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Acute Coronary Syndromes
Transcript of Acute Coronary Syndromes
Step 1: Assess time and risk
Time since onset of symptoms
Risk of STEMI
Risk of fibrinolysis
Time required to transport to skilled PCI catheterization suite
Step 2: Select reperfusion (fibrinolysis or invasive) strategy
Note: If presentation <3 hours and no delay for PCI, then no preference for either strategy. Fibrinolysis is generally preferred if:
Early presentation (≤3 hours from symptom onset)
Invasive strategy is not an option (eg, lack of access to skilled PCI facility or difficult vascular access) or would be delayed
No contraindications to fibrinolysis Medical contact-to-balloon or door-balloon >90 minutes
(Door-to-balloon) minus (door-to-needle) is >1 hour Invasive strategy is generally preferred if:
Late presentation (symptom onset >3 hours ago)
Skilled PCI facility available with surgical backup
Medical contact-to-balloon or door-to-balloon <90 minutes
(Door-to-balloon) minus (door-to-needle) is <1 hour
Contraindications to fibrinolysis, including increased risk of bleeding and ICH
High risk from STEMI (CHF, Killip class is ≥3)
Diagnosis of STEMI is in doubt Appropriate treatment of ACS or STEMI, including PCI or fibrinolysis, should be initiated regardless of coma (Class I, LOE B) Nitroglycerin In patients with recurrent ischemia, nitrates are indicated in the first 24 to 48 hours. The use of nitrates in patients with hypotension (SBP <90 mm Hg or ≥30 mm Hg below baseline), extreme bradycardia (<50 bpm), or tachycardia in the absence of heart failure (>100 bpm) and in patients with RV infarction is contraindicated (Class III, LOE C). Administer a loading dose (300 mg) of clopidogrel in addition to standard care (aspirin, anticoagulants, and reperfusion) for patients determined to have moderate- to high-risk NSTEMI and STEMI (Class I, LOE A). In patients who are not at high risk for bleeding, administration of prasugrel (60-mg oral loading dose) prior to angiography in patients determined to have STEMI ≤12 hours after the initial symptoms may be substituted for administration of clopidogrel (Class IIa, LOE B). Prasugrel is not recommended in STEMI patients managed with fibrinolysis or NSTEMI patients before angiography. Clopidogrel Glycoprotein IIb/IIIa Inhibitors Glycoprotein IIb/IIIa Inhibitors benefit largely in patients who have elevated cardiac troponin and a planned invasive strategy or specific subsets such as those patients with diabetes or significant ST-segment depression on the presenting ECG. beta-Blockers Early beta-blocker administration may help prevent dangerous arrhythmias and reduce re-infarction, but there is an increased incidence of cardiogenic shock. Contraindications to beta-blockers are moderate to severe LV failure and pulmonary edema, bradycardia (<60 bpm), hypotension (SBP <100 mm Hg), signs of poor peripheral perfusion, 2nd-degree or 3rd-degree heart block, or reactive airway disease. Heparin (UFH or LMWH) Patients initially treated with enoxaparin should not be switched to UFH and vice versa because of increased risk of bleeding (Class III, LOE C) In younger patients <75 years the initial dose of enoxaparin is 30 mg IV bolus followed by 1 mg/kg SC every 12 hours (first SC dose shortly after the IV bolus) (Class IIb, LOE A).
Patients ≥75 years may be treated with 0.75 mg/kg SC enoxaparin every 12 hours without an initial IV bolus (Class IIb, LOE B).
Patients with impaired renal function (creatinine clearance <30 mL/min) may be given 1 mg/kg enoxaparin SC once daily (Class IIb, LOE B).
Patients with known impaired renal function may alternatively be managed with UFH (Class IIb, LOE B). ACE Inhibitor Administration of an oral ACE inhibitor is recommended within the first 24 hours after onset of symptoms in STEMI patients with pulmonary congestion or LV ejection fraction <40%, in the absence of hypotension (SBP <100 mm Hg or 30 mm Hg below baseline) (Class I, LOE A). Management of Arrhythmias Primary VF accounts for the majority of early deaths during AMI. The incidence of primary VF is highest during the first 4 hours after onset of symptoms.
Prophylactic antiarrhythmics are not recommended for patients with suspected ACS or MI in the prehospital or ED (Class III, LOE A).
Routine IV administration of beta-blockers to patients without hemodynamic or electric contraindications is associated with a reduced incidence of primary VF (Class IIb, LOE C).
Low serum potassium, but not magnesium, has been associated with ventricular arrhythmias. It is prudent clinical practice to maintain serum potassium >4 mEq/L and magnesium >2 mEq/L (Class IIB, LOE A). Circulation. 2010;122:S787-S817 ACC/AHA 2009 Guidelines for STEMI & PCI
ACC/AHA 2007 Guidelines for UA/NSTEMI
Circulation. 2007;116;e148-e304 PCI Following ROSC After Cardiac Arrest Patients with OHCA due to VF in the setting of STEMI (or new or presumably new LBBB), emergent angiography with prompt recanalization of the infarct-related artery is recommended (Class I, LOE B). PPCI after ROSC in subjects with arrest of presumed ischemic cardiac etiology may be reasonable, even in the absence of a clearly defined STEMI (Class IIb, LOE B).