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STEMI-WRAP on Evidence-Based Management of STEMI: The Emergency Department Perspective

STEMI-WRAP on Evidence-Based Management of STEMI: The Emergency Department Perspective. Charles V. Pollack, Jr., M.A., M.D., FACEP, FAHA Professor and Chair, Emergency Medicine, Pennsylvania Hospital University of Pennsylvania Health System Philadelphia. STEMI.

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STEMI-WRAP on Evidence-Based Management of STEMI: The Emergency Department Perspective

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  1. STEMI-WRAP on Evidence-Based Management of STEMI:The Emergency Department Perspective Charles V. Pollack, Jr., M.A., M.D., FACEP, FAHA Professor and Chair, Emergency Medicine, Pennsylvania HospitalUniversity of Pennsylvania Health System Philadelphia

  2. STEMI • Accounts for 15-20% of cases of ACS seen in ED; UA/NSTEMI (collectively, NSTE ACS) account for majority • High-visibility diagnosis because of its high morbidity and mortality, patient and family fears and expectations, and intensity of monitoring by observers inside and outside the hospital—QI, payors, JCAHO, P4P

  3. STEMI • Pathophys: STEMI is caused by complete obstruction of an epicardial vessel, which causes angina or anginal equivalent and diagnostic ECG changes of ST-segment elevation • Recognition of STEMI, which by GLs should occur within 10 minutes of ED arrival, launches the ED-cardiology team on a fast-moving track that demands prompt stabilization, evidence-based medical management, and quick decisions regarding reperfusion therapy • Dx of STEMI is clinical + electrocardiographic and DOES NOT require assessment of cardiac markers

  4. STEMI • STEMI typically result from fissure or frank rupture of an atherosclerotic plaque • Stimulates local activation of: • platelets • coagulation cascade • complement • Platelet aggregate forms over site of plaque injury and as it matures (fibrinogen→fibrin) causes complete obstruction of distal flow. To the extent that collateral flow downstream is lacking, ischemia quickly ensues and infarction starts to occur within minutes

  5. STEMI • Pharmacologic therapy in STEMI is therefore directed at this triad of abnormal activity: • Platelet activation—anti-activation and anti-aggregation • ASA and clopidogrel • GPIs • Coagulation activation—anticoagulants • Complement activation—anti-inflammatories . . . ? Statins • In preparation for reperfusion therapy by lysis or angiography and primary PCI

  6. Guidelines for STEMI diagnosis and management • complex disease state with broad ranges of presentation and a multitude of therapeutic options • Many important and pertinent clinical studies • Information overload! • Need evidence-based guidelines to promote consistency of care and resulting better outcomes

  7. Guidelines for STEMI management • ACC/AHA Joint Task Force: 1990, 1996, 1999 • Last comprehensive update in 2004 • Widely read, lots of interest • Clear evidence scoring, sensible recommendations, temporal sequencing • “soup to nuts” • Recapitulation, interpretation, and promulgation for upstream providers in Annals of Emergency Medicine

  8. Guidelines for STEMI management • ACC/AHA Joint Task Force: presented “focused update” in December 2007 • “focus” (from upstream perspective) on reperfusion strategies and opportunities to minimize delays to reperfusion • Beta blockers • Choices of anticoagulants • New recommendations regarding clopidogrel

  9. Applying Classification of Recommendations

  10. “The Guidelines”Weighing the Evidence • Weight of evidence grades: = Data from many large, randomized trials = Data from fewer, smaller randomized trials, careful analyses of nonrandomized studies, observational registries = Expert consensus

  11. Time Delays and 30 Day Outcome in STEMI Loss of benefitper hour of delay1.6±0.6 lives per 1000 patients 40 3000 14,000 45,000 patients in placebo controlled lytic trials. 30 12,000 9000 Lives saved/1000 patients 20 10 7000 0 0 6 12 18 24 Hours from onset of symptomsto randomization Collins. NEJM. 1997;336:847.

