,961 (%) 55 (0.2) 134 (0.6) 1. Sabatine MS, et al.

N Engl J Med

. 2005;352:1179-1189.

2. Chen Z, et al.

Lancet

. 2005;366:1607-1621. Placebo n=1719 (%) 12 (0.7) 19 (1.1) 30 (1.7) Placebo n=22,891 (%) 56 (0.2) 125 (0.5)

P

Value .38

.64

.80

P

Value .90

.59

COMMIT/CCS-2: Metoprolol Results

End Point (%) Death, reinfarction, or cardiac arrest Metoprolol, n=22,929 9.4

Placebo, n=22,923 9.9

P

.10

All-cause mortality Reinfarction Ventricular fibrillation Other cardiac arrest Cardiogenic shock 7.7

2.0

2.5

3.0

5.0

7.8

2.5

3.0

2.8

3.9

.69

.001

.001

.14

<.00001

COMMIT =

C

l

O

pidogrel &

M

etoprolol in

M

yocardial

I

nfarction

T

rial. Adapted with permission from Chen ZM, et al.

Lancet

. 2005;366:1622-1632.

Implications for the ED



Lytics are underused, even when preference for PPCI is accepted



Lytic therapy can be optimized with proper use of adjunctive medications

– Enoxaparin – Clopidogrel 

Beta blockers should be used appropriately

2007 ACC/AHA STEMI Focused Update



-Blockers



Modified Class I Recommendation

Oral  -blocker therapy should be initiated in the first 24 hours for patients who do not have any of the following: – Signs of heart failure – Evidence of a low output state – Increased risk a for cardiogenic shock – Other relative contraindications to  -blockade (PR interval >0.24 second, second- or third-degree heart block, active asthma, or reactive airway disease) a Risk factors for cardiogenic shock: age >70 years, systolic blood pressure <120 mm Hg, sinus tachycardia >110 bpm or heart rate <60 bpm, and increased time since onset of symptoms of STEMI.

Antman E, et al.

J Am Coll Cardiol.

doi:10.1016/j.jacc.2007.10.001.

2007 ACC/AHA STEMI Focused Update



-Blockers (cont.)



New Class III Recommendation

IV  -blockers should not be administered to STEMI patients who have any of the following: – Signs of heart failure – Evidence of a low output state – Increased risk a for cardiogenic shock, – Other relative contraindications to  -blockade (PR interval >0.24 second, second- or third-degree heart block, active asthma, or reactive airway disease) a Risk factors for cardiogenic shock: age >70 years, systolic blood pressure <120 mm Hg, sinus tachycardia >110 bpm or heart rate <60 bpm, and increased time since onset of symptoms of STEMI.

Antman E, et al.

J Am Coll Cardiol.

doi:10.1016/j.jacc.2007.10.001.

2007 ACC/AHA STEMI Focused Update

Anticoagulants as Ancillary Therapy to Reperfusion Therapy in PCI

●

New Class I Recommendation

For patients undergoing PCI after having received an anticoagulant regimen, the following dosing recommendations should be followed: ● For prior treatment with UFH, administer additional boluses of UFH as needed to support the procedure, taking into account whether GP IIb/IIIa receptor antagonists have been administered. Bivalirudin may also be used in patients treated previously with UFH ● For prior treatment with enoxaparin, if the last SC dose was administered within the prior 8 hours, no additional enoxaparin should be given; if the last SC dose was administered at least 8 to 12 hours earlier, an IV dose of 0.3 mg per kg of enoxaparin should be given ● For prior treatment with fondaparinux, administer additional IV treatment with an anticoagulant possessing anti-IIa activity, taking into account whether GP IIb/IIIa receptor antagonists have been administered Antman E, et al.

J Am Coll Cardiol.

doi:10.1016/j.jacc.2007.10.001.

2007 ACC/AHA STEMI Focused Update

PCI After Fibrinolysis or for Patients Not Undergoing Primary Reperfusion



Modified Class IIb Recommendation

PCI of a hemodynamically significant stenosis in a patent infarct artery >24 hours after STEMI may be considered as part of an invasive strategy 

New Class III Recommendation

PCI of a totally occluded infarct artery >24 hours after STEMI is not recommended in asymptomatic patients with 1- or 2-vessel disease if they are hemodynamically and electrically stable and do not have evidence of severe ischemia Antman E, et al.

