1. “Acute Coronary Syndrome”
July 24, 2013

2. Item 72
A 78 year old man is evaluated in the ED with chest pain. The patient reports that the pain, which is present in the left substernal area, began at rest, and has been present for 12 hours. He reports no similar episodes of chest pain. Medical history is significant for hypertension and a 30-pack year history of ongoing tobacco use. His only medication is nifedipine.
On PE, temperature is 37.90C, BP 130/80 mm Hg, pulse rate is 72/minute and respiration rate is 12/min. BMI is 28. A normal carotid upstroke without carotid bruits is noted, jugular venous pulsations are normal and S1 and S2 are heard without murmurs. Lung fields are clear, distal pulses are normal and no peripheral edema is present.

3. Item 72 (Con’t)
Serum creatinine kinase level is 500 units/L and troponin I level is 26 ng/mL. Lab findings are otherwise normal.
EKG shows sinus rhythm at 70/min; 2 mm ST-segment elevation in leads II, III and aVF; and 1 mm ST segment depression in leads V2 and V3. He is taken to the cardiac cath lab and found to have single vessel coronary disease with severe stenosis of the proximal left anterior descending coronary artery.

4. Item 72 (Con’t)
Which of the following is the most appropriate treatment?
Coronary artery bypass surgery
Intracoronary thrombolytic therapy
Medical therapy
Primary percutaneous coronary intervention

5. STEMI Care and Time to Treatment Goals
IIa
IIb
III
2013 ACC/AHA Guideline A
Primary PCI is the recommended method of reperfusion when it can be performed in a timely fashion by experienced operators.
JACC 2013;61:e1-63

6. STEMI Care and Time to Treatment Goals
IIa
IIb
III
2013 ACC/AHA Guideline A
Reperfusion therapy should be administered to all eligible patients with STEMI with symptom onset within the prior 12 hours
JACC 2013;61:e1-63

7. STEMI Care and Time to Treatment Goals
IIa
IIb
III
2013 ACC/AHA Guideline B
Reperfusion therapy is reasonable for patients with STEMI within the prior 12 to 24 hours who have clinical and/or ECG evidence of ongoing ischemia. Primary PCI is the preferred strategy in this population
JACC 2013;61:e1-63

8. Item 38: MKSAP
A 54 year old man is evaluated in the ED for acute coronary syndrome that began 30 minutes ago. He has type 2 diabetes mellitus and hypertension. He reports no history of bleeding or stroke. He has a remote history of peptic ulcer disease for which he takes no medications. Medications are lisinopril and glipizide.
On physical exam, he is afebrile, BP is 160/90 mm Hg, pulse rate is 80 and respiration 12/min. CV examination reveals a normal S1 and S2 without an S3 and no murmurs. Lung fields are clear.

9. MKSAP: Item 38
Serum troponin and creatinine kinase levels are pending. Hematocrit is 42% and platelet count is 220,000/L
EKG shows 3 mm ST segment elevation in leads V2 through V4 and a 1 mm ST segment depression in leads II, III and aVF. A chest radiograph is normal.
There is no cardiac cath lab present at the hospital and it would take approximately 1.5 hours to transfer the patient to the closest facility that performs PCI. -blockers, unfractionated heparin, clopidogrel and aspirin are initiated.

10. MKSAP: Item 38
Which of the following is the most appropriate management?
Abciximab and thrombolytic therapy
Await the results of troponin and CK
Thrombolytic therapy
Transfer for primary PCI

11. STEMI Care and Time to Treatment Goals
IIa
IIb
III
2004 ACC/AHA Guideline B
If the symptom duration is within 3 hours and the expected door to balloon time minus the expected door to needle time is:
Within 1 hour, primary PCI is preferred
Greater than 1 hour, fibrinolytic therapy is generally preferred.
Circulation 2004;110:

12. Target Door to Balloon Time
Door to Balloon Time for Transfer and Direct Arrival Patients, National CV Data Registry (NCDR)
Am Heart J 2011;161:76-83
210
180
Transfer PCI
150
120
Target Door to Balloon Time
Time (Minutes)
Direct PCI 90 60 30
Year
2005 QI
2005 Q3
2006 Q1
2006 Q3
2007 Q1
2007 Q3

13. Transfer and Direct PCI Door to Balloon Time
Am Heart J 2011;161:76-83 50
90 minutes 40
Direct PCI = 79 min
(n=86,382) 30
63.4%
Percentage of Patients 20
Transfer PCI = 149 min 10
(n=29,248)
9.7% 1 2 3 4 5 6
Door to Balloon Time (hours)

14. STEMI Care and Time to Treatment Goals
IIa
IIb
III
2013 ACCF/AHA Guideline B
Immediate transfer to a PCI-capable hospital for primary PCI is recommended strategy for STEMI patients who initially arrive at or are transported to a non-PCI-capable hospital with a FMC-to-device time goal of 120 minutes or less.

15. STEMI Patient, First Medical Contact
PCI Capable Hospital
Non-PCI Capable Hospital
Door In Door Out (DIDO) ≤30 mins
FMC* to Device Time ≤120 min
Anticipated FMC* to Device Time ≥120 min
FMC* to Device Time ≤90 mins
Transfer for Primary PCI
Cath Lab for PCI
Thrombolytic Therapy within 30 mins
*FMC: First Medical Contact
JACC 2013;61:e1-63

16. Acute Coronary Syndrome
Definition
A constellation of clinical symptoms due to acute myocardial ischemia
Circulation 2011,123:e426-e579

17. Myocardial Infarction
Definition
Myocardial necrosis (or myocardial cell death) due to prolonged ischemia.
Third Universal Definition of MI
Circulation 2012,126:

18. Causes of Acute Coronary Syndrome
Atherosclerosis
Compression
- Muscle bridges
- Aortic aneurysm
Congenital
- Anomalous origin
- Anomalous course
- Single artery
Drugs
- Sumatriptan
- Ergot alkaloids
- Cocaine
Embolic
- Vegetations
- Tumor
- Calcium
Aortic dissection
Vasospasm
Intimal proliferation
- Fibromuscular hyperplasia
- Radiation
Trauma
Arteritis

19. 3 Major Causes of ACS
Atherosclerosis
Atherosclerosis
Atherosclerosis

20. Types of Myocardial Infarction
Type 1: Spontaneous MI due to plaque rupture, ulceration, fissuring, erosion, etc.
Type 2: MI secondary to an ischemic imbalance
Type 3: MI resulting in death and biomarkers are unavailable
Type 4a: MI related to PCI
Type 4b: MI related to stent thrombosis
Type 5: MI related to CABG
Circulation 2012;126:

21. MI Type 1

22. Plaque Rupture

23. Healed Plaque

24. Erosion

25. Atherothrombosis: A Generalized and Progressive Process
Atherothrombosis, or thrombosis superimposed on underlying atherosclerosis, is the usual underlying disease process for acute coronary syndromes.1
Everyone has atherosclerotic lesions from childhood on.2 Early atherosclerotic changes, such as fatty streaks (consisting primarily of layers of macrophage foam cells and lipid-laden smooth muscle cells) are not clinically apparent. As atherosclerosis evolves over time, the lesions progress to atheromas, in which a lipid-laden core is separated from the lumen by a fibrous cap.
Once the lumen narrows, symptoms such as angina on effort and intermittent claudication may develop, depending on the affected vascular bed.2
Unstable plaque (ie, having a large lipid core and a thin cap infiltrated with macrophages and lymphocytes) is associated with plaque rupture or fissure, hemorrhage, and thrombosis.1 Rupture of the cap permits blood from the arterial lumen to enter the core and come in contact with highly thrombogenic tissue factor and collagen from the vessel wall. Formation of platelet-rich and fibrin-rich thrombi can partly or totally occlude arteries.
Note that the neat progression shown on the slide does not occur in all cases. Even small lesions may rupture; in fact, small lesions may be responsible for ACS in two thirds of patients.3
Atherothrombosis can result in acute coronary syndromes, ischemic stroke, transient ischemic attack, sudden cardiac death, or acute limb ischemia.1
Rauch U, Osende JI, Fuster V, et al. Thrombus formation on atherosclerotic plaques: pathogenesis and clinical consequences. Ann Intern Med. 134;
Stary HC, Chandler AB, Dinsmore RE, et al. A definition of advanced types of atherosclerotic lesions and a histological classification of atherosclerosis. Circulation. 1995;92:
Fuster V, Fayad ZA, Badimon JJ. Acute coronary syndromes: biology. Lancet. 1999;353(suppl II):5-9. 25