  12. Time Delays and 30 Day Outcome in STEMI: Primary PCI (NRMI-2) Cannon C, et al. JAMA 2000;283:2941-2947

  13. Time Delays and 30 Day Outcome in STEMI: Primary PCI (NRMI-2) Cannon C, et al. JAMA 2000;283:2941-2947

  14. Prehospital Issues • EMS • Emphasis on early defibrillation; AEDs; 911 dispatchers training & use of national protocols; 12-lead ECGs • Chest Pain Evaluation & Treatment • Emphasis on giving chewable ASA, unless contraindicated & prehospital ECG & checklist • Prehospital Fibrinolysis • Upgraded to a Class IIa (Level B) Recommendation • although not particularly likely in most systems • Prehospital Destination Protocols • Where to transport STEMI patients: a plan must be in place • Special considerations • Cardiogenic Shock • Fibrinolytic contraindicated

  15. Patients Transported by EMS After Calling 9-1-1 Hospital Fibrinolysis: Door-to-needle within<30 min Call 911 Call Fast EMS Triage Plan Not PCI Capable Hospital • EMS on-scene • Encourage 12-lead ECG • Consider prehospital fibrinolytic ifcapable and EMS-to-needle < 30 min Onset of STEMI Symptoms 9-1-1 EMS Dispatch Interhospital Transfer PPCI: Door-to-balloon within<90 min PCI Capable Hospital Goals EMS on scene EMS transport Patient Dispatch EMS transport:EMS to Balloon within 90 min 5’ after sx onset Within 8 min Patient self-transport: Hospital Door-to-Balloon within 90 min 1 min Total ischemic time: Within 120 min*

  16. ACC/AHA 2007 STEMI Focused Update: Acute Medical Therapy a Patients routinely taking NSAIDs (except for aspirin), both nonselective as well as COX-2 selective agents, before STEMI should have those agents discontinued at the time of presentation with STEMI because of the increased risk of mortality, reinfarction, hypertension, heart failure, and myocardial rupture associated with their use. b Because of the risk of catheter thrombosis, fondaparinux should not be used as the sole anticoagulant to support PCI. An additional anticoagulant with anti-IIa activity should be administered. Antman E, et al. J Am Coll Cardiol. doi:10.1016/j.jacc.2007.10.001.

  17. 2007 ACC/AHA STEMI Focused Update Reperfusion Therapy for STEMI • 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 (Level of Evidence: A) • 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 (Level of Evidence: B) Class I Modified Recommendations Antman E, et al. J Am Coll Cardiol. doi:10.1016/j.jacc.2007.10.001.

  18. Determine Whether Fibrinolysis or PCI Is Preferred No Preference for Either Strategy If Presentation Is 3 hr and There Is No Delay in Invasive Strategy However, fibrinolysis generally preferred when • Invasive strategy not an option • Vascular access difficulties • No access to skilled PCI lab • Delay to invasive strategy • Prolonged transport • Door-to-balloon time >90 min • >1 hr vs fibrinolysis (fibrin-specific agent) now Adapted with permission from Antman EM, et al. J Am Coll Cardiol. 2004;44:671-719. Photo courtesy of ACC/AHA guidelines for STEMI slide set. http://www.cardiosource.com/srch/results.asp?searchterm=STEMI+PowerPoint+Slides&parsedquery+&x+10&y=5. Accessed January 10, 2008.

  19. Determine Whether Fibrinolysis or PCI Is Preferred (cont.) No Preference for Either Strategy If Presentation Is 3 hr and There Is No Delay in Invasive Strategy However, invasive strategy generally preferred when • Skilled PCI lab is available with surgical backup • Door-to-balloon time <90 min • High risk from STEMI • Cardiogenic shock*, Killip class ≥III • Contraindications to fibrinolysis, including increased risk of bleeding and ICH • Late presentation • >3 hr from symptom onset • Diagnosis of STEMI is in doubt *PCI strongly preferred, but if immediate PCI not available/transfer for PCI delayed and presentation ≤3 hours, treat with fibrinolytic therapy and transfer to a skilled PCI lab.Adapted from Antman EM, et al. J Am Coll Cardiol. 2004;44:671-719. Photo courtesy of ACC/AHA guidelines for STEMI slide set. http://www.cardiosource.com/srch/results.asp?searchterm=STEMI+PowerPoint+Slides&parsedquery+&x+10&y=5. Accessed January 10, 2008.

  20. PCI Thrombolytic therapy Primary PCI vs Thrombolysis in STEMI: Quantitative Analysis (23 RCTs*, N=7739) 25 Short-term outcomes (4–6 wk) P<.0001 20 P<.0001 15 P<.0001 P=.0002 Frequency, % P=.032 10 5 P<.0001 0 Death Nonfatal MI Recurrent Ischemia Hemor- rhagic Stroke Major Bleed Death, Nonfatal Reinfarction, or Stroke *The criterion for time to treatment was 6 h or less in 9 of the trials, 12 h in 13 trials, and up to 36 h in the SHOCK trial. Adapted with permission from Keeley EC, et al. Lancet. 2003;361:13-20.

