ST elevation myocardial infarction oxygen therapy
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Editors-In-Chief: C. Michael Gibson, M.S., M.D. [1] and Tom Quinn, FRCN, FESC [2]
Overview
Oxygen therapy is commonly used within the STEMI patient population. Theoretical models suggest that the usage of oxygen therapy can influence the ventilation perfusion mismatch which occurs early on in the patient's course of disease. Randomized clinical data to support this therapy is still lacking.
Oxygen Therapy
Mechanism of Benefit
Oxygen is administered to the vast majority (98%) of patients with ST elevation myocardial infarction (STEMI). There is limited data to suggest that supplemental oxygen improves ST segment resolution (a surrogate endpoint)[1] The theoretical basis for oxygen administration is also based on the fact that there may be ventilation perfusion mismatch early in the patient's course[2]
Clinical Trial Data
Large scale randomized clinical trial data is lacking regarding its impact on mortality or other hard clinical endpoints. A recent review of available trial data indicated no benefit of supplemental oxygen, and in fact there was signs of a hazard [3]. Three randomized trial have enrolled a total of 387 patients. There were 14 deaths. Oxygen administration was associated with non-significant 2.88 fold increase in mortality (95% CI 0.88-9.39). It should be emphasized that given the small numbers of deaths in the trials, the trend toward a hazard associated with oxygen could represent a play of chance, and was not statistically significant. Large randomized trials would be necessary to evaluate the risks and benefits of oxygen. Current guideline recommendations are based upon expert consensus, and not clinical trial data.
Dosing
In general oxygen is administered via nasal canula or face mask to patients with an uncomplicated course to maintain an oxygen saturation greater than 90%. However, endotracheal intubation may be required in those patients with a clinical course complicated by severe pulmonary edema, cardiogenic shock or mechanical complications (e.g. papillary muscle rupture, free wall rupture, or acquired ventricular septal defect).
Side Effects
While the majority of patients may benefit from supplemental oxygen administration, excess oxygen administration may be harmful to those patients with chronic obstructive pulmonary disease. Administration of oxygen to these patients should be judicious and guided by periodic arterial blood gas values.
2004 ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction (DO NOT EDIT) [4]
| Class I |
| "1. Supplemental oxygen should be administered to patients with arterial oxygen desaturation (SaO2 less than 90%). (Level of Evidence: B) " |
| Class IIa |
| "1. It is reasonable to administer supplemental oxygen to all patients with uncomplicated STEMI during the first 6 hours. (Level of Evidence: C) " |
Sources
- The 2004 ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction [5]
- The 2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients with ST-Elevation Myocardial Infarction [6]
References
- ↑ Madias JE, Hood WB (March 1976). "Reduction of precordial ST-segment elevation in patients with anterior myocardial infarction by oxygen breathing". Circulation 53 (3 Suppl): I198–200. PMID 1253359.
- ↑ Fillmore SJ, Shapiro M, Killip T (May 1970). "Arterial oxygen tension in acute myocardial infarction. Serial analysis of clinical state and blood gas changes". Am. Heart J. 79 (5): 620–9. PMID 5444451.
- ↑ Cabello JB, Burls A, Emparanza JI, et al. Oxygen therapy for acute myocardial infarction. Cochrane Database Syst Rev 2010; 6: CD007160. DOI: 10.1002/14651858.CD007160.pub2. Available at: http://www.cochrane.org/cochrane-reviews
- ↑ Antman EM, Anbe DT, Armstrong PW, Bates ER, Green LA, Hand M et al. (2004). "ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction--executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1999 Guidelines for the Management of Patients With Acute Myocardial Infarction).". Circulation 110 (5): 588-636. doi:10.1161/01.CIR.0000134791.68010.FA. PMID 15289388.
- ↑ Antman EM, Anbe DT, Armstrong PW, Bates ER, Green LA, Hand M, Hochman JS, Krumholz HM, Kushner FG, Lamas GA, Mullany CJ, Ornato JP, Pearle DL, Sloan MA, Smith SC, Alpert JS, Anderson JL, Faxon DP, Fuster V, Gibbons RJ, Gregoratos G, Halperin JL, Hiratzka LF, Hunt SA, Jacobs AK (August 2004). "ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of Patients with Acute Myocardial Infarction)". Circulation 110 (9): e82–292. PMID 15339869.
- ↑ Antman EM, Hand M, Armstrong PW, et al (January 2008). "2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines: developed in collaboration With the Canadian Cardiovascular Society endorsed by the American Academy of Family Physicians: 2007 Writing Group to Review New Evidence and Update the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction, Writing on Behalf of the 2004 Writing Committee". Circulation 117 (2): 296–329. doi:10.1161/CIRCULATIONAHA.107.188209. PMID 18071078.
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