26. Progressive Narrowing of the Arterial Lumen
Vessel Lumen
Lipid Core
Clot
Atherosclerotic Vessel
Progressive Narrowing (Time)
Thrombotic Occlusion

27. Plaque Rupture and Atherothrombosis
Vessel Lumen
Lipid Core
Thrombus
Atherosclerotic Vessel
Plaque Rupture
Platelet Adhesion Activation and Aggregation
Thrombus Formation
Thrombotic Occlusion MI
Stroke
Vascular Death
Am J Med 1996;101:

28. Most MI’s Arise From Smaller Stenoses
Baseline Study
Circulation 1988;78:

29. Most MI’s Arise From Smaller Stenoses
13 Days Later
Circulation 1988;78:

30. Most MI’s Arise From Smaller Stenoses
Baseline Study
Circulation 1988;78:

31. Most MI’s Arise From Smaller Stenoses
2 months later
Circulation 1988;78:

32. Most MI’s Arise From Smaller Stenoses
Circulation 1995;92: 80
68%
Asymptomatic 60
Symptomatic
MI Patients (%) 40
18% 20
14%
< 50%
50-70%
> 70%
Percentage Stenosis

33. Acute Coronary Syndrome
Circulation 2002;105:
PCI With Stent
Systemic Medical Therapy to Stabilize Plaque
Aspirin
Clopidogrel/Prasugrel/Ticagrelor
Statins
ACE Inhibitors/ARBs
Beta Blockers
Smoking Cessation

34. Multiple Plaques in ACS
Circulation 2002;106:
79% of patients had >1 plaque ruptured 40
29% 30
25%
21%
MI Patients (%) 20
12.5% 10
7.5%
4.5%
Culprit Lesion 1 2 3 4 5
Number of Ruptured Plaques in Addition to Culprit Lesion Detected by IVUS

35. The Asymptomatic Progression of CAD
Initial Presentation
62%
MEN (65.8 years)
46%
ACS or Sudden Cardiac Death
WOMEN (70.4 years) 10 20 30 40 50 60 70
Levy D, Textbook of CV Medicine 1998
AHA: Heart Disease and Stroke Statistics-2006 Update

36. Ventricular Fibrillation

37. Ventricular Fibrillation and Survival
1.0
0.8
0.6
Proportion Surviving
0.4
0.2 1 2 3 4 5 6 7 8 9 10
Minutes

38. Ventricular Fibrillation

39. Deaths due to Acute MI
In-hospital mortality had improved significantly
1960’s – prior to introduction of CCUs, in-hospital mortality averaged ~25-30%.
1980’s – CCU, pre-reperfusion era ~16%
’s – era of fibrinolysis, coronary interventions, those who participated in clinical trials, one month mortality is ~4-6%
Eur HJ 2208;29:

40. Mortality in Acute MI 21% 8% 52% 19%
Pre-Hospital
21%
24 Hours In-Hospital 8%
52%
48 Hours In-Hospital
30 Days
19%
One-half of all deaths occur “in the field” within one hour after symptom onset