  21. NRMI: Advantage of PCI Compared With Fibrinolysis Decreases as PCI-Related Delay Increases 2.0 Odds of Death With Fibrinolysis 1.5 PCI Better 1.25 1.0 0.8 Fibrinolysis Better 0.5 60 75 90 105 114 135 150 165 180 PCI-Related Delay (door-to-balloon–door-to-needle time), min Adapted with permission from Pinto DS, et al. Circulation. 2006;114:2019-2025.

  22. Door to Balloon (D2B): An Alliance for Quality Campaign • Door to Balloon (D2B) Campaign—joint program of ACC, AHA, and other health organizations • Aims to increase percentage of AMI patients who receive primary angioplasty within 90 minutes of hospital presentation to 75%; current figures indicate only 35% achieve this goal • D2B implementation kit contains 6 evidence-based strategies for reducing door-to-balloon times D2B: An Alliance for Quality Web site. http://www.d2balliance.com. Accessed December 27, 2007.

  23. Door to Balloon (D2B): An Alliance for Quality CampaignStrategies Associated With a Significant Reduction in DTB Time *P<.05 for all. Bradley EH, et al. N Engl J Med. 2006;355:2308-2320.

  24. 2007 ACC/AHA STEMI Focused Update Anticoagulants as Ancillary Therapy to Reperfusion Therapy • Patients undergoing reperfusion with fibrinolytics should receive anticoagulant therapy for a minimum of 48 hours and preferably for the duration of the index hospitalization, up to 8 days (regimens other than UFH are recommended if anticoagulant therapy is given for more than 48 hours because of the risk of heparin-induced thrombocytopenia with prolonged UFH treatment) • Anticoagulants regimens with established efficacy include: • UFH • Enoxaparin • Fondaparinux New Class I Recommendation Antman E, et al. J Am Coll Cardiol. doi:10.1016/j.jacc.2007.10.001.

  25. 2007 ACC/AHA STEMI Focused Update Anticoagulants • It is reasonable for patients with STEMI who do not undergo reperfusion therapy to be treated with anticoagulant therapy (non-UFH regimen) for the duration of the index hospitalization, up to 8 days (Level of Evidence: B). Convenient strategies that can be used include those with LMWH (Level of Evidence: C) or fondaparinux (Level of Evidence: B) using the same dosing regimens as for patients who receive fibrinolytic therapy Modified Class IIa Recommendation Antman E, et al. J Am Coll Cardiol. doi:10.1016/j.jacc.2007.10.001.

  26. Adapted with permission from Antman EM, et al. N Engl J Med. 2006;354:1477-1488. Main Results From ExTRACT–TIMI 25 Main Secondary End Point: Death, nonfatal re-MI, or urgent revascularization by 30 days Primary End Point: Death or nonfatal re-MI by 30 days UFH UFH 15 12.0 14.5 12 9.9 11.7 12 ENOX 9 ENOX 9 RR=0.83 P<.001 6 % RR=0.81 P<.001 6 % 3 3 RR=0.88P=.02 0 0 0 5 10 15 20 25 30 0 5 10 15 20 25 30 Days Days • Major bleeding at 30 days: 1.4% with UFH vs 2.1% with enoxaparin (P<.001) • ICH: 0.7% for UFH vs 0.8% for enoxaparin (P=.14)

  27. ExTRACT–TIMI 25: For Every 1000Patients Treated With Enoxaparin vs UFH 4 5 0 (No increase in nonfatal ICH) -5 Events/1000 Patients -6 -7 -10 -15 -15 Nonfatal reMI Urgent Revasc. Nonfatal TIMI Major Bleed -20 Death Antman EM, et al. N Engl J Med. 2006;354:1477-1488.Adapted with permission from clinicaltrialresults.org.

  28. OASIS-6 Trial: Study Design 12,092 patients presenting with STEMI within 24 hours of symptom onset (shortened to 12 hours of symptom onset midway through trial) Randomized. Blinded. Factorial. 28% female; mean age, 62 years; mean follow-up, 3-6 months Stratum 2 (UFH) n=6434 Stratum 1 (No UFH) n=5658 UFH n=3221 Fondaparinux n=3213 2.5 mg/day for up to 8 days or hospital discharge Fondaparinux n=2823 2.5 mg/day for up to 8 days or hospital discharge Placebo n=2835 • Primary end point: composite of death or reinfarction at 30 days • Secondary end point: composite of death or reinfarction at 9 days and at final follow-up Yusuf S, et al. JAMA. 2006;295:1519-1530. Adapted with permission from www.clinicaltrialresults.org.

