STEMI Questions and Answers

STEMI Questions and Answers Immediate transfer to a PCI-capable hospital for primary PCI is the recommended triage strategy for patients with STEMI who initially arrive at or are transported to a non-PCI-capable hospital, with an FMC-to-device time system goal of 120 minutes or less* In the absence of contraindications, fibrinolytic therapy should be administered to patients with STEMI at non-PCI-capable hospitals when the anticipated FMC-to-device time at a PCI capable hospital exceeds 120 minutes because of unavoidable delays Previous Play Next Rewind 10 seconds Move forward 10 seconds Unmute 0:00 / 0:15 Full screen Brainpower Read More When fibrinolytic therapy is indicated or chosen as the primary reperfusion strategy, it should be administered within 30 minutes of hospital arrival* interhospital transfer to a PCI-capable hospital is the recommended triage strategy if primary PCI consistently can be performed within 120 minutes of FMC Fibrinolytic therapy, in the absence of contraindications to its use, should be administered within 30 minutes of first door arrival facilitated PCI full- or half-dose fibrinolysis, with or without administration of a glycoprotein (GP) IIb/IIIa receptor antagonist, with immediate transfer for planned PCI within 90 to 120 minutes rescue PCI transfer for PCI of patients who demonstrate findings of failed reperfusion with fibrinolysis pharmacoinvasive strategy refers to the administration of fibrinolytic therapy either in the prehospital setting or at a non-PCI-capable hospital, followed by immediate transfer to a PCI-capable hospital for early coronary angiography and PCI when appropriate. Patients with STEMI who are best suited for immediate interhospital transfer for primary PCI without fibrinolysis are those patients who present with shock or other high-risk features, those with high bleeding risk with fibrinolytic therapy, and those who present 3 to 4 hours after symptom onset and who have short transfer times Patients best suited for initial fibrinolytic therapy are those with low bleeding risk who present very early after symptom onset (2 to 3 hours) to a non-PCI-capable hospital and who have longer delay to PCI A meta-analysis of 6 higher-quality RCTs revealed an approximately 60-minute reduction in time from symptom onset to delivery of fibrinolytic therapy with prehospital versus hospital-based administration, with a corresponding 17% reduction in risk of all-cause hospital mortality Therapeutic hypothermia should be started as soon as possible in comatose patients with STEMI and out-of-hospital cardiac arrest caused by ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT), including patients who undergo primary PCI 23% of out-of-hospital cardiac arrest cases have a shockable initial rhythm (primarily VF), the majority of neurologically intact survivors come from this subgroup rate of survival to hospital discharge with any first recorded rhythm is only 7.9% (175); the rate of survival in patients who are in VF initially is much higher (median 22%, range 8% to 40%) Two RCTs have reported improved rates of neurologically intact survival to hospital discharge when comatose patients with out-of-hospital VF or nonperfusing VT cardiac arrest were cooled to 32°C to 34°C for 12 or 24 hours beginning minutes to hours after the return of spontaneous circulation Cooling should begin before or at the time of cardiac catheterization Primary PCI should be performed in patients with STEMI and ischemic symptoms of less than 12 hours' duration Primary PCI should be performed in patients with STEMI and cardiogenic shock or acute severe HF, irrespective of time Primary PCI is reasonable in patients with STEMI if there is clinical and/or ECG evidence of ongoing ischemia between 12 and 24 hours after symptom onset Manual thrombus aspiration at the time of primary PCI results in improved tissue perfusion and more complete ST resolution, though not all studies have shown positive results Two RCTs (221,235) and a meta-analysis (234) support the use of manual aspiration thrombectomy during primary PCI to improve microvascular reperfusion and to decrease deaths and adverse cardiac events However, infarct size was not reduced by manual aspiration thrombectomy in the INFUSE-AMI. The trial was underpowered to detect differences in clinical outcomes Compared with balloon angioplasty, BMS