2017 esc guideline on management of stemi

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Information about 2017 esc guideline on management of stemi

Published on May 23, 2020

Author: AhmedMamunulHuq

Source: slideshare.net

1. 2017 ESC GUIDELINE ON MANAGEMENT OF STEMI Presenter Dr. Ahmed Mamunul Huq MD Cardiology NICVD Moderator Dr. Aminur Razzaque Junior Consultant NICVD

2. Emergency care • Working diagnosis of STEMI • Persistent chest pain And • ST segment elevation at J point in at least 2 contiguous leads in12 lead ECG • In lead V2 – V3 • ≥ 2.5 mm in men < 40 yrs age • ≥ 2mm in men > 40 years age • ≥ 1.5 mm in women • And/ or • ≥ 1 mm in other leads • ≥ 0.5 mm in posterior leads (V7 – V9) (ST depression and upright T in V1 – V3)

3. Emergency care Hypoxia SaO2 < 90% or PaO2 < 60 mmHg Oxygen indicated class I SaO2 > 90% or PaO2 > 60 mmHg oxygen not indicated class III Pain iv opioid Class IIa Anxiety benzodiazepine Class IIa

4. Few definitions First medical contact (FMC) The time point when the patient is either initially assessed by a physician, paramedic, nurse or other trained EMS personnel who can obtain and interpret the ECG and deliver initial interventions(defibrillation). FMC can be either in the pre hospital setting or upon patient arrival at the hospital (emergency department) STEMI diagnosis The time at which the ECG of a patient with ischaemic symptoms is interpreted as presenting ST segment elevation or equivalent Primary PCI strategy Emergent coronary angiography and PCI of the IRA if indicated Pharmacoinvasive strategy Fibrinolysis combined with rescue PCI or routine early PCI strategy

5. FMC FMC Within 10 mins

6. Reperfusion strategy If PCI not possible < 120 min of STEMI diagnosis If PCI possible < 120 mins of STEMI diagnosis If symptomatic, heamodynamic instability, arrythmia If asymptomatic and stable (IIa) 12 h 48 h If symptomatic, heamodynamic instability, arrythmia If asymptomatic and stable (III) fibrinolysis Primary PCI 0Time since symptom onset

7. Procedural aspects of primary PCI IRA Non IRA • Primary PCI • Stenting with new generation DES • Radial access preferred if done by experienced radial operator • Routine thrombus aspiration not recommended • Routine use of deferred stenting not recommended • Revascularization considered in STEMI patients with MVD before hospital discharge • Considered during index procedure in patients with cardiogenic shock

8. Periprocedural pharmacotherapy during PCI DAPT IV anticoagulant A T/ P CLO CAN UFH ENX BIV FON Before and during PCI After PCI OralorIVforminallpatientswithout contraindication Upto12monthsunlessexcessive bleedingrisk IfT/Pcontraindicated GPI NotpretreatedwithP2Y12inhibitorsat thetimeofPCI Bailouttherapyineventofno-reflowor athromboticcomplication Routineuseis recommended IncasesofHIT Routineuseisconsidered notrecommendedfor primaryPCI Routine use of post procedural anticoagulant is not indicated after primary PCI except AF, mechanical valve, LV thrombus, prophylaxis for DVT

9. pharmacoinvasive strategy Fibrinolysis Transfer to PCI capable center Angiogram and PCI When fibrinolysis is the option then it should be started within 10 mins of STEMI diagnosis, preferably pre- hospital setting. Indicated in all patients immediately after fibrinolysis Emergency PCI When heart failure/ shock present Fibrin specific agent should be used • Retaplase • Altaplase • Tenecteplase Rescue PCI (90 min – 120 min) when Failed fibrinolysis Heamodynamic instability Arrythmia Half dose tenectaplase if age > 75 y Routine PCI (2 hrs – 24 hrs) All patients after successful fibrinolysis