  29. Reduction in Death/MI at 30 days: Stratum 1 (No UFH Indicated) P<.05 14% 14% Primary End Point: Death/Reinfarction (%) 11.2% 12% 10% 14.8% 15% 8% 13.4% 6% 11.2% 12% 4% 9.7% 8.9% 2% 9% 7.4% 0% Fondaparinux Placebo 6% Reduction in Death/MI: Stratum 2 (UFH Indicated) P=NS 14% 3% P=.008 P=.003 P=.008 12% 0% 10% 8.7% 8.3% 30 days 9 days 3-6 months 8% p=0.97 6% Control (n=6056) Fondaparinux (n=6036) 4% 2% 0% Fondaparinux UFH OASIS-6 Trial: Results Frequency Yusuf S, et al. JAMA. 2006;295:1519-1530. Adapted with permissionfrom clinicaltrialresults.org.

  30. OASIS-6: PCI Substudy at 30 Days Primary End Point of Death or MI in Primary PCI Cohort (%) P=.04 8% • Guiding catheter thrombosis in the primary PCI cohort occurred more often with fondaparinux compared with control (n=22 vs n=0, P<.001) 6.0% 6% 4.9% 4% 2% 0% Fondaparinux Control Yusuf S, et al. JAMA. 2006;295:1519-1530. Adapted with permission from www.clinicaltrialresults.org.

  31. HORIZONS AMI: Bivalirudin vs Heparin + GP IIb/IIIa for Primary PCI in STEMI Bivalirudin monotherapy (n=1800) Heparin + GP IIb/IIIa inhibitor (n=1802) 20 Diff = -2.9% [-4.9, -0.8] RR = 0.76 [0.63, 0.92] PNI ≤ .0001 Psup = .006 Diff = -3.3% [-5.0, -1.6] RR = 0.60 [0.46, 0.77] PNI ≤ .0001 Psup ≤ .0001 Diff = 0.0% [-1.6, 1.5] RR = 0.99 [0.76, 1.30] Psup = 1.00 15 12.1 10 30-day event rates (%) 9.2 8.3 5 5.5 5.4 4.9 1 end point 1 end point 0 Net adverse clinical events Major bleedinga MACEb • aNot related to CABG; bMACE = All-cause death, reinfarction, ischemic TVR or stroke. Stone GW, et al. Presented at: Transcatheter Cardiovascular Therapeutics 2007; October 20-25, 2007; Washington, DC.

  32. 2007 ACC/AHA STEMI Focused Update Thienopyridines New Class I Recommendation • Clopidogrel 75 mg per day orally should be added to aspirin in patients with STEMI regardless of whether they undergo reperfusion with fibrinolytic therapy or do not receive reperfusion therapy. Treatment with clopidogrel should continue for at least 14 days 2004 Class I Recommendation (remains current) • In patients taking clopidogrel in whom CABG is planned, the drug should be withheld for at least 5 days, and preferably for 7 days, unless the urgency for revascularization outweighs the risks of excess bleeding Antman E, et al. J Am Coll Cardiol. doi:10.1016/j.jacc.2007.10.001.

  33. 2007 ACC/AHA STEMI Focused Update Thienopyridines (cont.) New Class IIa Recommendations • In patients less than 75 years of age who receive fibrinolytic therapy or who do not receive reperfusion therapy, it is reasonable to administer an oral loading dose of clopidogrel 300 mg (No data are available to guide decision making regarding an oral loading dose in patients 75 years of age or older) • Long-term maintenance therapy (eg, 1 year) with clopidogrel (75 mg per day orally) is reasonable in STEMI patients regardless of whether they undergo reperfusion with fibrinolytic therapy or do not receivereperfusion therapy Antman E, et al. J Am Coll Cardiol. doi:10.1016/j.jacc.2007.10.001.

  34. CLARITY- TIMI 28 Trial: Study Design Double-blind, randomized, placebo-controlled trial in3491 patients, aged 18-75 yrs, with STEMI <12 hours Fibrinolytic, ASA, Heparin Randomized Clopidogrel 300 mg + 75 mg qd Placebo Study Drug Primary end point: Occluded artery (TIMI flow grade 0/1) or death/MI by time of angio Coronary Angiogram (2-8 days) Open-label clopidogrel per MD inboth groups 30-day clinical follow-up Sabatine MS, et al. N Engl J Med. 2005;352:1179-1189.

