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STEMI VS Non STEMI COMPARISON IN ADMITTED MANAGEMENT

STEMI VS Non STEMI COMPARISON IN ADMITTED MANAGEMENT. 2004 ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction ACC/AHA 2002 Guideline Update for the Management of Patients With Unstable Angina and Non–ST-Segment Elevation Myocardial Infarction

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STEMI VS Non STEMI COMPARISON IN ADMITTED MANAGEMENT

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  1. STEMI VS Non STEMICOMPARISON IN ADMITTED MANAGEMENT 2004 ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction ACC/AHA 2002 Guideline Update for the Management of Patients With Unstable Angina and Non–ST-Segment Elevation Myocardial Infarction Management of acute coronary syndromes: an Update, Heart 2004;90;698-706 Ri徐子茜/VS柯文哲

  2. Acute coronary syndrome

  3. First step-Triage • 1.a typical clinical syndrome + • 2.electrocardiographic changes+/- • 3.Markers of myocyte injury • Unstable angina • Non ST-elevation MI • ST-elevation MI • Decide whether or not to receive acute reperfusion therapy (thrombolytic agent, PCI, emergent CABG )

  4. General measures • pain relief • Adequate arterial oxygen concentration • relief of ischemia • assisted ventilation • reperfusion of critically ischemic myocardium • hemodynamic support (IABP) • control hypertension • treat acute heart failure and mechanical complications

  5. ACC/AHA guideline • Class I:有益之適應症 • Class II:使用效果有爭議 • Class IIa:證據偏向有效 • Class IIb:無有效之證據 • Class III:該處置無效,甚至有害

  6. ST-elevation MI

  7. Managementinitial therapy • a. Oxygen • For at least 2-3 hrs after presentation • b. Nitroglycerin • Class I : ongoing ischemic discomfort → sublingual nitroglycerin (0.4 mg) every 5 minutes for a total of 3 doses →consider iv nitroglycerin a.) relief of ongoing ischemic discomfort b.) control of hypertension c.) management of pulmonary congestion • Class III :SBP<90 mmHg HR<50 or >100 suspected RV infarction phosphodiesterase inhibitor for erectile dysfunction in the past 24 hrs

  8. Managementinitial therapy • c. Analgesia • Class I: Morphine sulfate 2 to 4 mg IV repeated at 5- to 15-minute intervals • d. Aspirin • Class I :chewed, 162 mg to 325 mg • e. Beta-Blockers • Class I : Oral beta-blocker should be administered promptly to those patients without a contraindication • Class IIa: IV beta-blockers promptly to STEMI patients without contraindications ,especially if a tachyarrhythmia or hypertension is present. • f. ACE Inhibitor

  9. Managementearly therapy • Reperfusion: as soon as possible • Thrombolytic therapy • Primary PCI • Emergent CABG • Refractory ischemia • Cardiogenic shock • The coronary vasculature is not amentable to PCI or the procedures has failed • Acute mechanical complications of MI(papillary muscle rupture, VSD, ventricular free wall rupture)

  10. Thrombolytic therapy • rapid administration • the risk of intracranial hemorrage • Sudden change in neurologic status • DC anticoagulatnt & thrombolytic agent • Head CT • FFP, platelet transfusion • whether the normal flow was restored in the infarct-related area • Within 90mins,induce clot lysis in 60-90% patients, but only 30-60% normal flow in the infarct-related area

  11. Thrombolytic therapy • Most effective if given within 12hrs, not beyond 24 hrs • Not indicated if the symptoms resolved or patients with ST-depression on EKG • 1.Recombinant tissue-plasminogen activator (rt-PA) • 2.Reteplase (r-PA) • 3.Tenecteplase (TNK) • 4.Streptokinase • TNK has a lower rate of non-cerebral bleeds and a lesser need for blood transfusion.

  12. Primary PCI • With experienced team (door-to-balloon time <90mins), superior to the fibrinolytic therapy • Immediate assessment LV function • Identification of other diseased vessel • Effective when the symptoms persist

  13. PCI combined with fibrinolysis • fibrinolytic agent is administered followed by PCI. • larger scale trials are awaited. • PCI combined with Gp IIb/IIIa (abciximab) • clear benefit in reducing MI when primary PCI is combined with abciximab. • Death or MI at 30 days was 3.2% (59/1843) with abciximab versus 4.8% (88/1823) without • modern reference standard

  14. Rescue PCI • PCI procedure performed in patients without evidence of a response to thrombolysis (,50% ST segment resolution) • No insufficient data to demonstrate the improvement in mortality or further MI

