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    Add as FriendSTEMI Guidelines

    by: Vinod

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    1 : STEMI Guidelines
    2 : 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction Vinod Raxwal MD
    3 : Updated from 2004 Guideline for STEMI STEMI comprises 25-40% of the 683,000 patients with ACS The concept of “door-to-balloon time” or “door-to-needle time” has been revised to “first medical contact (FMC)-to-device time.” Emergency medical technicians to perform ECG in the field Hypothermic cooling protocols to treat patients who suffer cardiac arrest.
    4 : Classification of Recommendations and Levels of Evidence A recommendation with Level of Evidence B or C does not imply that the recommendation is weak. Many important clinical questions addressed in the guidelines do not lend themselves to clinical trials. Although randomized trials are unavailable, there may be a very clear clinical consensus that a particular test or therapy is useful or effective.   *Data available from clinical trials or registries about the usefulness/ efficacy in different subpopulations, such as sex, age, history of diabetes, history of prior myocardial infarction, history of heart failure, and prior aspirin use. †For comparative effectiveness recommendations (Class I and IIa; Level of Evidence A and B only), studies that support the use of comparator verbs should involve direct comparisons of the treatments or strategies being evaluated.
    5 : Reperfusion Therapy for Patients with STEMI *Patients with cardiogenic shock or severe heart failure initially seen at a non–PCI-capable hospital should be transferred for cardiac catheterization and revascularization as soon as possible, irrespective of time delay from MI onset (Class I, LOE: B). †Angiography and revascularization should not be performed within the first 2 to 3 hours after administration of fibrinolytic therapy.
    6 : Keep it simple
    7 : Regional Systems of STEMI Care, Reperfusion Therapy, and Time-to-Treatment Goals Create a regional system of STEMI care : Lifeline and the D2B Alliance. 12-lead ECG by EMS personnel at the site of FMC
    8 : Regional Systems of STEMI Care, Reperfusion Therapy, and Time-to-Treatment Goals Reperfusion therapy with symptom onset within the prior 12 hours. Primary PCI is the recommended method of reperfusion FMC-to-device time system goal of 90 minutes or less.* *The proposed time windows are system goals. For any individual patient, every effort should be made to provide reperfusion therapy as rapidly as possible.
    9 : Regional Systems of STEMI Care, Reperfusion Therapy, and Time-to-Treatment Goals Immediate transfer to a PCI-capable hospital who are transported to a non–PCI-capable hospital, with an FMC-to-device time system goal of 120 minutes or less.* Fibrinolytic therapy at non–PCI-capable hospitals when the anticipated FMC-to-device time at a PCI-capable hospital exceeds 120 minutes *The proposed time windows are system goals. For any individual patient, every effort should be made to provide reperfusion therapy as rapidly as possible.
    10 : Regional Systems of STEMI Care, Reperfusion Therapy, and Time-to-Treatment Goals Fibrinolytic therapy should be administered within 30 minutes of hospital arrival.* Reperfusion therapy is reasonable for patients with STEMI and symptom onset within the prior 12 to 24 hours who have clinical and/or ECG evidence of ongoing ischemia. Primary PCI is the preferred strategy in this population. *The proposed time windows are system goals. For any individual patient, every effort should be made to provide reperfusion therapy as rapidly as possible.
    11 : Guideline for STEMI Reperfusion at a PCI-Capable Hospital
    12 : Primary PCI in STEMI Reperfusion at a PCI-Capable Hospital
    13 : Primary PCI in STEMI
    14 : Aspiration Thrombectomy Manual aspiration thrombectomy is reasonable for patients undergoing primary PCI.
    15 : Use of Stents in Patients With STEMI Placement of a stent (BMS or DES) is useful in primary PCI for patients with STEMI. BMS* - high bleeding risk, inability to comply with 1 year of DAPT, or anticipated invasive or surgical procedures in the next year. DES should not be used in primary PCI - unable to comply with a prolonged course of DAPT *Balloon angioplasty without stent placement may be used in selected patients. Harm
    16 : Simple so far….
    17 : Adjunctive Antithrombotic Therapy for Primary PCI Reperfusion at a PCI-Capable Hospital
    18 : Antiplatelet Therapy to Support Primary PCI for STEMI It is reasonable to use 81 mg of aspirin per day in preference to higher maintenance doses after primary PCI.
    19 : Adjunctive Antithrombotic Therapy to Support Reperfusion With Primary PCI *The recommended maintenance dose of aspirin to be used with ticagrelor is 81 mg daily.
    20 : Adjunctive Antithrombotic Therapy to Support Reperfusion With Primary PCI (cont.) *The recommended maintenance dose of aspirin to be used with ticagrelor is 81 mg daily. †Balloon angioplasty without stent placement may be used in selected patients. It might be reasonable to provide P2Y12 inhibitor therapy to patients with STEMI undergoing balloon angioplasty alone according to the recommendations listed for BMS. (LOE: C).
