2012ESC STEAMI 诊治指南更新 解放军总医院心血管病中心 杨庭树

What is new? Early Diagnosis Expanded section, atypical presentations Cardiac Arrest Expanded section. The role of therapeutic hypothermia and angiography defined. Pre Hospital Logistics of Care Role of pre hospital diagnosis, triage and networks highlighted Reperfusion strategies Modified recommended maximal time delays, angio post fibrinolysis PCI strategies Stent recommendations, anti thrombotic therapy Routine therapies and strategies Duration of hospital stay, secondary prevention, duration of anti thrombotic therapy, Evaluation of LV function and viability European Heart Journal doi: /eurheartj/ehs215

更新指南明确将心肌梗死分为 5 个类型 I 型 自发性心肌梗死； Ⅱ型 继发性心肌梗死； Ⅲ型 心脏性猝死； Ⅳ a 型 PCI 相关性心梗； Ⅳ b 型 支架内血栓相关心梗； Ⅴ型 冠脉搭桥术相关心梗。 Early Diagnosis

Spontaneous myocardial infarction related to atherosclerotic plaque rupture, fissuring, or dissection with resulting intraluminal thrombus in one or more coronary arteries leading to decreased myocardial blood flow with ensuing myocyte necrosis.

Myocardial Infarction Type 2 Myocardial infarction where a condition other than CAD contributes to an imbalance between myocardial oxygen supply and/or demand, e.g. coronary artery spasm, tachy- /brady-arrhythmia, anaemia, respiratory failure, hypotension or hypertension.

Myocardial Infarction Type 3 Cardiac death with symptoms suggestive of myocardial ischemia and presumed new ischemic ECG changes or new LBBB but death occurring before blood samples could be obtained or before cardiac biomarkers could rise.

Myocardial Infarction Type 4a PCI-related MI is defined by elevation of cardiac troponin values >5 X 99 th percentile URL. In addition, either (i) symptoms suggestive of myocardial ischemia or (ii) new ischaemic ECG changes or (iii) angiographic findings consistent with a procedural complication or (iv) imaging demonstration of new loss of viable myocardium or new regional wall motion abnormality. R

Myocardial Infarction Type 4b Myocardial infarction related to stent-thrombosis is detected by coronary angiography or autopsy in the setting of myocardial ischemia and with a rise and/or fall of cardiac biomarkers with at least one value >99 th percentile URL. R

Myocardial Infarction Type 5 CABG-related MI is defined by elevation of cardiac troponin values >10 X 99 th percentile URL. In addition, either (i) new pathological Q waves or new LBBB, or (ii) angiographic documented new graft or new native coronary artery occlusion, or (iii) imaging evidence of new loss of viable myocardium or new regional wall motion abnormality

Cardiac arrest European Heart Journal doi: /eurheartj/ehs215

Components of delay in STEMI and ideal time intervals for intervention European Heart Journal doi: /eurheartj/ehs215 关键：尽量缩短两个 “ 延迟 ”

Prehospital and in-hospital management, and reperfusion strategies within 24 h of FMC European Heart Journal doi: /eurheartj/ehs215

Important delays and treatment goals in the management of acute STEMI European Heart Journal doi: /eurheartj/ehs215

Reperfusion therapy European Heart Journal doi: /eurheartj/ehs215

Procedural aspects of primary PCI European Heart Journal doi: /eurheartj/ehs215

Periprocedural anti thrombotic medication in primary PCI European Heart Journal doi: /eurheartj/ehs215

Periprocedural anti thrombotic medication in primary PCI, con’t European Heart Journal doi: /eurheartj/ehs215

Periprocedural anti thrombotic medication in primary PCI, con’t European Heart Journal doi: /eurheartj/ehs215

Emergency revascularization with either PCI or CABG in suitable patients must be considered. I A Fibrinolysis should be considered if revascularization is unavailable. IIaC Intra-aortic balloon pumping may be considered.IIbB LV assist devices may be considered for circulatory support in patients in refractory shock. IIb C Treatment of cardiogenic shock (Killip class IV) A recent meta-analysis examined three randomized trials comparing a percutaneous LVAD vs. IABP in a total of 100 patients. Although the LVAD appeared safe and demonstrated better haemodynamics, there was no improvement in 30-day mortality.

Specialized electrophysiological evaluation of ICD implantation for secondary prevention of sudden cardiac death is indicated in patients with significant LV dysfunction, who suffer from haemodynamically unstable sustainedVT or who are resuscitated from VF occurring beyond the initial acute phase I A Secondary preventive ICD therapy is indicated to reduce mortality in patients with significant LV dysfunction, and haemodynamically unstable sustainedVT or survivedVF, not occurring within the initial acute phase. IA Risk evaluation for sudden cardiac death should be performed to assess indication for primary preventive ICD therapy by assessing LVEF (from echocardiography) at least 40 days after the acute event in patients with LVEF ≤40%. IIaC Management of ventricular arrhythmias and risk evaluation for sudden death on long term

Routine therapies in the acute, subacute and long term phase of STEMI European Heart Journal doi: /eurheartj/ehs215

Routine therapies in the acute, subacute and long term phase of STEMI European Heart Journal doi: /eurheartj/ehs215

Routine therapies in the acute, subacute and long term phase of STEMI European Heart Journal doi: /eurheartj/ehs215 A fasting lipid profile must be obtained in all STEMI patients, as soon as possible after presentation. I C It is recommended to initiate or continue high dose statins early after admission in all STEMI patients without contraindication or history of intolerance, regardless of initial cholesterol values. IA Reassessment of LDL-cholesterol should be considered after 4–6 weeks to ensure that a target value of ≤1.8 mmol/L(70 mg/dL) has been reached. IIaC ACE inhibitors are indicated starting within the first 24 h of STEMI in patients with evidence of heart failure, LV systolic dysfunction, diabetes or an anterior infarct. IA

Routine therapies in the acute, subacute and long term phase of STEMI European Heart Journal doi: /eurheartj/ehs215 An ARB, preferably valsartan, is an alternative to ACE inhibitors in patients with heart failure or LV systolic dysfunction, particularly those who are intolerant to ACE inhibitors. I B ACE inhibitors should be considered in all patients in the absence of contraindications. IIaA Aldosterone antagonists, e.g. eplerenone, are indicated in patients with an ejection fraction ≤40% and heart failure or diabetes, provided no renal failure or hyperkalaemia. IB

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