  35. 25 15 Placebo 20% 20 10 Clopidogrel End Point, % 15 Odds Ratio: 0.80 (95% CI, 0.65-0.97) P=.03 5 10 0 30 5 0 20 10 15 25 5 Days 0 CLARITY–TIMI 28: Clopidogrel 300 mg/75 mg qd vs Placebo With Thrombolysis for STEMI (n = 3491) Primary End Point: Occluded Artery (or Death/MI Through Angio/HD) CV Death, MI, RI  Urg Revasc 36% Odds Reduction 21.7 15.0 Occluded Artery or Death/MI, % n=1752 n=1739 Clopidogrel Placebo P <.001 Adapted with permission from Sabatine MS, et al. N Engl J Med. 2005;352:1179-1189.

  36. COMMIT/CCS-2: Effect of Clopidogrel 75 mg qd vs Placebo (n = 45,852) Death, Re-MI, or Stroke Death in the Hospital Placebo + ASA: 1845 deaths (8.1%) Placebo + ASA: 2310events (10.1%) 9 8 7 6 5 4 3 2 1 0 7 6 5 4 3 2 1 0 Clopidogrel + ASA: 1726 deaths (7.5%) Clopidogrel + ASA: 2121 events (9.2%) 9% (SE 3) relative risk reduction (P=.002) 7% (SE 3) relative risk reduction (P=.03) Event, % Mortality, % 0 7 14 21 28 0 7 14 21 28 Days Since Randomization (up to 28 days) Days Since Randomization (up to 28 days) a All patients received aspirin 162 mg/d.SE = standard error.Adapted with permission from COMMIT Collaborative Group. Lancet. 2005;366:1607-1621.

  37. CLARITY–TIMI 28 and COMMIT/CCS-2:Intracranial Hemorrhage and Major Bleeding 1. Sabatine MS, et al. N Engl J Med. 2005;352:1179-1189.2. Chen Z, et al. Lancet. 2005;366:1607-1621.

  38. COMMIT/CCS-2: Metoprolol Results End Point (%) Metoprolol, n=22,929 Placebo, n=22,923 P Death, reinfarction, or cardiac arrest 9.4 9.9 .10 All-cause mortality 7.7 7.8 .69 Reinfarction 2.0 2.5 .001 Ventricular fibrillation 2.5 3.0 .001 Other cardiac arrest 3.0 2.8 .14 Cardiogenic shock 5.0 3.9 <.00001 COMMIT = ClOpidogrel & Metoprolol in MyocardialInfarction Trial. Adapted with permission from Chen ZM, et al. Lancet. 2005;366:1622-1632.

  39. Implications for the ED • Lytics are underused, even when preference for PPCI is accepted • Lytic therapy can be optimized with proper use of adjunctive medications • Enoxaparin • Clopidogrel • Beta blockers should be used appropriately

  40. 2007 ACC/AHA STEMI Focused Update -Blockers Modified Class I Recommendation • Oral -blocker therapy should be initiated in the first 24 hours for patients who do not have any of the following: • Signs of heart failure • Evidence of a low output state • Increased riska for cardiogenic shock • Other relative contraindications to -blockade (PR interval >0.24 second, second- or third-degree heart block, active asthma, or reactive airway disease) a Risk factors for cardiogenic shock: age >70 years, systolic blood pressure <120 mm Hg, sinus tachycardia >110 bpm or heart rate <60 bpm, and increased time since onset of symptoms of STEMI. Antman E, et al. J Am Coll Cardiol. doi:10.1016/j.jacc.2007.10.001.

  41. 2007 ACC/AHA STEMI Focused Update -Blockers (cont.) New Class III Recommendation • IV -blockers should not be administered to STEMI patients who have any of the following: • Signs of heart failure • Evidence of a low output state • Increased riska for cardiogenic shock, • Other relative contraindications to -blockade (PR interval >0.24 second, second- or third-degree heart block, active asthma, or reactive airway disease) a Risk factors for cardiogenic shock: age >70 years, systolic blood pressure <120 mm Hg, sinus tachycardia >110 bpm or heart rate <60 bpm, and increased time since onset of symptoms of STEMI. Antman E, et al. J Am Coll Cardiol. doi:10.1016/j.jacc.2007.10.001.

