|
|
| (19 intermediate revisions by 8 users not shown) |
| Line 1: |
Line 1: |
| {{Infobox_Disease |
| |
| Name = Myocardial infarction|
| |
| Image = AMI scheme.png |
| |
| Caption = Diagram of a '''myocardial infarction''' (2) of the tip of the [[Sternocostal surface|anterior wall of the heart]] (an ''apical infarct'') after occlusion (1) of a branch of the [[left coronary artery]] (LCA, [[right coronary artery]] = RCA).|
| |
| DiseasesDB = 8664 |
| |
| ICD10 = {{ICD10|I|21||i|20}}-{{ICD10|I|22||i|20}} |
| |
| ICD9 = {{ICD9|410}} |
| |
| ICDO = |
| |
| OMIM = |
| |
| MedlinePlus = 000195 |
| |
| eMedicineSubj = med |
| |
| eMedicineTopic = 1567 |
| |
| eMedicine_mult = {{eMedicine2|emerg|327}} {{eMedicine2|ped|2520}} |
| |
| MeshID = |
| |
| }}
| |
| {{SI}}
| |
| {{WikiDoc Cardiology Network Infobox}}
| |
| __NOTOC__ | | __NOTOC__ |
| | {{ST elevation myocardial infarction}} |
| {{CMG}} | | {{CMG}} |
|
| |
| '''Associate Editor-In-Chief:''' {{CZ}}
| |
|
| |
|
| {{Editor Join}}
| | ==Overview== |
| | Current ACA/AHA guidelines support the usage of reperfusion therapy among STEMI patients. It is of critical importance to facilitate a timely introduction of reperfusion therapy to the patient. Reperfusion therapy can be achieved either by percutaneous coronary intervention or thrombolytic therapy. |
|
| |
|
| ==Reperfusion== | | ==2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction (DO NOT EDIT) <ref name="pmid18071078">{{cite journal |author=Antman EM, Hand M, Armstrong PW, ''et al'' |title=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 |journal=Circulation |volume=117 |issue=2 |pages=296–329 |year=2008 |month=January |pmid=18071078 |doi=10.1161/CIRCULATIONAHA.107.188209 |url=}}</ref>== |
|
| |
|
| Regardless of the mode of reperfusion, the overarching concept is to minimize total ischemic time, which is defined as the time from onset of symptoms of STEMI to initiation of reperfusion therapy.
| | {|class="wikitable" |
| | |- |
| | | colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]] |
| | |- |
| | | bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' [[STEMI]] patients presenting to a hospital with [[PCI]] capability should be treated with [[primary PCI]] within 90 minutes of first medical contact as a systems goal. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]]) <nowiki>"</nowiki> |
| | |- |
| | | bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' [[STEMI]] patients presenting to a hospital without [[PCI]] capability and who cannot be transferred to a [[PCI]] center and undergo [[PCI]] within 90 minutes of first medical contact should be treated with [[fibrinolytic therapy]] within 30 minutes of hospital presentation as a systems goal unless [[fibrinolytic therapy]] is contraindicated. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])<nowiki>"</nowiki> |
| | |} |
|
| |
|
| It is increasingly clear that 2 types of hospital systems provide reperfusion therapy:
| | ==Related Chapters== |
| | * [[The Living Guidelines: STEMI | The STEMI Living Guidelines: Vote on current recommendations and suggest revisions to the guidelines]] |
|
| |
|
| * Hospitals with percutaneous coronary intervention (PCI) capability | | ==Sources== |
| * Hospitals without PCI capability.