41. Acute Coronary Syndrome
ST elevation myocardial infarction
Non-ST elevation myocardial infarction
Unstable Angina

42. Hospitalizations in the US due to ACS
Acute Coronary Syndromes
1.57 Million Hospital Admissions
79%
21%
UA/NSTEMI
STEMI
Approximately 2.3 million Americans will present to the emergency department with chest pain due to acute coronary syndrome.[1] Of these patients, twice as many (1.43 million) will be admitted and diagnosed with unstable angina (UA) or non–ST-segment elevation myocardial infarction (NSTEMI; also known as non–Q-wave MI) compared with 829,000 patients who will be diagnosed with ST-segment elevation MI (STEMI; also known as Q-wave MI).[1]
According to the American Heart Association, 1.1 million new or recurrent coronary attacks (defined as MI or coronary heart disease) will occur this year.[2] Of these cases, 650,000 will be first cases and 450,000 will be recurrent cases. Additionally, about 150,000 new cases of UA will be diagnosed.[2]
National Center for Health Statistics National Hospital Discharge Survey: Annual Summary with Detailed Diagnosis and Procedure Data. Hyattsville, Maryland: US Dept of Health and Human Services; 2001: Series 13, No. 151.
American Heart Association Heart and Stroke Statistical Update
0.33 million admissions
1.24 million admissions
0.57 million NSTEMI
0.67 million UA
Heart Disease and Stroke Statistics 2007 Update
Circulation 2007;115:69-171
ACC/AHA 2009 Joint STEMI/PCI Guidelines Focused Update 42

43. Incidence Rate (No. of cases/100,000 per person-year)
Rates of Acute MI,
JACC 2013;61e7
300 MI
250
200
Non-STEMI
150
Incidence Rate (No. of cases/100,000 per person-year)
100
STEMI 50
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
Year

44. Acute Coronary Syndrome
Typical Symptoms:
Central chest pain
Chest discomfort
Chest pressure
Chest tightness
Heaviness
Cramping or burning sensation
Indigestion or heartburn
Call 911

45. Acute Coronary Syndrome
Symptoms of Acute MI
Hospitalized
Recommended
Discouraged
Call 911
Ambulance Transport
Self Transport
JACC 2008;51:

46. Percentage of Patients with ACS Calling 911
National Registry of MI -2
Emergency Medical System
53%
Survey of confirmed ACS patients in 20 US communities
Emergency Medical System
10-48% (23%)
Driven by someone else
60%
16%
Drove themselves
Circulation May, 2011 e440

47. Acute Coronary Syndrome
Physical signs:
No physical signs diagnostic of Acute MI
Activation of autonomic nervous system
Pallor
Sweating
Hypotension or narrow pulse pressure
Irregularities in heart rate, bradycardia, tachycardia
Third heart sound
Basal rales

48. Acute Coronary Syndrome
Symptoms of Acute MI
Ambulance
Self Transport
12-Lead ECG
Hospital/ED
Obtained and Interpreted <10 mins
12 Lead-ECG
JACC 2008;51:

49. Hospitalizations in the US due to ACS
Acute Coronary Syndrome
1.57 Million Hospital Admissions
79%
21%
STEMI
UA/NSTEMI
Approximately 2.3 million Americans will present to the emergency department with chest pain due to acute coronary syndrome.[1] Of these patients, twice as many (1.43 million) will be admitted and diagnosed with unstable angina (UA) or non–ST-segment elevation myocardial infarction (NSTEMI; also known as non–Q-wave MI) compared with 829,000 patients who will be diagnosed with ST-segment elevation MI (STEMI; also known as Q-wave MI).[1]
According to the American Heart Association, 1.1 million new or recurrent coronary attacks (defined as MI or coronary heart disease) will occur this year.[2] Of these cases, 650,000 will be first cases and 450,000 will be recurrent cases. Additionally, about 150,000 new cases of UA will be diagnosed.[2]
National Center for Health Statistics National Hospital Discharge Survey: Annual Summary with Detailed Diagnosis and Procedure Data. Hyattsville, Maryland: US Dept of Health and Human Services; 2001: Series 13, No. 151.
American Heart Association Heart and Stroke Statistical Update
1.24 million
Admissions per year
0.33 million
Admissions per year
Heart Disease and Stroke Statistics 2007 Update
Circulation 2007;115:69-171
ACC/AHA 2009 Joint STEMI/PCI Guidelines Focused Update 49

