ST elevation myocardial infarction management of patients who were not reperfused

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ST elevation myocardial infarction management of patients who were not reperfused On the Web

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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

STEMI patients who do not receive reperfusion therapy can be stratified for a differed mortality risk than those who do. The ACC/AHA guidelines recommend specific guidelines for care in this patient population.

Clinical Trial Data

[1]

Adjusted probability of death or cerebral bleeding in relation to fibrinolytic therapy in patients with ST elevation myocardial infarction (STEMI) who were 75 years or older (dotted line) versus that among patients with STEMI not receiving fibrinolysis (solid line). At 30 days and 1 year this was 23% and 32% versus 26% and 36%, respectively.

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

Coronary Angiography in Patients Who Initially Were Managed With Fibrinolytic Therapy or Who Did Not Receive Reperfusion

Class I
"1. Cardiac catheterization and coronary angiography with intent to perform revascularization should be performed after STEMI in patients with any of the following:
"a. Cardiogenic shock or acute severe HF that develops after initial presentation(Level of Evidence: B)"
"b. Intermediate- or high-risk findings on predischarge noninvasive ischemia testing(Level of Evidence: B)"
"b. Intermediate- or high-risk findings on predischarge noninvasive ischemia testing(Level of Evidence: C)"


Class IIa
"1. Coronary angiography with intent to perform revascularization is reasonable for patients with evidence of failed reperfusion or reocclusion after fibrinolytic therapy. Angiography can be performed as soon as logistically feasible (Level of Evidence: B)"
"2. Coronary angiography is reasonable before hospital discharge in stable patients with STEMI after successful fibrinolytic therapy. Angiography can be performed as soon as logistically feasible, 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)"

PCI of an Infarct Artery in Patients Who Initially Were Managed With Fibrinolysis or Who Did Not Receive Reperfusion Therapy(DO NOT EDIT)

Class I
"1. PCI of an anatomically significant stenosis in the infarct artery should be performed in patients with suitable anatomy and any of the following:
"a. Cardiogenic shock or acute severe HF(Level of Evidence: B)"
"b. Intermediate- or high-risk findings on predischarge noninvasive ischemia testing (Level of Evidence: C)"
"c. Myocardial ischemia that is spontaneous or provoked by minimal exertion during hospitalization (Level of Evidence: C)"
Class III (No Benefit)
"1. Delayed PCI of a totally occluded infarct artery greater than 24 hours after STEMI should not be performed in asymptomatic patients with 1- or 2-vessel disease if they are hemodynamically and electrically stable and do not have evidence of severe ischemia (Level of Evidence: B)"
Class IIa
"1. Delayed PCI is reasonable in patients with STEMI and evidence of failed reperfusion or reocclusion after fibrinolytic therapy. PCI can be performed as soon as logistically feasible at the receiving hospital (Level of Evidence: B)"
"2. Delayed PCI of a significant stenosis in a patent infarct artery is reasonable in stable patients with STEMI after fibrinolytic therapy. PCI 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)"
Class IIb
"1. Delayed PCI of a significant stenosis in a patent infarct artery greater than 24 hours after STEMI may be considered as part of an invasive strategy in stable patients (Level of Evidence: B)"

PCI of a Noninfarct Artery Before Hospital Discharge(DO NOT EDIT)

Class I
"1. PCI is indicated in a noninfarct artery at a time separate from primary PCI in patients who have spontaneous symptoms of myocardial ischemia(Level of Evidence: C)"
Class IIa
"1. PCI is reasonable in a noninfarct artery at a time separate from primary PCI in patients with intermediate- or high-risk findings on noninvasive testing (Level of Evidence: B)"

Adjunctive Antithrombotic Therapy to Support Delayed PCI After Fibrinolytic Therapy(DO NOT EDIT)

