ST elevation myocardial infarction fibrinolysis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Yamuna Kondapally, M.B.B.S[2]

2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease[1]

Recommendations for Duration of DAPT in Patients With STEMI Treated With Fibrinolytic Therapy

Class I
"1. In patients with STEMI treated with DAPT in conjunction with fibrinolytic therapy, P2Y12 therapy (clopidogrel) should be continued for a minimum of 14 days(Level of Evidence: A) and ideally at least 12 months (Level of Evidence: C-EO)"
"2. In patients treated with DAPT, a daily aspirin dose of 81 mg (range, 75 mg to 100 mg) is recommended (Level of Evidence: B-NR)"
Class IIa
"1. In patients with NSTE–ACS who are managed with medical therapy alone (without revascularization or fibrinolytic therapy) and treated with DAPT, it is reasonable to use ticagrelor in preference to clopidogrel for maintenance P2Y12 inhibitor therapy (Level of Evidence: B-R)"
Class IIb
"1. In patients with STEMI treated with fibrinolytic therapy who have tolerated DAPT without bleeding complication and who are not at high bleeding risk (e.g., prior bleeding on DAPT, coagulopathy, oral anticoagulant use), continuation of DAPT for longer than 12 months may be reasonable (Level of Evidence: A SR)"

2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction: Executive Summary(DO NOT EDIT)[2]

Reperfusion at a Non–PCI-Capable Hospital: Recommendations (DO NOT EDIT)

Fibrinolytic Therapy When There Is an Anticipated Delay to Performing Primary PCI Within 120 Minutes of FMC (DO NOT EDIT)

Class I
"1. In the absence of contraindications, fibrinolytic therapy should be given to patients with STEMI and onset of ischemic symptoms within the previous 12 hours when it is anticipated that primary PCI cannot be performed within 120 minutes of FMC (Level of Evidence: A)"
Class III (Harm)
"1. Fibrinolytic therapy should not be administered to patients with ST depression except when a true posterior (inferobasal) MI is suspected or when associated with ST elevation in lead aVR (Level of Evidence: B)"
Class IIa
"1. In the absence of contraindications and when PCI is not available, fibrinolytic therapy is reasonable for patients with STEMI if there is clinical and/or electrocardiographic evidence of ongoing ischemia within 12 to 24 hours of symptom onset and a large area of myocardium at risk or hemodynamic instability (Level of Evidence: C)"

Adjunctive Antithrombotic Therapy With Fibrinolysis (DO NOT EDIT)

Adjunctive Antiplatelet Therapy With Fibrinolysis (DO NOT EDIT)
Class I
"1. Aspirin (162- to 325-mg loading dose) and clopidogrel (300-mg loading dose for patients ≤75 years of age, 75-mg dose for patients >75 years of age) should be administered to patients with STEMI who receive fibrinolytic therapy(Level of Evidence: A)"
"2. Aspirin should be continued indefinitely (Level of Evidence: A) and clopidogrel (75 mg daily) should be continued for at least 14 days (Level of Evidence: A) and up to 1 year (Level of Evidence: C) in patients with STEMI who receive fibrinolytic therapy"
Class IIa
"1. It is reasonable to use aspirin 81 mg per day in preference to higher maintenance doses after fibrinolytic therapy (Level of Evidence: B)"
Adjunctive Anticoagulant Therapy With Fibrinolysis (DO NOT EDIT)
Class I
"1. Patients with STEMI undergoing reperfusion with fibrinolytic therapy should receive anticoagulant therapy for a minimum of 48 hours, and preferably for the duration of the index hospitalization, up to 8 days or until revascularization if performed. Recommended regimens include(Level of Evidence: A)"
"a. UFH administered as a weight-adjusted intravenous bolus and infusion to obtain an activated partial thromboplastin time of 1.5 to 2.0 times control, for 48 hours or until revascularization(Level of Evidence: C)"
"b. Enoxaparin administered according to age, weight, and creatinine clearance, given as an intravenous bolus, followed in 15 minutes by subcutaneous injection for the duration of the index hospitalization, up to 8 days or until revascularization(Level of Evidence: A)"
"c.Fondaparinux administered with initial intravenous dose, followed in 24 hours by daily subcutaneous injections if the estimated creatinine clearance is greater than 30 mL/min, for the duration of the index hospitalization, up to 8 days or until revascularization(Level of Evidence: B)"

Transfer to a PCI-Capable Hospital After Fibrinolytic Therapy (DO NOT EDIT)

Transfer of Patients With STEMI to a PCI-Capable Hospital for Coronary Angiography After Fibrinolytic Therapy
Class I
"1. Immediate transfer to a PCI-capable hospital for coronary angiography is recommended for suitable patients with STEMI who develop cardiogenic shock or acute severe HF, irrespective of the time delay from MI onset(Level of Evidence: B)"
Class IIa
"1. Urgent transfer to a PCI-capable hospital for coronary angiography is reasonable for patients with STEMI who demonstrate evidence of failed reperfusion or reocclusion after fibrinolytic therapy (Level of Evidence: B)"
"2. Transfer to a PCI-capable hospital for coronary angiography is reasonable for patients with STEMI who have received fibrinolytic therapy even when hemodynamically stable and with clinical evidence of successful reperfusion. Angiography can be performed as soon as logistically feasible at the receiving hospital, and ideally within 24 hours, but should not be performed within the first 2 to 3 hours after administration of fibrinolytic therapy (Level of Evidence: B)"

References

  1. Levine GN, Bates ER, Bittl JA, Brindis RG, Fihn SD, Fleisher LA; et al. (2016). "2016 ACC/AHA guideline focused update on duration of dual antiplatelet therapy in patients with coronary artery disease: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.". J Thorac Cardiovasc Surg. 152 (5): 1243–1275. PMID 27751237. doi:10.1016/j.jtcvs.2016.07.044. 
  2. American College of Emergency Physicians. Society for Cardiovascular Angiography and Interventions. O'Gara PT, Kushner FG, Ascheim DD, Casey DE; et al. (2013). "2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.". J Am Coll Cardiol. 61 (4): 485–510. PMID 23256913. doi:10.1016/j.jacc.2012.11.018. 

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