Transcript STEMI
Alyssa Morris, R5
Thanks to Drs Rob Hall and Lisa Campfens
ASA
Plavix
BB
Morphine
Nitro
Heparin
Reperfusion
CURE
CLARITY
SYNERGY
COMMIT
TACTICS
GUSTO
DANAMI
SHOCK
ISIS
CRUSADE
FRISC
38
NNT to prevent one
Death in STEMI with
ASA
35
NNT to prevent one
Death in STEMI with
streptokinase
NO Mortality decrease
AVOID
- Hypotension
- Cardiogenic Shock
CAUTION
- HR<50
- RV infarct
- Recent viagra or cialis
AHA guidelines state “reasonable”( II a)
CRUSADE study
AVOID
hypotension, shock, tenuous respiratory status
Focus should be on other anti-ischemic
therapy!
Main evidence is for secondary
prevention of the next MI
Limited evidence from early 80s when
used as monotherapy
COMMIT TRIAL
5
fewer vfib episodes
5
fewer reinfarctions
11
more cardiogenic shock
NO Benefit of early IV beta-blockade
Rapid Atrial Fibrillation
Ventricular arrythmias
Hypertensive + Tachycardic
…….or just use iv nitro
Oral Beta-Blockade should be initiated
within 24 hours (Class I, Level B) as long as
none of:
Signs of CHF
2nd or 3rd degree heart block, PR. 0.24
Low output states (shock, confusion, oliguria)
Increased risk for cardiogenic shock (HR > 110, SBP < 120, age > 75)
IV Beta-Blockade is reasonable for control
of hypertension (not tachycardia alone) if
no contraindications are present
STEMI
Fibrinolysis
▪ 300-600mg
PCI
▪ 300- 600mg
Clopidogrel should be held for 5, preferably 7
days before CABG
STEMIs got lytic, followed by cath b/w 2-8
days
Endpoint = death, recurrent MI, occluded
artery on angiography
21% - 15%, ARR 6%, NNT 16
Benefit was gained artery occlusion rates on
angiography not mortality or recurrent MI
rates
NOT a benign treatment
NNH 50 for minor bleeding
NNH 100 for major bleeding
NNT of 40-80 for benefits of composite end points of
recurrent angina, MI, death, urgent revascularization
NO benefit in low risk patients
STEMIs
Fondaparinux or UFH
PCI or Medical Mx
Reperfusion with fibrinolytics
UFH 60U/kg max 4000U
Enoxaparin 30mg IV bolus
Fondaparinux 2.5mg IV
Reperfusion with PCI
UFH
Enoxaparin
Fondaparinux
How long has the patient been symptomatic?
Are there absolute or relative
contraindications to lytic?
How long of a transport to PCI?
Is the patient in CHF, shock, arrhythmias
Is there a mechanical complication requiring
surgery?
How bad is this particular STEMI?
Mortality 75%
0.25 - 1%, NNH 100-400
Rates increase with number of risk factors
> 75 years old
< 70 kg
BP > 169/95
Prior CVA
Excessive anticoagulation
Inferior STEMI
Mortality 5%
Inferior + RV STEMI
Mortality 8%
Anterior STEMI
Mortality 12%
20
New LBBB
27
Anterior MI
125
Inferior MI
Outcome
Lytic
PCI
ARR
NNT
Mortality
9%
7%
2%
50
Death/MI/
CVA
14%
8%
6%
16
PCI vs LYTIC
30d mortality
46% vs 56%
6m mortality
50% vs 63%
>30m chest pain
At least 1mm STE in at least 2 limb leads or
At least 1mm STE in 2 contiguous
precordial leads
New or presumed new LBBB
True posterior STEMI
ABSOLUTE
Prior ICH
Malignant intracranial neoplasm
Cerebral vascular lesion (AVM)
Ischemic CVA<3m
Ao Dissection
Active bleeding or bleeding
diathesis
Sig CHI or Facial trauma <3m
RELATIVE
Chronic, severe HTN
SBP>180 DBP>110
Hx ischemic stroke >3m,
dementia
Traumatic or prolonged CPR
Recent major surgery <3w
Recent internal bleeding <4w
Noncompressible vascular
puncture
Pregnancy
Active PUD
Current use of OAC: higher INR=
higher risk of bleeding
Door to Needle 30 min
Door to Balloon 90 min
DTB-DTN>1hr
Prolonged transport
DTB>90min
REACT trial
CARESS-AMI
TRANSFER-AMI
2009- TRANSFER TO PCI CENTER
Lytic treated STEMI meeting high risk
criteria
Non-high risk who received lytic may be
considered for transfer asap to a PCI center
for PCI prn
TNK 30-50mg single dose
ASA 162-325mg chewed
Plavix 300mg (or up to 600mg)
Heparin
UFH
Enoxaparin
Fondaparinux
ASA 162-325mg chewed
Plavix 300-600mg
Heparin
UFH*
Enoxaparin
Fondaparinux