Medical therapy verses Angioplasty in Major Heart Attack (STEMI) ACC/AHA Guidelines for the Management of Patients With Major Heart Attack (ST-Elevation Myocardial Infarction)— Medical therapy (fibrinolytic therapy) 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) Indications for medical therapy (Fibrinolytic Therapy) Class I In the absence of contraindications, fibrinolytic therapy should be administered to STEMI patients with symptom onset within the prior 12 hours and ST elevation greater than 0.1 mV in at least 2 contiguous precordial leads or at least 2 adjacent limb leads. (Level of Evidence: A In the absence of contraindications, fibrinolytic therapy should be administered to STEMI patients with symptom onset within the prior 12 hours and new or presumably new LBBB. (Level of Evidence: A Class IIa In the absence of contraindications, it is reasonable to administer fibrinolytic therapy to STEMI patients with symptom onset within the prior 12 hours and 12-lead ECG findings consistent with a true posterior MI. (Level of Evidence: C In the absence of contraindications, it is reasonable to administer fibrinolytic therapy to patients with symptoms of STEMI beginning within the prior 12 to 24 hours who have continuing ischemic symptoms and ST elevation greater than 0.1 mV in at least 2 contiguous precordial leads or at least 2 adjacent limb leads. (Level of Evidence: B Class III Fibrinolytic therapy should not be administered to asymptomatic patients whose initial symptoms of STEMI began more than 24 hours earlier. (Level of Evidence: C Fibrinolytic therapy should not be administered to patients whose 12-lead ECG shows only ST-segment depression except if a true posterior MI is suspected. (Level of Evidence: A Because the benefit of fibrinolytic therapy is directly related to the time from symptom onset, treatment benefit is maximized by the earliest possible application of therapy. The constellation of clinical features that must be present (although not necessarily at the same time) to serve as an indication for fibrinolysis includes symptoms of myocardial ischemia and ST elevation greater than 0.1 mV, in at least 2 contiguous leads, or new or presumably new LBBB on the presenting ECG.2 Indications of Angioplasty (Primary PCI) Class I 1. General considerations: If immediately available, primary PCI should be performed in patients with STEMI (including true posterior MI) or MI with new or presumably new LBBB who can undergo PCI of the infarct artery within 12 hours of symptom onset, if performed in a timely fashion (balloon inflation within 90 minutes of presentation) by persons skilled in the procedure (individuals who perform more than 75 PCI procedures per year). The procedure should be supported by experienced personnel in an appropriate laboratory environment (performs more than 200 PCI procedures per year, of which at least 36 are primary PCI for STEMI, and has cardiac surgery capability). (Level of Evidence: A 2. Specific considerations: a. Primary PCI should be performed as quickly as possible, with a goal of a medical contact–to-balloon or door-to-balloon time of within 90 minutes. (Level of Evidence: B b. If the symptom duration is within 3 hours and the expected door-to-balloon time minus the expected door-to-needle time is: i) within 1 hour, primary PCI is generally preferred. (Level of Evidence: B ii) greater than 1 hour, fibrinolytic therapy (fibrin-specific agents) is generally preferred. (Level of Evidence: B c. If symptom duration is greater than 3 hours, primary PCI is generally preferred and should be performed with a medical contact–to-balloon or door-to-balloon time as brief as possible, with a goal of within 90 minutes. (Level of Evidence: B d. Primary PCI should be performed for patients younger than 75 years old with ST elevation or LBBB who develop shock within 36 hours of MI and are suitable for revascularization that can be performed within 18 hours of shock, unless further support is futile because of the patient’s wishes or contraindications/unsuitability for further invasive care. (Level of Evidence: A e. Primary PCI should be performed in patients with severe CHF and/or pulmonary edema (Killip class 3) and onset of symptoms within 12 hours. The medical contact–to-balloon or door-to-balloon time should be as short as possible (ie, goal within 90 min). (Level of Evidence: B Class IIa 1. Primary PCI is reasonable for selected patients 75 years or older with ST elevation or LBBB or who develop shock within 36 hours of MI and are suitable for revascularization that can be performed within 18 hours of shock. Patients with good prior functional status who are suitable for revascularization and agree to invasive care may be selected for such an invasive strategy. (Level of Evidence: B 2. It is reasonable to perform primary PCI for patients with onset of symptoms within the prior 12 to 24 hours and 1 or more of the following: a. Severe CHF (Level of Evidence: C b. Hemodynamic or electrical instability (Level of Evidence: C c. Persistent ischemic symptoms. (Level of Evidence: C Class IIb The benefit of primary PCI for STEMI patients eligible for fibrinolysis is not well established when performed by an operator who performs fewer than 75 PCI procedures per year. (Level of Evidence: C Class III PCI should not be performed in a noninfarct artery at the time of primary PCI in patients without hemodynamic compromise. (Level of Evidence: C Primary PCI should not be performed in asymptomatic patients more than 12 hours after onset of STEMI if they are hemodynamically and electrically stable. (Level of Evidence: C If the expected door-to-balloon time exceeds the expected door-to-needle time by more than 60 minutes, fibrinolytic treatment with a fibrin-specific agent should be considered unless it is contraindicated. This is particularly important when symptom duration is less than 3 hours but is less important with longer symptom duration, when less ischemic myocardium can be salvaged. facebook/dkguptahearttreatment
Posted on: Mon, 22 Dec 2014 07:50:45 +0000