50. Atherosclerotic plaque
Acute Coronary Syndromes
Pathophysiology
Large Fissure
Small Fissure
Mural thrombus (unstable angina/ non-ST elevation MI)
Occlusive thrombus (ST Elevation MI)
Thrombus
Lipid Pool
Macrophages
Stress, tensile, internal
Shear forces, external
Fissure
Atherosclerotic plaque
Plaque rupture
Fuster V et al. NEJM. 1992; 326:
Davies MJ et al. Circulation. 1990; 82 (Suppl II): II-38, II-46.

51. TIMI Flow Grade TIMI 0 Complete Occlusion TIMI 1 TIMI 2 TIMI 3
Penetration of obstruction by contrast but no distal perfusion
TIMI 2
Perfusion of entire artery but delayed flow
TIMI 3
Full perfusion, normal flow

52. ST elevation = coronary artery is completely occluded
Myocardial Ischemia
Blood Supply
Oxygen Demand
TIMI 0 Flow
Heart Rate
Blood Pressure
Inotropicity
ST elevation = coronary artery is completely occluded
= TIMI 0 blood flow

53. ST Elevation MI Hours “Time is Muscle” Benefit (%)
Circulation 1992;85;
100 80 60
Benefit (%)
“Time is Muscle” 40 20 1 2 3 4 5 6 7 8 9 10 11 12
Hours

54. The 12-Lead ECG
The 12-lead ECG is the only modality that can best identify the presence of a completely occluded coronary artery

55. Acute Coronary Syndrome
Diagnostic and Therapeutic Pathways in Patients With and Without ST-Segment Elevation
Acute Coronary Syndrome
ECG
ST Elevation
No ST Elevation
Aspirin, clopidogrel, UFH or LMWH, 2B/3A antagonists
b-blockers, nitrates
Thrombolysis, PCI
Hamm CW et al. Lancet. 2001;358:
2002 ACC/AHA UA/NSTEMI Guideline Update. Available at:

56. Normal ECG

57. Acute Coronary Syndrome
ST Elevation MI

58. Acute Coronary Syndrome
ASA
Chest Pain

59. Aspirin
Give ASA as soon as possible unless there is GI bleed or patient is allergic to aspirin
Dose mg one dose
Aspirin should be chewable or soluble
If patient cannot take ASA due to nausea or GI disorder, use ASA suppositories
Other than ASA, do not make the mistake of giving NSAID such as Motrin, Naprosyn, Celebrex, etc since NSAID increases mortality, re-infarction, myocardial rupture, CHF, and HBP
JACC 2007;50:

60. Acute Coronary Syndrome
ASA
Chest Pain
NTG
Arrival in ED
ECG within 10 minutes
ST Elevation
NTG
NTG
NTG

61. ST Segment Elevation
Baseline ECG

62. ST Segment Elevation
After NTG

63. ST Segment Elevation
Baseline ECG
After NTG

64. ST Segment Elevation
Baseline

65. ST Segment Elevation
After NTG

66. ST Segment Elevation
Baseline
After NTG

67. Nitroglycerin
For relief of chest pain, give NTG up to 3 doses at 3-5 minute intervals until pain is relieved or blood pressure is low
Dose of NTG is 0.4 mg sublingual tablet or spray
JACC 2007;50:

68. Nitroglycerin Do not give if:
Taking PDE Inhibitors for erectile dysfunction
sildenafil (Viagra, Revatio) 24 h
taladafil (Cialis, Adcirca) 48 h
vardenafil (Levitra) ?
Systolic BP <90 mm Hg or there is a drop of >30 mm Hg below baseline BP
Bradycardia of <50 beats per minute
Tachycardia of >100 beats per minute
Suspected right ventricular MI
JACC 2007;50:

69. ST Elevation MI Thrombolytic Therapy Primary PCI Chest Pain
ASA
Chest Pain
NTG
ECG within 10 minutes
ST Elevation
NTG
Self-Transport: Door to Needle <30 mins
Self-Transport: Door to Balloon <90 mins
NTG
EMS Transport: <30 mins
NTG
EMS transport: <90 mins
Thrombolytic Therapy
Primary PCI

70. Acute Inferior MI
Thrombolytic Therapy

71. Post Thrombolytic Therapy
One Hour Later

72. Initial ECG
Thrombolysis: One Hour Later

73. Thrombolysis No contraindication to thrombolysis
Best results within 2 hours after onset of symptoms
Hemodynamically stable:
Not in cardiogenic shock or CHF or with mechanical complications of AMI

74. Contraindications to Thrombolysis
Relative Contraindications
History of chronic severe, poorly controlled hypertension
Severe uncontrolled hypertension (SBP >180 mm Hg or DBP >110 mm Hg)
History of prior ischemic stroke >3 mos, dementia or IC pathology
Traumatic or prolonged (>10 mins) CPR or major surgery <3 weeks
Recent (2-4 weeks) internal bleeding
Pregnancy
Active peptic ulcer
Current use of anticoagulants
Absolute Contraindications
Any prior ICH
Known structural cerebral vascular lesion (AVM)
Known malignant intracranial neoplasm (primary/metastatic)
Ischemic stroke within 3 months
Suspected aortic dissection
Active bleeding or bleeding diathesis (excluding menses)
Closed head or facial trauma within 3 months

75. Thrombolytic Therapy and Mortality According to Admission ECG
Lancet 1994;343: 60
49% 50 40
37% 30
Lives Saved per Thousand 20 8% 10
-14%
Anterior ST Elevation
Inferior ST Elevation
BBB
-10
ST Depression
Admission ECG

76. ST Elevation Criteria for STEMI
≥1 mm any 2 adjacent standard leads
In V2 and V3:
Males
<40 years of age ≥2.5 mm for males
≥40 years of age ≥2.0 mm for males
Females (any age)
≥1.5 mm
ST elevation is measured at the J point
JACC 2009;53:

79. Fibrinolytic Agents Fibrin-specific Non-fibrin-specific Patency Rate
90 min TIMI 2 or 3
Tenecteplase (TNK-tPA)
85%
Reteplase (rPA)
84%
Alteplase (tPA)
73-84%
Non-fibrin-specific
Streptokinase
60-68%
(No longer marketed in the US)
JACC 2013;61e78-140

80. ST Elevation MI Thrombolytic Therapy Primary PCI Chest Pain
ASA
Chest Pain
NTG
ECG within 10 minutes
ST Elevation
NTG
Self-Transport: Door to Needle <30 mins
Self-Transport: Door to Balloon ≤90 mins
NTG
EMS Transport: <30 mins
NTG
EMS transport: ≤90 mins
Thrombolytic Therapy
Primary PCI

82. AMI: Post PCI

83. ST Segment Elevation
Admission
Post PCI

84. STEMI PCI: National CV Data Registry
In hospital mortality of 43,801 patients with STEMI undergoing PCI: JACC 2009;54:
P <0.001 10
8.4%
7.0%
5.6%
Mortality 5
4.3% 3%
3.5%
30 mins
60 mins
90 mins
120 mins
150 mins
180 mins
Delay in Reperfusion in Minutes