10. Adjunctive therapies with fibrinolysis DAPT Anticoagulant It is recommended in patients with fibrinolysis until revascularization (if done) or for the duration of hospital stay up to 8 days Enoxaparin i.v. followed by s.c. is preferred over UFH Fondaparinux i.v. then s.c. if streptokinase is used as fibrinolytic agent aspirin clopT/P 48 hrs after fibrinolysis if subsequent PCI is done and continued for 12 months

11. Length of hospital stay Successful reperfusion Kept in CCU for at least 24 hours Early discharge(within 48 – 72 hrs) if low risk and early follow up and rehabilitation can be arranged May be moved to step down monitored bed for an additional 24 – 48 hours Same day transfer of selected patients to non PCI center

12. Recommendations about imaging and stress testing At presentation After primary PCI After discharge Emergency echo without delaying angiogram for cases of cardiogenic shock, hemodynamic instability, mechanical complication routine echo for all patients Repeat echo 6 – 12 weeks after MI in patients who have pre discharge LVEF < 40% Emergency echo before angiogram when diagnosis is uncertain Emergency echo in hemodynamically unstable patients Routine echo delaying angiogram not recommended

13. Lifestyle intervention and risk factor control • Smoking cessation • Diet, alcohol, weight control • Exercise based rehabilitation • Resumption of activities • Blood pressure control • Adherence to treatment

14. Long term drug therapies Lipid lowering therapy Beta blocker ACE inhibitors/ ARB MRA (eplenorone) High intensity statin asap and maintain long term IV beta blocker in patients undergoing PCI if no HF, SBP > 120 mmHg ACEI in patients HF or LVEF <40%, DM, anterior infarct. Patients with HF and LVEF < 40% or DM who are already receiving ACEI + BB but no renal failure or ↑K+Do lipid profile asap (non fasting) Oral beta blocker in patents with HF and/ or LVEF < 40% if no contraindication All patients without contraindication Goal LDL < 70 mg/ dl Or 50% reduction if 70 – 135 mg/dl Routine oral beta blocker in all patients without contraindication and continued ARB (valsartan) in patients with ACEI intolerance If goal not reached despite max tolerated dose then add non statin

15. MINOCA • Myocardial infarction with non – obstructive coronary arteries • Incidence 1 – 14% • Diagnosis • Universal AMI criteria • Non obstructive coronaries on angiogram (no coronary artery stenosis > 50% in any potential IRA) • No specific cause for acute presentation

16. MINOCA • Cause • Epicardial coronary artery disorder (atherosclerotic plaque rapture, ulcer, fissure or dissection with non obstructive or no CAD) • Imbalance between oxygen supply and demand (coronary spasm, pulmonary embolism) • Coronary endothelial dysfunction (micro vascular spasm) • Secondary to other medical disorders (myocarditis, takotsubo syndrome)

17. MINOCA MINOCA diagnosed Further investigations to determine cause Treatment according to cause • TTE • Contrast echo • CMR • D – dimer • CT scan • Blood tests • Endomyocardial biopsy • IVUS/ OCT • Ergonovine/ ach test • Pressure/ Doppler wire

18. What changed in 2017 version Recommendation 2012 2017 Oxygen SpO2 < 95% SpO2 < 90% Radial access IIa I DES over BMS IIa I Complete revascularization III IIa Thrombus aspiration IIa III Early hospital discharge IIb IIa

19. What’s new in 2017 version Recommendation COR Additional lipid lowering therapy IIa Complete revascularization during 1oPCI if pt is in shock IIa Cangrelor if P2Y12 inhibitors not given before PCI IIb Switch to P/T 48 hrs after fibrinolysis IIb Extend ticagrelor upto 36 months in high risk pt IIb Use of polypill to increase adherence IIb Routine use of deferred stenting III

20. New or revised concepts • MINOCA • Strategy clock starts from ‘STEMI diagnosis’ • Maximum delay from STEMI diagnosis to bolus of fibrinolytics is 10 min • ‘door to balloon’ term eliminated • Time limit for opening of IRA (within 12h I, within 48 h IIa, > 48h III) • Time of CAG after thrombolysis 2- 24 hrs • LBBB and RBBB considered equal for recommending CAG in presence of ischemia.


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