implantation during primary PCI decreases the risk for subsequent targetlesion and target-vessel revascularization and possibly the risk for reinfarction, but is not associated with a reduction in the mortality rate Compared with BMS, DES implantation decreases restenosis rates and the need for reintervention but does not definitively reduce rates of death or reinfarction The lowest rates of stent thrombosis have been reported with cobalt-chromium everolimus-eluting stents The greatest challenge in deciding the approach at the time of primary PCI, however, is determining emergently whether the patient is a candidate for a prolonged (i.e., 1-year) course of DAPT DES should be avoided in the presence of financial or social barriers that may limit patient compliance, elevated bleeding risk, the anticipated need for invasive or surgical procedures in the subsequent year, or an independent indication for long-term anticoagulant therapy P2Y12 inhibitor therapy should be given for 1 year to patients with STEMI who receive a stent (BMS or DES) during primary PCI using the following maintenance doses: It is reasonable to begin treatment with an intravenous GP IIb/IIIa receptor antagonist such as abciximab (Level of Evidence: A), high-bolus-dose tirofiban (268,269) (Level of Evidence: B), or double-bolus eptifibatide (270) (Level of Evidence: B) at the time of primary PCI (with or without stenting or clopidogrel pretreatment) in selected patients with STEMI who are receiving unfractionated heparin Prasugrel should not be administered to patients with a history of prior stroke or transient ischemic attack Prasugrel, an alternative thienopyridine, achieves greater inhibition of platelet aggregation than clopidogrel. In the TRITON-TIMI 38 trial(260) of prasugrel versus clopidogrel in patients with ACS for whom an invasive strategy was planned, patients with STEMI who were assigned to prasugrel had a lower 30-day rate of the composite primary outcome. This difference persisted to 15 months. In addition, the rate of stent thrombosis reported at 30 days was significantly lower with prasugrel Prasugrel should not be administered to patients with a history of stroke or transient ischemic attack and was not shown to be beneficial in patients 75 years of age or patients who weigh 60 kg The PLATO (Platelet Inhibition and Patient Outcomes) study compared ticagrelor (180-mg loading dose, 90 mg twice daily thereafter) with clopidogrel (300- or 600-mg loading dose, 75 mg daily thereafter) for the prevention of cardiovascular events in 18,624 patients with ACS, of whom 35% had STEMI (294). Among the 7544 patients enrolled with ST elevation or LBBB who underwent primary PCI, findings were consistent with the overall trial results. Significant reductions favoring ticagrelor were seen in the primary PCI subgroup for stent thrombosis and total deaths, though there were more strokes and episodes of ICH withticagrelor several studies have failed to show benefit with the administration of "upstream" GP IIb/IIIa receptor antagonists before primary PCI in the setting of DAPT with either UFH or bivalirudin anticoagulation, (103,268,271-276) a meta-analysis restricted to the use of abciximab has suggested it may be useful in this setting adjunctive use of GP IIb/IIIa agents at the time of PCI can be considered on an individual basis for large thrombus burden or inadequate P2Y12 receptor antagonist loading For patients with STEMI undergoing primary PCI, the following supportive anticoagulant regimens are recommended: a. UFH, with additional boluses administered as needed to maintain therapeutic activated clotting time levels, taking into account whether a GP IIb/IIIa receptor antagonist has been administered In patients with STEMI undergoing PCI who are at high risk of bleeding, it is reasonable to use bivalirudin monotherapy in preference to the combination of UFH and a GP IIb/IIIa receptor antagonist Fondaparinux should not be used as the sole anticoagulant to support primary PCI because of the risk of catheter thrombosis Bivalirudin in this setting may provide a long-term survival benefit related to decreased bleeding but with a higher risk of early stent thrombosis In the absence of contraindications and when PCI is not available, fibrinolytic therapy is reasonable for patients with STEMI if there is clinical and/or ECG evidence of ongoing ischemia within