Antiplatelet Therapy to Support PCI After Fibrinolytic Therapy
Class I
"1. After PCI, aspirin should be continued indefinitely (Level of Evidence: A)"
"2.Clopidogrel should be provided as follows:
"a. A 300-mg loading dose should be given before or at the time of PCI to patients who did not receive a previous loading dose and who are undergoing PCI within 24 hours of receiving fibrinolytic therapy(Level of Evidence: C)"
"b. A 600-mg loading dose should be given before or at the time of PCI to patients who did not receive a previous loading dose and who are undergoing PCI more than 24 hours after receiving fibrinolytic therapy(Level of Evidence: C)"
"c. A dose of 75 mg daily should be given after PCI(Level of Evidence: C)"
Class III (Harm)
"1. Prasugrel should not be administered to patients with a history of prior stroke or transient ischemic attack (Level of Evidence: B)"
Class IIa
"1. After PCI, it is reasonable to use 81 mg of aspirin per day in preference to higher maintenance doses (Level of Evidence: B)"
"2. Prasugrel, in a 60-mg loading dose, is reasonable once the coronary anatomy is known in patients who did not receive a previous loading dose of clopidogrel at the time of administration of a fibrinolytic agent, but prasugrel should not be given sooner than 24 hours after administration of a fibrin-specific agent or 48 hours after administration of a non–fibrin-specific agent(Level of Evidence: B)"
"3. Prasugrel, in a 10-mg daily maintenance dose, is reasonable after PCI(Level of Evidence: B)"
Anticoagulant Therapy to Support PCI After Fibrinolytic Therapy
Class I
"1. For patients with STEMI undergoing PCI after receiving fibrinolytic therapy with intravenous UFH, additional boluses of intravenous UFH should be administered as needed to support the procedure, taking into account whether GP IIb/IIIa receptor antagonists have been administered.(Level of Evidence: C)"
"2. For patients with STEMI undergoing PCI after receiving fibrinolytic therapy with enoxaparin, if the last subcutaneous dose was administered within the prior 8 hours, no additional enoxaparin should be given; if the last subcutaneous dose was administered between 8 and 12 hours earlier, enoxaparin 0.3 mg/kg IV should be given(Level of Evidence: B)"
Class III (Harm)
"1. Fondaparinux should not be used as the sole anticoagulant to support PCI. An additional anticoagulant with anti-IIa activity should be administered because of the risk of catheter thrombosis (Level of Evidence: C)"

2013 Revised ACCF/AHA Guidelines for the Management of ST-Elevation Myocardial Infarction (DO NOT EDIT)[3]

PCI of an Infarct Artery in Patients Who Initially Were Managed With Fibrinolysis or Who Did Not Receive Reperfusion Therapy (DO NOT EDIT)[3]

Class I
"1. PCI of an anatomically significant stenosis in the infarct artery should be performed in patients with suitable anatomy and any of the following:
"a. Cardiogenic shock or acute severe HF[4](Level of Evidence: B)"
"b. Intermediate- or high-risk findings on predischarge noninvasive ischemia testing[5][6](Level of Evidence: C)"
"c. Myocardial ischemia that is spontaneous or provoked by minimal exertion during hospitalization.(Level of Evidence: C)"
Class III (No Benefit)
"1. Delayed PCI of a totally occluded infarct artery greater than 24 hours after STEMI should not be performed in asymptomatic patients with 1- or 2-vessel disease if they are hemodynamically and electrically stable and do not have evidence of severe ischemia.[7][8] (Level of Evidence: B)"
Class IIa
"1. Delayed PCI is reasonable in patients with STEMI and evidence of failed reperfusion or reocclusion after fibrinolytic therapy. PCI can be performed as soon as logistically feasible at the receiving hospital.[9][10][11][12](Level of Evidence: B)"
"2. Delayed PCI of a significant stenosis in a patent infarct artery is reasonable in stable patients with STEMI after fibrinolytic therapy. PCI 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.[13][14][15][16][17][18](Level of Evidence: B)"
Class IIb
"1. Delayed PCI of a significant stenosis in a patent infarct artery greater than 24 hours after STEMI may be considered as part of an invasive strategy in stable patients.[7][5][6][19][20][21][8][22][23](Level of Evidence: B)"

Sources

  • 2013 Revised ACCF/AHA Guidelines for the Management of ST-Elevation Myocardial Infarction [3]