J Am Coll Cardiol.

doi:10.1016/j.jacc.2007.10.001.

2007 ACC/AHA/SCAI PCI Focused Update

Antiplatelet Therapy: Clopidogrel

Modified Class I Recommendations

● A loading dose of clopidogrel, generally 600 mg, should be administered before or when PCI is performed ● In patients undergoing PCI within 12 to 24 hours of receiving fibrinolytic therapy, a clopidogrel oral loading dose of 300 mg may be considered King SB III, et al.

J Am Coll Cardiol.

doi:10.1016/j.jacc.2007.10.002.

2007 ACC/AHA/SCAI PCI Focused Update

Antiplatelet Therapy: Clopidogrel (cont.)

Modified Class IIa Recommendation

● If clopidogrel is given at the time of the procedure, supplementation with GP IIb/IIIa receptor antagonists can be beneficial

Class IIa Recommendation (No Change)

● For patients with an absolute contraindication to aspirin, it is reasonable to give a 300 mg to 600 mg loading dose of clopidogrel, administered at least 6 hours before PCI, and/or GP IIb/IIIa antagonists, administered at the time of PCI King SB III, et al.

J Am Coll Cardiol.

doi:10.1016/j.jacc.2007.10.002.

DES vs BMS in STEMI: Meta-analysis

Primary Efficacy End Point: Reintervention 13.3% 13.3% 5.0% 5.0%

Reintervention = target lesion revascularization. Reproduced with permission from Kastrati A, et al.

Eur Heart J.

2007;28:2706-2713.

DES vs BMS in STEMI: Meta-analysis

Primary Safety End Point: Stent Thrombosis

Reproduced with permission from Kastrati A, et al.

Eur Heart J.

2007;28:2706-2713.

2007 ACC/AHA STEMI Focused Update



Antiplatelet Therapy for Post-PCI Patients

Class I Recommendations

PCI without stenting

– ASA 75-162 mg/d indefinitely –

and

Clopidogrel 75 mg/d for at least 14 d 

Bare-metal stent

– ASA 162-325 mg/d for at least 1 mo, 75-162 mg/d indefinitely –

and

Clopidogrel 75 mg/d for at least 1 mo, ideally up to 1 y 

Drug-eluting stent

– ASA 162-325 mg/d for at least 3 (sirolimus) to 6 (paclitaxel) mo, 75-162 mg/d indefinitely –

and

Clopidogrel 75 mg/d for at least 1 y Antman E, et al.

J Am Coll Cardiol.

doi:10.1016/j.jacc.2007.10.001.

2007 ACC/AHA STEMI Focused Update

Secondary Prevention: Clopidogrel

 

New Class I Recommendation

For all STEMI patients not undergoing stenting (medical therapy alone or PTCA without stenting), treatment with clopidogrel should continue for at least 14 days

New Class IIa Recommendation

Long-term maintenance therapy (eg, 1 year) with clopidogrel (75 mg per day orally) is reasonable in STEMI patients regardless of whether they undergo reperfusion with fibrinolytic therapy or do not receive reperfusion therapy Antman E, et al.

J Am Coll Cardiol.

doi:10.1016/j.jacc.2007.10.001.

2007 ACC/AHA STEMI Focused Update

Secondary Prevention: Additional Recommendations

 Smoking cessation – At each visit, every tobacco user and family members who smoke should be advised to quit (Class I, B) – Exposure to environmental tobacco smoke at work and at home should be avoided (Class I, B)  Statin goal – LDL-C <100 mg/dL (Class I, A) – Consider LDL-C <70 mg/dL (Class IIa, A)  Daily physical activity 30 min/d, min 5 d/wk (Class I, B)  Annual influenza immunization (Class I, B) Antman E, et al.

J Am Coll Cardiol.

doi:10.1016/j.jacc.2007.10.001.

Conclusion: STEMI

Optimal medical care of STEMI begins in the prehospital setting, continues in the ED, and culminates in a prompt and informed decision about reperfusion strategy.

Optimal outcomes in STEMI can be achieved only with a multidisciplinary approach. The ACC/AHA GLs invest initial decisionmaking authority in the emergency physician.

Summary

● ● Acute therapy in STEMI focuses on reperfusion and antithrombotic therapy – new ACC/AHA guidelines provide current recommendations Long-term treatment involves aggressive multifactorial lifestyle modification and both antithrombotic and anti ischemic therapies