ST elevation myocardial infarction initial care

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Pre-Hospital Care

Initial Care

Oxygen
Nitrates
Analgesics
Aspirin
Beta Blockers
Antithrombins
The coronary care unit
The step down unit
STEMI and Out-of-Hospital Cardiac Arrest
Pharmacologic Reperfusion
Reperfusion Therapy (Overview of Fibrinolysis and Primary PCI)
Fibrinolysis
Reperfusion at a Non–PCI-Capable Hospital:Recommendations
Mechanical Reperfusion
The importance of reducing Door-to-Balloon times
Primary PCI
Adjunctive and Rescue PCI
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Adjunctive PCI
CABG
Management of Patients Who Were Not Reperfused
Assessing Success of Reperfusion
Antithrombin Therapy
Antithrombin therapy
Unfractionated heparin
Low Molecular Weight Heparinoid Therapy
Direct Thrombin Inhibitor Therapy
Factor Xa Inhibition
DVT prophylaxis
Long term anticoagulation
Antiplatelet Agents
Aspirin
Thienopyridine Therapy
Glycoprotein IIbIIIa Inhibition
Other Initial Therapy
Inhibition of the Renin-Angiotensin-Aldosterone System
Magnesium Therapy
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Calcium Channel Blocker Therapy
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Recommendations for Perioperative Management–Timing of Elective Noncardiac Surgery in Patients Treated With PCI and DAPT

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Overview
Inhibition of the Renin-Angiotensin-Aldosterone System
Cardiac Rehabilitation
Pacemaker Implantation
Long Term Anticoagulation
Implantable Cardioverter Defibrillator
ICD implantation within 40 days of myocardial infarction
ICD within 90 days of revascularization

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Cafer Zorkun, M.D., Ph.D. [2]

Overview

The goal of initial care of the STEMI patient is to restore epicardial artery patency as rapidly and fully as possible, and to reduce the risk of early vessel reocclusion. Other goals include reducing the risk of lethal ventricular arrhythmias and other mechanical complications as well as reducing myocardial oxygen demands to limit infarct size with beta blockers.

Overview of Initial Therapies

Initial therapies include oxygen, aspirin, nitroglycerin or glyceryl trinitrate (an important exception is if the patient has a right ventricular myocardial infarction) and analgesia (usually morphine). [1] Morphine is the preferred analgesic agent due to its ability to reduce adrenergic drive and reduce preload (it is a venodilator). NSAIDs and COX-2 inhibitors should be discontinued due to their association with higher rates of adverse events.[2] [3] The antiplatelet agent aspirin has been associated with a reduction in mortality and has limited adverse effects. [4] Full dose non-enteric coated aspirin (162 mg to 325 mg) should be administered to a STEMI patient who does not have a history of hypersensitivity to ASA as soon as possible. In the absence of cardiogenic shock or heart failure, a beta blocker should also be administered.

Once the diagnosis of myocardial infarction is confirmed and diagnoses that would contraindicate the administration of antithrombins such as aortic dissection and pericarditis have been excluded, antithrombin therapy should be initiated. [1]

Initial Care

Triage and transfer for PCI in STEMI:

Triage in STEMI.png

You can read in greater detail about each of the therapies below in greater detail by clicking on the link for that therapy.

Oxygen | Nitrates | Analgesics | Aspirin | Beta Blockers | The coronary care unit | The step down unit

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

  1. 1.0 1.1 Antman EM, Anbe DT, Armstrong PW; 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. PMID 15289388. doi:10.1161/01.CIR.0000134791.68010.FA.  Unknown parameter |month= ignored (help)
  2. C. Michael Gibson, Yuri B. Pride, Philip E. Aylward, Jacques J. Col, Shaun G. Goodman, Dietrich Gulba, Mijo Bergovec, Vijayalakshmi Kunadian, Cafer Zorkun, Jacqueline L. Buros, Sabina A. Murphy and Elliott M. Antman.Association of non-steroidal anti-inflammatory drugs with outcomes in patients with ST-segment elevation myocardial infarction treated with fibrinolytic therapy: an ExTRACT-TIMI 25 analysis. DOI10.1007/s11239-008-0264-4.
  3. Gaziano JM, Gibson CM (2006). "Potential for drug-drug interactions in patients taking analgesics for mild-to-moderate pain and low-dose aspirin for cardioprotection". Am. J. Cardiol. 97 (9A): 23–9. PMID 16675319. doi:10.1016/j.amjcard.2006.02.020.  Unknown parameter |month= ignored (help)
  4. "Randomised trial of intravenous streptokinase, oral aspirin, both, or neither among 17,187 cases of suspected acute myocardial infarction: ISIS-2. ISIS-2 (Second International Study of Infarct Survival) Collaborative Group". Lancet. 2 (8607): 349–60. 1988. PMID 2899772.  Unknown parameter |month= ignored (help)
  5. 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 (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.  Unknown parameter |month= ignored (help)
  6. Antman EM, Hand M, Armstrong PW; et al. (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. PMID 18071078. doi:10.1161/CIRCULATIONAHA.107.188209.  Unknown parameter |month= ignored (help)

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