Management of AMI in patients presenting with STEMI 2017 ECS Guidelines Management of AMI in patients presenting with STEMI

2017 ESC Guidelines Introduction

2017 ESC guidelines Introduction STEMI: patients with persistent chest discomfort or other symptoms suggestive of ischemia and STE in at least 2 contiguous leads. Ischemic Heart Disease is the single most common cause of death incidences of STEMI is decreasing, NSTEMI is increasing Mortality - influenced by age, time delay to Tx, history of MI, DM, renal failure, number of diseased arteries, LVEF, presence of EMS based STEMI network IHD develops 7-10 years later in women, still a leading cause of death, present atypically and later. majority of pts >75 = women.

2017 ESC guidelines Whats New

2017 ESC Guidelines EMergency Care Reduction in CP after nitroglycerin administration can be misleading and is not recommended as a diagnostic maneuver response to nitro is neither sensitive nor specific in diagnosing ACS If clinical suspicion of ACS - if EKG is equivocal or does not show evidence of MI, EKGs should be repeated and compared with previous EKGs STEMI does not just mean >1mm elevation in 2 contiguous leads. criteria for V2 and V3 is different depending on age and gender.

2017 ESC guidelines Emergency Care V2, V3 STE > 2.5mm in men <40 STE >2.0 in men >40 STE >1.5 in women Inferior MI -> get R precordial leads to identify concomitant RV infarction ST depression in V1-V3, with positive T wave suggests posterior MI -> get posterior leads (V7-V9) The Presence of Q waves should not change reperfusion strategy

2017 ESC guidelines Emergency Care

2017 ESC guidelines Emergency care

2017 ESC guidelines Bundle Branch Block Emergency Care Bundle Branch Block presence of concordant STE appears to be one of the best indicators of AMI with occluded infarct artery presence of new LBBB does not predict MI Patients with RBBB and MI have a poor prognosis difficult to detect ischemia PCI should be considered with persistent ischemic symptoms in presence of RBBB

2017 ESC guidelines Ventricular paced rhythms Emergency Care Ventricular paced rhythms Scarbossas criteria can be used on paced EKGs, not as specific Isolated Posterior MI Isolated ST depression in V1-V3 (>0.5mm) and STE (>0.5mm) in V7-V9 Left main coronary obstruction presence of ST depression >1mm in 8 or more leads coupled with STE in aVR and/or V1 suggests multivessel ischemia or L main disease

2017 ESC guidelines atypical EKGs that should prompt primary PCI in patients with ongoing symptoms suggestive of myocardial ischemia

2017 esc guidelines Non diagnostic EKGs emergency care Non diagnostic EKGs sometimes they present very early (look for hyperacute T waves), some just may not have STEs repeat the EKG for dynamic changes as many as 20% of STEMIs are diagnosed on subsequent EKG Suspicion of ongoing myocardial ischemia is an indication for primary PCI even without STE.

2017 esc guidelines emergency care Pain should be managed; pain means increased sympathetic activation -> vasoconstriction -> increased cardiac workload

2017 esc guidelines emergency care Cardiac arrest In patients following cardiac arrest and STE on EKG - primary PCI is indicated Urgent angiography (2hours) should be considered after cardiac arrest when there is a high index of suspicion of ongoing infarction chest pain before arrest, known CAD, abnormal EKG, shockable arrest… unfavorable conditions should be taken into consideration against PCI Cooling should not delay primary PCI

2017 esc guidelines

2017 esc guidelines STEMI should be diagnosed <10 minutes after FMC Pre hospital care STEMI should be diagnosed <10 minutes after FMC when STEMI is diagnosed by EMS - bypass ED to PCI pre-hospital fibrinolysis is indicated in patients presenting early when STEMI diagnosis to PCI mediated reperfusion time is >120 min.