| | *The 2004 ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction <ref name="pmid15339869">{{cite journal |author=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 |title=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) |journal=Circulation |volume=110 |issue=9 |pages=e82–292 |year=2004 |month=August |pmid=15339869 |doi= |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=15339869}}</ref> |
|
| |
|
| When PCI capability is available, the best outcomes are achieved by offering this strategy 24 hours per day, 7 days per week.<ref>Antman EM. Manual for ACC/AHA Guideline Writing Committees: Methodologies and Policies from the ACC/AHA Task Force on Practice Guidelines. 2004. Available at: http://www.acc.org/qualityandscience/clinical/manual/pdfs/methodology.pdf Accessed September 24, 2007.</ref>
| | *The 2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients with ST-Elevation Myocardial Infarction <ref name="pmid18071078">{{cite journal |author=Antman EM, Hand M, Armstrong PW, ''et al'' |title=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 |journal=Circulation |volume=117 |issue=2 |pages=296–329 |year=2008 |month=January |pmid=18071078 |doi=10.1161/CIRCULATIONAHA.107.188209 |url=}}</ref> |
| | |
| The concept of reperfusion has become so central to the modern treatment of acute myocardial infarction, that we are said to be in the reperfusion era.<ref name="pmid7882472">{{cite journal |author=Lee KL, Woodlief LH, Topol EJ, ''et al'' |title=Predictors of 30-day mortality in the era of reperfusion for acute myocardial infarction. Results from an international trial of 41,021 patients. GUSTO-I Investigators |journal=Circulation |volume=91 |issue=6 |pages=1659–68 |year=1995 |month=March |pmid=7882472 |doi= |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=7882472}}</ref><ref name="pmid14645641">{{cite journal |author=Wang K, Asinger RW, Marriott HJ |title=ST-segment elevation in conditions other than acute myocardial infarction |journal=N. Engl. J. Med. |volume=349 |issue=22 |pages=2128–35 |year=2003 |month=November |pmid=14645641 |doi=10.1056/NEJMra022580 |url=}}</ref> Patients who present with suspected acute myocardial infarction and ST segment elevation (STEMI) or new bundle branch block on the 12 lead [[ECG]] are presumed to have an occlusive thrombosis in an epicardial coronary artery. They are therefore candidates for immediate reperfusion, either with [[thrombolysis|thrombolytic therapy]], [[percutaneous coronary intervention]] (PCI) or when these therapies are unsuccessful, [[Coronary artery bypass surgery|bypass surgery]].
| |
| | |
| Individuals without ST segment elevation are presumed to be experiencing either unstable angina (UA) or non-ST segment elevation myocardial infarction (NSTEMI). They receive many of the same initial therapies and are often stabilized with [[antiplatelet drug]]s and [[Anticoagulant|anticoagulated]]. If their condition remains ([[Hemodynamics|hemodynamically]]) stable, they can be offered either late [[Coronary catheterization|coronary angiography]] with subsequent restoration of blood flow (revascularization), or [[Minimally invasive procedure|non-invasive]] [[Cardiac stress test|stress testing]] to determine if there is significant ischemia that would benefit from revascularization. If hemodynamic instability develops in individuals with NSTEMIs, they may undergo urgent coronary angiography and subsequent revascularization. The use of thrombolytic agents is contraindicated in this patient subset, however.