  42. 2007 ACC/AHA STEMI Focused Update Anticoagulants as Ancillary Therapy to Reperfusion Therapy in PCI • For patients undergoing PCI after having received an anticoagulant regimen, the following dosing recommendations should be followed: • For prior treatment with UFH, administer additional boluses of UFH as needed to support the procedure, taking into account whether GP IIb/IIIa receptor antagonists have been administered. Bivalirudin may also be used in patients treated previously with UFH • For prior treatment with enoxaparin, if the last SC dose was administered within the prior 8 hours, no additional enoxaparin should be given; if the last SC dose was administered at least 8 to 12 hours earlier, an IV dose of 0.3 mg per kg of enoxaparin should be given • For prior treatment with fondaparinux, administer additional IV treatment with an anticoagulant possessing anti-IIa activity, taking into account whether GP IIb/IIIa receptor antagonists have been administered New Class I Recommendation Antman E, et al. J Am Coll Cardiol. doi:10.1016/j.jacc.2007.10.001.

  43. 2007 ACC/AHA STEMI Focused Update PCI After Fibrinolysis or for Patients Not Undergoing Primary Reperfusion Modified Class IIb Recommendation • PCI of a hemodynamically significant stenosis in a patent infarct artery >24 hours after STEMI may be considered as part of an invasive strategy New Class III Recommendation • PCI of a totally occluded infarct artery >24 hours after STEMI is not recommended in asymptomatic patients with 1- or 2-vessel disease if they are hemodynamically and electrically stable and do not have evidence of severe ischemia Antman E, et al. J Am Coll Cardiol. doi:10.1016/j.jacc.2007.10.001.

  44. 2007 ACC/AHA/SCAI PCI Focused Update Antiplatelet Therapy: Clopidogrel Modified Class I Recommendations • A loading dose of clopidogrel, generally 600 mg, should be administered before or when PCI is performed • In patients undergoing PCI within 12 to 24 hours of receiving fibrinolytic therapy, a clopidogrel oral loading dose of 300 mg may be considered King SB III, et al. J Am Coll Cardiol. doi:10.1016/j.jacc.2007.10.002.

  45. 2007 ACC/AHA/SCAI PCI Focused Update Antiplatelet Therapy: Clopidogrel (cont.) Modified Class IIa Recommendation • If clopidogrel is given at the time of the procedure, supplementation with GP IIb/IIIa receptor antagonists can be beneficial Class IIa Recommendation (No Change) • For patients with an absolute contraindication to aspirin, it is reasonable to give a 300 mg to 600 mg loading dose of clopidogrel, administered at least 6 hours before PCI, and/or GP IIb/IIIa antagonists, administered at the time of PCI King SB III, et al. J Am Coll Cardiol. doi:10.1016/j.jacc.2007.10.002.

  46. DES vs BMS in STEMI: Meta-analysisPrimary Efficacy End Point: Reintervention 13.3% 13.3% 5.0% 5.0% Reintervention = target lesion revascularization. Reproduced with permission from Kastrati A, et al. Eur Heart J. 2007;28:2706-2713.

  47. DES vs BMS in STEMI: Meta-analysisPrimary Safety End Point: Stent Thrombosis Reproduced with permission from Kastrati A, et al. Eur Heart J. 2007;28:2706-2713.

  48. 2007 ACC/AHA STEMI Focused Update Antiplatelet Therapy for Post-PCI PatientsClass I Recommendations • PCI without stenting • ASA 75-162 mg/d indefinitely and • Clopidogrel 75 mg/d for at least 14 d • Bare-metal stent • ASA 162-325 mg/d for at least 1 mo, 75-162 mg/d indefinitely and • Clopidogrel 75 mg/d for at least 1 mo, ideally up to 1 y • Drug-eluting stent • ASA 162-325 mg/d for at least 3 (sirolimus) to 6 (paclitaxel) mo, 75-162 mg/d indefinitely and • Clopidogrel 75 mg/d for at least 1 y Antman E, et al. J Am Coll Cardiol. doi:10.1016/j.jacc.2007.10.001.

  49. 2007 ACC/AHA STEMI Focused Update Secondary Prevention: Clopidogrel New Class I Recommendation • For all STEMI patients not undergoing stenting (medical therapy alone or PTCA without stenting), treatment with clopidogrel should continue for at least 14 days New Class IIa Recommendation • Long-term maintenance therapy (eg, 1 year) with clopidogrel (75 mg per day orally) is reasonable in STEMI patients regardless of whether they undergo reperfusion with fibrinolytic therapy or do not receive reperfusion therapy Antman E, et al. J Am Coll Cardiol. doi:10.1016/j.jacc.2007.10.001.

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