References

  1. Stenestrand U, Wallentin L (2003). "Fibrinolytic therapy in patients 75 years and older with ST-segment-elevation myocardial infarction: one-year follow-up of a large prospective cohort". Arch. Intern. Med. 163 (8): 965–71. PMID 12719207. doi:10.1001/archinte.163.8.965.  Unknown parameter |month= ignored (help)
  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. 
  3. 3.0 3.1 3.2 O'Gara PT, Kushner FG, Ascheim DD; et al. (2012). "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". Circulation. PMID 23247303. doi:10.1161/CIR.0b013e3182742c84.  Unknown parameter |month= ignored (help)
  4. Hochman JS, Sleeper LA, White HD; et al. (2001). "One-year survival following early revascularization for cardiogenic shock". JAMA. 285 (2): 190–2. PMID 11176812.  Unknown parameter |month= ignored (help)
  5. 5.0 5.1 Erne P, Schoenenberger AW, Burckhardt D; et al. (2007). "Effects of percutaneous coronary interventions in silent ischemia after myocardial infarction: the SWISSI II randomized controlled trial". JAMA. 297 (18): 1985–91. PMID 17488963. doi:10.1001/jama.297.18.1985.  Unknown parameter |month= ignored (help)
  6. 6.0 6.1 Madsen JK, Grande P, Saunamäki K; et al. (1997). "Danish multicenter randomized study of invasive versus conservative treatment in patients with inducible ischemia after thrombolysis in acute myocardial infarction (DANAMI). DANish trial in Acute Myocardial Infarction". Circulation. 96 (3): 748–55. PMID 9264478.  Unknown parameter |month= ignored (help)
  7. 7.0 7.1 Hochman JS, Lamas GA, Buller CE; et al. (2006). "Coronary intervention for persistent occlusion after myocardial infarction". N. Engl. J. Med. 355 (23): 2395–407. PMC 1995554Freely accessible. PMID 17105759. doi:10.1056/NEJMoa066139.  Unknown parameter |month= ignored (help)
  8. 8.0 8.1 Ioannidis JP, Katritsis DG (2007). "Percutaneous coronary intervention for late reperfusion after myocardial infarction in stable patients". Am. Heart J. 154 (6): 1065–71. PMID 18035076. doi:10.1016/j.ahj.2007.07.049.  Unknown parameter |month= ignored (help)
  9. Sutton AG, Campbell PG, Graham R; et al. (2004). "A randomized trial of rescue angioplasty versus a conservative approach for failed fibrinolysis in ST-segment elevation myocardial infarction: the Middlesbrough Early Revascularization to Limit INfarction (MERLIN) trial". J. Am. Coll. Cardiol. 44 (2): 287–96. PMID 15261920. doi:10.1016/j.jacc.2003.12.059.  Unknown parameter |month= ignored (help)
  10. Gibson CM, Murphy SA, Rizzo MJ; et al. (1999). "Relationship between TIMI frame count and clinical outcomes after thrombolytic administration. Thrombolysis In Myocardial Infarction (TIMI) Study Group". Circulation. 99 (15): 1945–50. PMID 10208996.  Unknown parameter |month= ignored (help)
  11. Gibson CM, Cannon CP, Murphy SA, Marble SJ, Barron HV, Braunwald E (2002). "Relationship of the TIMI myocardial perfusion grades, flow grades, frame count, and percutaneous coronary intervention to long-term outcomes after thrombolytic administration in acute myocardial infarction". Circulation. 105 (16): 1909–13. PMID 11997276.  Unknown parameter |month= ignored (help)
  12. Sutton AG, Campbell PG, Price DJ; et al. (2000). "Failure of thrombolysis by streptokinase: detection with a simple electrocardiographic method". Heart. 84 (2): 149–56. PMC 1760890Freely accessible. PMID 10908249.  Unknown parameter |month= ignored (help)
  13. Bøhmer E, Hoffmann P, Abdelnoor M, Arnesen H, Halvorsen S (2010). "Efficacy and safety of immediate angioplasty versus ischemia-guided management after thrombolysis in acute myocardial infarction in areas with very long transfer distances results of the NORDISTEMI (NORwegian study on DIstrict treatment of ST-elevation myocardial infarction)". J. Am. Coll. Cardiol. 55 (2): 102–10. PMID 19747792. doi:10.1016/j.jacc.2009.08.007.  Unknown parameter |month= ignored (help)