<ref name="pmid7905143">{{cite journal |author= |title=Indications for fibrinolytic therapy in suspected acute myocardial infarction: collaborative overview of early mortality and major morbidity results from all randomised trials of more than 1000 patients. Fibrinolytic Therapy Trialists' (FTT) Collaborative Group |journal=Lancet |volume=343 |issue=8893 |pages=311–22 |year=1994 |month=February |pmid=7905143 |doi= |url=}}</ref><ref name="pmid17538045">{{cite journal |author=Jacobs AK, Antman EM, Faxon DP, Gregory T, Solis P |title=Development of systems of care for ST-elevation myocardial infarction patients: executive summary |journal=Circulation |volume=116 |issue=2 |pages=217–30 |year=2007 |month=July |pmid=17538045 |doi=10.1161/CIRCULATIONAHA.107.184043 |url=}}</ref><ref name="pmid17101617">{{cite journal |author=Bradley EH, Herrin J, Wang Y, ''et al'' |title=Strategies for reducing the door-to-balloon time in acute myocardial infarction |journal=N. Engl. J. Med. |volume=355 |issue=22 |pages=2308–20 |year=2006 |month=November |pmid=17101617 |doi=10.1056/NEJMsa063117 |url=}}</ref><ref name="pmid14530206">{{cite journal |author=Dalby M, Bouzamondo A, Lechat P, Montalescot G |title=Transfer for primary angioplasty versus immediate thrombolysis in acute myocardial infarction: a meta-analysis |journal=Circulation |volume=108 |issue=15 |pages=1809–14 |year=2003 |month=October |pmid=14530206 |doi=10.1161/01.CIR.0000091088.63921.8C |url=}}</ref><ref name="pmid16169311">{{cite journal |author=Henry TD, Unger BT, Sharkey SW, ''et al'' |title=Design of a standardized system for transfer of patients with ST-elevation myocardial infarction for percutaneous coronary intervention |journal=Am. Heart J. |volume=150 |issue=3 |pages=373–84 |year=2005 |month=September |pmid=16169311 |doi=10.1016/j.ahj.2005.01.059 |url=}}</ref><ref name="pmid16458125">{{cite journal |author=Garvey JL, MacLeod BA, Sopko G, Hand MM |title=Pre-hospital 12-lead electrocardiography programs: a call for implementation by emergency medical services systems providing advanced life support--National Heart Attack Alert Program (NHAAP) Coordinating Committee; National Heart, Lung, and Blood Institute (NHLBI); National Institutes of Health |journal=J. Am. Coll. Cardiol. |volume=47 |issue=3 |pages=485–91 |year=2006 |month=February |pmid=16458125 |doi=10.1016/j.jacc.2005.08.072 |url=}}</ref><ref name="pmid16630989">{{cite journal |author=Curtis JP, Portnay EL, Wang Y, ''et al'' |title=The pre-hospital electrocardiogram and time to reperfusion in patients with acute myocardial infarction, 2000-2002: findings from the National Registry of Myocardial Infarction-4 |journal=J. Am. Coll. Cardiol. |volume=47 |issue=8 |pages=1544–52 |year=2006 |month=April |pmid=16630989 |doi=10.1016/j.jacc.2005.10.077 |url=}}</ref><ref name="pmid15699253">{{cite journal |author=Nallamothu BK, Bates ER, Herrin J, Wang Y, Bradley EH, Krumholz HM |title=Times to treatment in transfer patients undergoing primary percutaneous coronary intervention in the United States: National Registry of Myocardial Infarction (NRMI)-3/4 analysis |journal=Circulation |volume=111 |issue=6 |pages=761–7 |year=2005 |month=February |pmid=15699253 |doi=10.1161/01.CIR.0000155258.44268.F8 |url=}}</ref><ref name="pmid17075010">{{cite journal |author=Pinto DS, Kirtane AJ, Nallamothu BK, ''et al'' |title=Hospital delays in reperfusion for ST-elevation myocardial infarction: implications when selecting a reperfusion strategy |journal=Circulation |volume=114 |issue=19 |pages=2019–25 |year=2006 |month=November |pmid=17075010 |doi=10.1161/CIRCULATIONAHA.106.638353 |url=}}</ref>
| |
| | |
| The basis for this distinction in treatment regimens is that ST segment elevations on an ECG are typically due to complete occlusion of a coronary artery. On the other hand, in NSTEMIs there is typically a sudden narrowing of a coronary artery with preserved (but diminished) flow to the distal myocardium. Anticoagulation and antiplatelet agents are given to prevent the narrowed artery from occluding.