  15. Non ST-elevation MI

  16. Risk profile • 1.TIMI score • Age>65 y/o • >= 3 coronary risk factor • Angiographically documented prior CAD • >2 angina episodes within 24 hrs • ST deviation on the EKG • Aspirin use within in 7 days • Elevated cardiac enzymes

  17. Management • 1.antiischemia therapy • Bed rest • O2 • Morphine Sulfate • Nitroglyceride • Beta-Blockers • 2.antiplatelet therapy

  18. Management • 3.antithrombic treatment • 4.early conservative VS early invasive strategy • 5.Coronary revascularization • PCI • CABG

  19. Antiplatelet therapy • highly significant reduction in the risk of MI/ stroke/vascular death • ASA • Thienopyridine (ADP antagonist) • GP IIb/IIIa antagonist

  20. Antiplatelet therapy • Class I • 1.ASA should be administered as soon as possible after presentation and continued indefinitely. • 2.Clopidogrel should be administered to hospitalized patients who are unable to take ASA • * 3.early noninterventional approach is planned, clopidogrel should be added to ASA as soon as possible on admission and administered for at least 1 month and for up to 9 months. • * 4.A platelet GP IIb/IIIa antagonist should be administered, in addition to ASA and heparin, to patients in whom catheterization and PCI are planned. The GP IIb/IIIa antagonist may also be administered just prior to PCI.

  21. Antiplatelet therapy • Class I • * 5.In patients for whom a PCI is planned and who are not at high risk for bleeding, clopidogrel should be started and continued for at least 1 month and for up to 9 months. • * 6.In patients taking clopidogrel in whom elective CABG is planned, the drug should be withheld for 5 to 7 days • Class IIa • * 1. Eptifibatide or tirofiban should be administered, in addition to ASA and LMWH or UFH, to patients with continuing ischemia, an elevated troponin, or with other high-risk features in whom an invasive management strategy is not planned.

  22. Antiplatelet therapy • Class IIa • * 2.A platelet GP IIb/IIIa antagonist should be administered to patients already receiving heparin, ASA, and clopidogrel in whom catheterization and PCI are planned. The GP IIb/IIIa antagonist may also be administered just prior to PCI. • Class IIb • *1. Eptifibatide or tirofiban, in addition to ASA and LMWH or UFH, to patients without continuing ischemia who have no other high-risk features and in whom PCI is not planned.

  23. Antiplatelet therapy • Class III • 1. Intravenous fibrinolytic therapy in patients without acute ST-segment elevation, a true posterior MI, or a presumed new left bundle-branch block. • *2. Abciximabadministration in patients in whom PCI is not planned.

  24. Anticoagulation treatment • Enoxaperin (LMWH) • UFH (unfractionated heparin)

  25. Anticoagulant Therapy • Class I • *1. Anticoagulation with subcutaneous LMWH or iv UFH should be added to antiplatelet therapy with ASA and/or clopidogrel.

  26. Early Conservative vs EarlyInvasive Strategies • 1.medium- and high-risk patients : • troponin T> 0.01 ng/mL or troponin I > 0.1ng/mL, the presence of ST-segment deviation, or a TIMI risk>=3 • The beneficial effects : I>C • 2.low-risk patients: • outcomes I=C • Rates of major bleeding were similar, and lengths of hospital stay were reduced in patients assigned to the invasive strategy.

  27. Class I • †1. An early invasive strategy in patients with UA/ NSTEMI without serious comorbidity and who have any of the following high-risk indicators: • *(a) Recurrent angina/ischemia at rest or with low-level activities despite intensive anti-ischemictherapy. • *(b) Elevated TnT or TnI • *(c) New or presumably new ST-segment depression • (d) Recurrent angina/ischemia with CHF symptoms, an S3 gallop, pulmonary edema, worsening rales, or new or worsening MR

  28. (e) High-risk findings on noninvasive stress testing • (f) Depressed LV systolic function (eg, EF <0.40 on noninvasive study) • (g) Hemodynamic instability • (h) Sustained ventricular tachycardia • (i) PCI within 6 months • (j) Prior CABG • 2. In the absence of any of these findings, either an early conservative or an early invasive strategy may be offered in hospitalized patients without contraindications for revascularization.

  29. Coronary revascularization • PCI • CABG • Significant left main CAD • 3 vessel disease and abnormal LV function (LVEF<50%) • 2 vessel disease with a significant proximal left ant. descending artery stenosis and abnormal LV function • DM and multivessel disease

  30. Coronary revascularization

  31. Coronary revascularization

  32. Comparison of different revascularization stragies • Lack of long term outcome • PCI • Coronary stenting • The adjuvant use of platelet inhibitors • CABG • Refinement of surgical management with right internal mammary artery grafts, radial artery grafts • less invasive methodology

  33. Take home message

  34. THANK YOU FOR YOUR ATTENEION!!

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