85. Primary PCI vs IV Thrombolytic Therapy for Acute MI: Review of 23 Randomized Trials
23 randomized clinical trials with 7739 patients with STEMI
Thrombolytic therapy = 3867
Primary PCI = 3872
Results: Primary PCI was better than thrombolytic therapy at reducing short-term and long-term death, non-fatal reinfarction, stroke and combined endpoint of death, non-fatal reinfarction and stroke
Conclusion: Primary PCI is more effective than thrombolytic therapy for the treatment of STEMI
Lancet 2003;361:13-20

86. PCI Vs Thrombolytic Therapy: Short Term Outcomes25
P<0.0001
PCI 20
Thrombolytic Therapy
P<0.0001 15
Frequency (%)
P=0.0002 10
P=0.0003
P<0.0001 5
P=0.0004
Death
Death, non-fatal re-infarction or stroke
Death Excluding SHOCK data
Non-fatal MI
Recurrent Ischemia
Total Stroke
Lancet 2003;361:13-20

87. PCI Vs Thrombolytic Therapy: Long Term Outcomes50
P<0.0001
PTCA 40
Thrombolytic Therapy
P<0.0001 30
Frequency (%)
P=0.0019 20
P<0.0001
P=0.0053
Data Not Available 10 * *
Death, non-fatal re-infarction or stroke
Death
Death Excluding SHOCK data
Non-fatal MI
Recurrent Ischemia
Total Stroke
Lancet 2003;361:13-20

88. Options for Transport of Patients With STEMI and Initial Reperfusion Treatment
Hospital fibrinolysis:
Door-to-Needle
within 30 min.
Not PCI
capable
Call 9-1-1
Call fast
EMS on-scene
Encourage 12-lead ECGs.
Consider prehospital fibrinolytic if capable and EMS-to-needle within 30 min.
Inter-Hospital
Transfer
Onset of symptoms of STEMI
9-1-1
EMS
Dispatch
EMS Triage Plan
PCI
capable
GOALS 5
min. 8
min.
EMS Transport
Patient
EMS
Prehospital fibrinolysis
EMS-to-needle
within 30 min.
EMS transport
EMS-to-balloon within 90 min.
Patient self-transport
Hospital door-to-balloon
within 90 min.
Dispatch
1 min.
Golden Hour = first 60 min.
Total ischemic time: within 120 min.
Antman EM, et al. J Am Coll Cardiol Published ahead of print on December 10, Available at

89. Coronary Angioplasty VS Fibrinolytic Therapy in Acute Myocardial Infarction
Fibrinolysis
Door-to-Needle or FMC to Needle
< 30 mins
Not PCI
capable
EMS Transport
PCI
capable
PCI
Door-to-Balloon or FMC to Balloon ≤ 90 mins

90. Coronary Angioplasty VS Fibrinolytic Therapy in Acute Myocardial Infarction
2004 STEMI Guideline
DIDO
PCI
Door-to-Balloon or FMC to Balloon ≤ 90 mins
30 mins
Not PCI
capable
EMS Transport
2013 STEMI Guideline
PCI
Door-to-Balloon or FMC to Balloon ≤ 90 mins
PCI
capable
PCI
Door-to-Balloon or FMC to Balloon ≤ 120 mins

91. Mortality and Ejection Fraction50
< 20%
N = 799
Mean EF = 46% 40 30
One Year Cardiac Mortality (%) 20
20-39% 10
40-59%
> 60% 10 20 30 40 50 60 70 80
Radionuclide Ejection Fraction (%)

92. STEMI: Standard Therapy
Thrombolytic Agent or PCI
Aspirin
Heparin
Clopidogrel
Beta Blockers within 24 hours
ACE Inhibitors or ARB’s within 24 hours
Aldosterone antagonists for EF ≤40%
Statins before hospital discharge