  14. Borgia F, Goodman SG, Halvorsen S; et al. (2010). "Early routine percutaneous coronary intervention after fibrinolysis vs. standard therapy in ST-segment elevation myocardial infarction: a meta-analysis". Eur. Heart J. 31 (17): 2156–69. PMID 20601393. doi:10.1093/eurheartj/ehq204.  Unknown parameter |month= ignored (help)
  15. Cantor WJ, Fitchett D, Borgundvaag B; et al. (2009). "Routine early angioplasty after fibrinolysis for acute myocardial infarction". N. Engl. J. Med. 360 (26): 2705–18. PMID 19553646. doi:10.1056/NEJMoa0808276.  Unknown parameter |month= ignored (help)
  16. Sosnowski C (2008). "[Commentary to the article: Di Mario C, Dudek D, Piscione F, et al.; CARESS-in-AMI (Combined Abciximab RE-teplase Stent Study in Acute Myocardial Infarction) Investigators. Immediate angioplasty versus standard therapy with rescue angioplasty after thrombolysis in the Combined Abciximab REteplase Stent Study in Acute Myocardial Infarction (CARESS-in-AMI): an open, prospective, randomised, multicentre trial. Lancet 2008; 371: 559-68]". Kardiol Pol (in Polish). 66 (4): 461–4; discussion 465–6. PMID 18634182.  Unknown parameter |month= ignored (help)
  17. Fernandez-Avilés F, Alonso JJ, Castro-Beiras A; et al. (2004). "Routine invasive strategy within 24 hours of thrombolysis versus ischaemia-guided conservative approach for acute myocardial infarction with ST-segment elevation (GRACIA-1): a randomised controlled trial". Lancet. 364 (9439): 1045–53. PMID 15380963. doi:10.1016/S0140-6736(04)17059-1. 
  18. White HD (2008). "Systems of care: need for hub-and-spoke systems for both primary and systematic percutaneous coronary intervention after fibrinolysis". Circulation. 118 (3): 219–22. PMID 18625904. doi:10.1161/CIRCULATIONAHA.108.790170.  Unknown parameter |month= ignored (help)
  19. D'Souza SP, Mamas MA, Fraser DG, Fath-Ordoubadi F (2011). "Routine early coronary angioplasty versus ischaemia-guided angioplasty after thrombolysis in acute ST-elevation myocardial infarction: a meta-analysis". Eur. Heart J. 32 (8): 972–82. PMID 21036776. doi:10.1093/eurheartj/ehq398.  Unknown parameter |month= ignored (help)
  20. Gupta M, Chang WC, Van de Werf F; et al. (2003). "International differences in in-hospital revascularization and outcomes following acute myocardial infarction: a multilevel analysis of patients in ASSENT-2". Eur. Heart J. 24 (18): 1640–50. PMID 14499226.  Unknown parameter |month= ignored (help)
  21. Gibson CM, Karha J, Murphy SA; et al. (2003). "Early and long-term clinical outcomes associated with reinfarction following fibrinolytic administration in the Thrombolysis in Myocardial Infarction trials". J. Am. Coll. Cardiol. 42 (1): 7–16. PMID 12849652.  Unknown parameter |month= ignored (help)
  22. Steg PG, Thuaire C, Himbert D; et al. (2004). "DECOPI (DEsobstruction COronaire en Post-Infarctus): a randomized multi-centre trial of occluded artery angioplasty after acute myocardial infarction". Eur. Heart J. 25 (24): 2187–94. PMID 15589635. doi:10.1016/j.ehj.2004.10.019.  Unknown parameter |month= ignored (help)
  23. Wilson SH, Bell MR, Rihal CS, Bailey KR, Holmes DR, Berger PB (2001). "Infarct artery reocclusion after primary angioplasty, stent placement, and thrombolytic therapy for acute myocardial infarction". Am. Heart J. 141 (5): 704–10. PMID 11320356. doi:10.1067/mhj.2001.114971.  Unknown parameter |month= ignored (help)

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