    21 : Adjunctive Antithrombotic Therapy to Support Reperfusion With Primary PCI (cont.)
    22 : Adjunctive Antithrombotic Therapy to Support Reperfusion With Primary PCI (cont.) ‡The recommended ACT with planned GP IIb/IIIa receptor antagonist treatment is 200 to 250 s. §The recommended ACT with no planned GP IIb/IIIa receptor antagonist treatment is 250 to 300 s (HemoTec device) or 300 to 350 s (Hemochron device).
    23 : Reperfusion at a Non–PCI-Capable Hospital Guideline for STEMI
    24 :
    25 : Fibrinolytic Therapy When There Is an Anticipated Delay to Performing Primary PCI Within 120 Minutes of FMC Reperfusion at a Non–PCI-Capable Hospital
    26 : Indications for Fibrinolytic Therapy When There Is a >120-Minute Delay From FMC to Primary PCI
    27 : Transfer to a PCI-Capable Hospital After Fibrinolytic Therapy Reperfusion at a Non–PCI-Capable Hospital
    28 :
    29 : Coronary Angiography in Patients Who Initially Were Managed With Fibrinolytic Therapy or Who Did Not Receive Reperfusion 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. *Although individual circumstances will vary, clinical stability is defined by the absence of low output, hypotension, persistent tachycardia, apparent shock, high-grade ventricular or symptomatic supraventricular tachyarrhythmias, and spontaneous recurrent ischemia.
    30 : PCI of a Noninfarct Artery Before Hospital Discharge PCI is indicated in a noninfarct artery at a time separate from primary PCI in patients who have spontaneous symptoms of myocardial ischemia. 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.
    31 : Sudden cardiac death and STEMI
    32 : Evaluation and Management of Patients With STEMI and Out-of-Hospital Cardiac Arrest Onset of Myocardial Infarction
    33 : Evaluation and Management of Patients With STEMI and Out-of-Hospital Cardiac Arrest Therapeutic hypothermia should be started as soon as possible in comatose patients with STEMI and out-of-hospital cardiac arrest caused by VF or pulseless VT Immediate angiography and PCI should be performed in resuscitated out-of-hospital cardiac arrest patients whose initial ECG shows STEMI.
    34 : CABG in Patient with STEMI
    35 : CABG in Patients With STEMI Urgent CABG - coronary anatomy not amenable to PCI who have ongoing or recurrent ischemia, cardiogenic shock, severe HF, or other high-risk features. operative repair of mechanical defects.
    36 : CABG in Patients With STEMI The use of mechanical circulatory support is reasonable in patients with STEMI who are hemodynamically unstable and require urgent CABG.
    37 : Timing of Urgent CABG in Patients With STEMI in Relation to Use of Antiplatelet Agents Coronary Artery Bypass Graft Surgery
    38 : Timing of Urgent CABG in Patients With STEMI in Relation to Use of Antiplatelet Agents Aspirin should not be withheld before urgent CABG. GP IIb/IIIa receptor antagonists should be discontinued at least 2 hours before urgent CABG. Clopidogrel or ticagrelor should be discontinued at least 24 hours before urgent on-pump CABG, if possible.
    39 : Timing of Urgent CABG in Patients With STEMI in Relation to Use of Antiplatelet Agents Abciximab should be discontinued 12 hours before Urgent off-pump CABG within 24 hours of clopidogrel or ticagrelor administration might be considered Urgent CABG within 5 days of clopidogrel or ticagrelor administration or within 7 days of prasugrel administration might be considered
    40 : need ….
    41 :
    42 : Routine Medical Therapies Guideline for STEMI
    43 : Beta Blockers Routine Medical Therapies
    44 : Beta Blockers Should be initiated in the first 24 hours Exception - (signs of HF, evidence of a low output state, increased risk for cardiogenic shock,* or other contraindications to use of oral beta blockers (PR interval >0.24 seconds, second- or third-degree heart block, active asthma, or reactive airways disease). *Risk factors for cardiogenic shock (the greater the number of risk factors present, the higher the risk of developing cardiogenic shock) are age >70 years, systolic BP <120 mm Hg, sinus tachycardia >110 bpm or heart rate <60 bpm, and increased time since onset of symptoms of STEMI.
    45 : Beta Blockers It is reasonable to administer intravenous beta blockers at the time of presentation to patients with STEMI and no contraindications to their use who are hypertensive or have ongoing ischemia.
    46 : Renin-Angiotensin-Aldosterone System Inhibitors Routine Medical Therapies
    47 : Renin-Angiotensin-Aldosterone System Inhibitors Administered within the first 24 hours to all patients with STEMI with anterior location, HF, or EF less than or equal to 0.40, unless contraindicated. An ARB should be given to patients with STEMI who have indications for but are intolerant of ACE inhibitors.