2017 ESC guidelines prehospital care Non PCI Center If fibrinolysis is contraindicated - transfer to PCI regardless of time

2017 esc guidelines reperfusion therapy

2017 ESC guidelines reperfusion therapy Primary PCI is preferred reperfusion strategy in patients with STEMI w/in 12 hours of symptom onset PCI is performed faster and results in lower mortality in high volume centers Lack of data to set the time limit to choose PCI over fibrinolysis time from STEMI Dx to PCI mediated reperfusion < 120min If fibrinolysis is indicated - bolus < 10 min from diagnosis

2017 ESC guidelines reperfusion therapy Fibrinolysis should be administered in prehospital setting if possible Patients should be transferred to PCI facility as soon as possible after bolus of lytics Rescue PCI is indicated if: failed fibrinolysis (STE resolution <50% w/in 60-90min) hemodynamic or electrical instability persistent chest pain or worsening ischemia Routine, early PCI (2-24hrs) is indicated after successful fibrinolysis

2017 ESC guidelines reperfusion therapy Primary PCI indicated for patients with symptoms >12 hours in presence of: EKG evidence of ongoing ischemia ongoing or recurrent CP and dynamic EKG changes ongoing or recurrent pain, signs/symptoms suggestive of heart failure, shock, arrhythmias No consensus on PCI after 12 hours of symptoms in absence of signs of ongoing ischemia - debatable Routine PCI of occluded IRA in asymptomatic patients >48hours after symptoms onset is NOT indicated.

2017 ESC guidelines

2017 ESC guidelines reperfusion therapy

2017 ESC guidelines reperfusion therapy

2017 ESC guidelines pharmacotherapy Patients undergoing primary PCI should receive DAPT (ASA plus P2Y12 inhibitor) plus parenteral anticoagulation limited evidence as to when the P2Y12 inhibitor should be given early administration may be preferable for early efficacy Prasugrel and Ticagrelor are superior to clopidogrel should be avoided in patients with previous hemorrhagic stroke, patients on oral AC and pts with mod/severe liver Dz. prasugrel is not recommended in patients with h/o CVA or >75 all should be used with caution in pts at risk of bleeding or significant anemia

2017 ESC guidelines reperfusion therapy

2017 ESC guidelines anticoagulation Options for primary PCI including UFH, enoxaparin, bivalirudin no evidence of increased bleeding with enoxaparin enoxaparin a/w significant reduction of death compared to UFH Enoxaparin should be considered in STEMI Bivalirudin should be considered in patients w/ high bleeding risk Bivalirudin is recommended for patients with HIT

2017 ESC guidelines ANticoagulation

2017 esc guidelines

2017 ESC guidelines Fibrinolysis Largest benefit when given <2 hrs after symptom onset Recommended within 12 hours of of symptoms onset if primary PCI cannot be performed within 120 min and no contraindications The later the patient presents, the more consideration should be given to transfer for PCI Pre-hospital fibrinolysis reduced early mortality by 17% compared with in hospital, particularly when administered in first 2 hours. Goal - Bolus within 10 min of STEMI Dx

2017 esc guidelines Fibrinolysis

2017 ESC guidelines Fibrinolysis Following initiation of lytic therapy, it is recommended to transfer ALL patient to PCI center In cases of failed fibrinolysis, or if evidence of re- occlusion/reinfarction, rescue PCI is indicated re-administration of fibrinolysis is not indicated If Successful PCI (>50% reduction of STE at 60-90min, reperfusion arrhythmia, resolution of CP), routine early angio and PCI still recommended (2-24 hours) reduces rates of reinfarction and recurrent ischemia

2017 ESC guidelines FIbrinolysis

2017 ESc guidelines fibrinolysis Adjunctive therapies in fibrinolysis Clopidogrel added to ASA reduces risk of cardiovascular events and overall mortality in patients treated with lytics Anticoagulation should be given until revascularization Enoxaparin a/w reduction in the risk of death and reinfarction at 30 days when compared with UFH, at the cost of increased non cerebral bleeding complications Net clinics benefit favored enoxaparin Cocktail - Weight adjusted tenecteplase, ASA, clopidogrel and enoxaparin IV followed by sc until PCI

2017 esc guidelines fibrinolysis

2017 esc guidelines Fibrinolysis

2017 ESC guidelines Hazards of lytics Fibrinolysis Hazards of lytics small but significant excess of strokes, hemorrhagic advanced age, lower weight, females, previous cerebrovascular disease and HTN on admission and predictors of hemorrhage approx 1% half dose tenecteplase by 50% if >75 years

fibrinolysis - contraindications 2017 ESD guidelines fibrinolysis - contraindications