| |
| | |
| At least 10% of patients with STEMI don't develop myocardial necrosis (as evidenced by a rise in cardiac markers) and subsequent q waves on EKG after reperfusion therapy. Such a successful restoration of flow to the infarct-related artery during an acute myocardial infarction is known as "aborting" the myocardial infarction. If treated within the hour, about 25% of STEMIs can be aborted.<ref name="pmid16543251">{{cite journal |author=Verheugt FW, Gersh BJ, Armstrong PW |title=Aborted myocardial infarction: a new target for reperfusion therapy |journal=Eur. Heart J. |volume=27 |issue=8 |pages=901–4 |year=2006 |month=April |pmid=16543251 |doi=10.1093/eurheartj/ehi829 |url=}}</ref>
| |
| | |
| The emphasis on primary PCI should not obscure the importance of fibrinolytic therapy. Many hospital systems in North America do not have the capability of meeting the time goal for primary PCI. Therefore, because of the critical importance of time to treatment from onset of symptoms of STEMI in reducing morbidity and mortality, fibrinolytic therapy is preferred. In these settings, transfer protocols need to be in place for arranging rescue PCI when clinically indicated.<ref name="pmid15699253">{{cite journal |author=Nallamothu BK, Bates ER, Herrin J, Wang Y, Bradley EH, Krumholz HM |title=Times to treatment in transfer patients undergoing primary percutaneous coronary intervention in the United States: National Registry of Myocardial Infarction (NRMI)-3/4 analysis |journal=Circulation |volume=111 |issue=6 |pages=761–7 |year=2005 |month=February |pmid=15699253 |doi=10.1161/01.CIR.0000155258.44268.F8 |url=}}</ref><ref name="pmid17075010">{{cite journal |author=Pinto DS, Kirtane AJ, Nallamothu BK, ''et al'' |title=Hospital delays in reperfusion for ST-elevation myocardial infarction: implications when selecting a reperfusion strategy |journal=Circulation |volume=114 |issue=19 |pages=2019–25 |year=2006 |month=November |pmid=17075010 |doi=10.1161/CIRCULATIONAHA.106.638353 |url=}}</ref><ref name="pmid17383297">{{cite journal |author=Sinno MC, Khanal S, Al-Mallah MH, Arida M, Weaver WD |title=The efficacy and safety of combination glycoprotein IIbIIIa inhibitors and reduced-dose thrombolytic therapy-facilitated percutaneous coronary intervention for ST-elevation myocardial infarction: a meta-analysis of randomized clinical trials |journal=Am. Heart J. |volume=153 |issue=4 |pages=579–86 |year=2007 |month=April |pmid=17383297 |doi=10.1016/j.ahj.2006.12.024 |url=}}</ref>
| |
|
| |
| For fibrinolytic therapy, the system goal is to deliver the drug within 30 minutes of the time that the patient presents to the hospital. The focus for primary PCI is from first medical contact because in regionalization strategies, extra time may be taken to transport patients to a center that performs the procedure. Consequently, it is important to consider the time from first medical contact.
| |
| | |
| ==Clinical Trial Data==
| |
|
| |
| ==Side Effects==
| |
| | |
| ==Guidelines (DO NOT EDIT)==
| |
| | |
| ===Class I===
| |
| | |
| 1. All STEMI patients should undergo rapid evaluation for reperfusion therapy and have a reperfusion strategy implemented promptly after contact with the medical system. (Level of Evidence: A)<ref name="pmid15289388">{{cite journal |author=Antman EM, Anbe DT, Armstrong PW, ''et al'' |title=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) |journal=Circulation |volume=110 |issue=5 |pages=588–636 |year=2004 |month=August |pmid=15289388 |doi=10.1161/01.CIR.0000134791.68010.FA |url=}}</ref>
| |
| | |
| =Available Resources=
| |
| | |
| ==Guidelines (DO NOT EDIT)==
| |
| | |
| ===Class I===
| |
| | |
| 1. STEMI patients presenting to a facility without the capability for expert, prompt intervention with primary PCI within 90 minutes of first medical contact should undergo fibrinolysis unless contraindicated. (Level of Evidence: A)<ref name="pmid18071078">{{cite journal |author=Antman EM, Hand M, Armstrong PW, ''et al'' |title=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 |journal=Circulation |volume=117 |issue=2 |pages=296–329 |year=2008 |month=January |pmid=18071078 |doi=10.1161/CIRCULATIONAHA.107.188209 |url=}}</ref>
| |
|
| |
|
| ==References== | | ==References== |
| {{reflist|2}} | | {{reflist|2}} |
|
| |
| {{Electrocardiography}}
| |
| {{Circulatory system pathology}}
| |
| {{SIB}}
| |
|
| |
|
| {{WikiDoc Help Menu}} | | {{WikiDoc Help Menu}} |
| {{WikiDoc Sources}} | | {{WikiDoc Sources}} |
| | [[Category:Disease]] |
| [[Category:Cardiology]] | | [[Category:Cardiology]] |
| {{mdr}}
| | [[Category:Ischemic heart diseases]] |
| | [[Category:Intensive care medicine]] |
| | [[Category:Emergency medicine]] |
| | [[Category:Mature chapter]] |