    48 : Renin-Angiotensin-Aldosterone System Inhibitors Aldosterone inhibitors should be given to patients with STEMI who are already receiving an ACE inhibitor and beta blocker and who have an EF less than or equal to 0.40 and either symptomatic HF or diabetes mellitus. ACE inhibitors are reasonable for all patients with STEMI.
    49 :
    50 : Lipid Management High-intensity statin therapy should be initiated
    51 : Complications
    52 : Cardiogenic Shock Complications After STEMI
    53 : Treatment of Cardiogenic Shock The use of intra-aortic balloon pump counterpulsation can be useful for patients with cardiogenic shock after STEMI who do not quickly stabilize with pharmacological. Alternative LV assist devices for circulatory support may be considered in patients with refractory cardiogenic shock.
    54 : Electrical Complications During the Hospital Phase of STEMI Complications After STEMI
    55 : Implantable Cardioverter-Defibrillator Therapy Before Discharge Complications After STEMI
    56 : Implantable Cardioverter-Defibrillator Therapy Before Discharge ICD therapy is indicated before discharge in patients who develop sustained VT/VF more than 48 hours after STEMI
    57 : Bradycardia, AV Block, and Intraventricular Conduction Defects Complications After STEMI
    58 : Pacing in STEMI Temporary pacing is indicated for symptomatic bradyarrhythmias unresponsive to medical treatment.
    59 : Pericarditis Complications After STEMI
    60 : Management of Pericarditis After STEMI Aspirin is recommended for treatment of pericarditis after STEMI. Glucocorticoids and nonsteroidal antiinflammatory drugs are potentially harmful for treatment of pericarditis after STEMI. Administration of acetaminophen, colchicine, or narcotic analgesics may be reasonable if aspirin, even in higher doses, is not effective. Harm
    61 : Thromboembolic and Bleeding Complications Complications After STEMI
    62 : Anticoagulation Individuals with STEMI who do not receive an intracoronary stent, the duration of DAPT beyond 14 days has not been studied adequately for patients who undergo balloon angioplasty alone, are treated with fibrinolysis alone, or do not receive reperfusion therapy.
    63 : Anticoagulation Anticoagulant therapy with a vitamin K antagonist should be provided to patients with STEMI and atrial fibrillation with CHADS2* score greater than or equal to 2, mechanical heart valves, DVT, or hypercoagulable disorder. *CHADS2 (Congestive heart failure, Hypertension, Age =75 years, Diabetes mellitus, previous Stroke/transient ischemic attack (doubled risk weight)) score. †Individual circumstances will vary and depend on the indications for triple therapy and the type of stent placed during PCI. After this initial treatment period, consider therapy with a vitamin K antagonist plus a single antiplatelet agent. For patients treated with fibrinolysis, consider triple therapy for 14 days, followed by a vitamin K antagonist plus a single antiplatelet agent. The duration of triple-antithrombotic therapy with a vitamin K antagonist, aspirin, and a P2Y12 receptor inhibitor should be minimized to the extent possible to limit the risk of bleeding.†
    64 : Anticoagulation Anticoagulant therapy with a vitamin K antagonist is reasonable for patients with STEMI and asymptomatic LV mural thrombi. Targeting a lower INR (e.g., 2.0 to 2.5) might be considered in patients with STEMI who are receiving DAPT. Anticoagulant therapy may be considered for patients with STEMI and anterior-apical akinesis or dyskinesis.
    65 : Risk Assessment After STEMI Guideline for STEMI
    66 : Use of Noninvasive Testing for Ischemia Before Discharge Risk Assessment After STEMI
    67 : Use of Noninvasive Testing for Ischemia Before Discharge Noninvasive testing for ischemia might be considered before discharge to guide the postdischarge exercise prescription. Noninvasive testing for ischemia might be considered before discharge to evaluate the functional significance of a noninfarct artery stenosis previously identified at angiography.
    68 : Assessment of LV Function Risk Assessment After STEMI LVEF should be measured in all patients with STEMI.
    69 : Assessment of Risk for SCD Risk Assessment After STEMI
    70 : Assessment of Risk for SCD Patients with an initially reduced LVEF who are possible candidates for ICD therapy should undergo reevaluation of LVEF 40 or more days after discharge.
    71 : Posthospitalization Plan of Care Exercise-based cardiac rehabilitation programs are recommended for patients with STEMI. Stop smoking and to avoid secondhand smoke
    72 : Protect from sun exposure Just kidding
    73 : www.Slideworld.org
    74 : 100 yr old runner Fauja Singh completed a marathon
    75 : Questions!

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