段抬高心梗指南解讀

1WritingCommittee&TaskForceMembersWritingCommitteeMembersElliottM.Antman,Chair DanielT.Anbe,PaulWayneArmstrong,EricR.Bates,LeeA.Green,MaryHand,JudithS.Hochman,HarlanM.Krumholz,FrederickG.Kuschner,GervasioA.Lamas,CharlesJ.Mullany,JosephP.Ornato,DavidL.Pearle,MichaelA.Sloan,SidneyC.Smith,Jr.TaskForceMembersElliottM.Antman,ChairSidneyCSmith,Jr.ViceChairJosephS.Alpert,JefferyL.Anderson,DavidP.Faxon,ValentinFuster,RaymondJ.Gibbons,GabrielGregoratos,JonathanLHalperin,LorenF.Hiratzka,SharonAnnHunt,AliceK.Jacobs,JosephP.Ornato2AMIStatsIncidenceintheUnitedStates*Estimated900,000willsufferAMIthisyear~565,000willbenewattacks(avg.age-65.8yrs/males,70.4yrs/female)~300,000willberecurrentattacks42%ofAMIptswilldiewithin1yearApproximatelyhalfofthesedeathsoccurbeforereachingtheemergencydepartmentMostcardiacdeathsaretheresultoffatalarrhythmiasTypesofarrival/dischargeAMIs**Uponarrival:STEMIon1stECG-26%;STEMIon1storsubsequentECG-35%;NSTEMI-65%Non-Q-wave:75%Q-wave:25%*AmericanHeartAssociation.HeartDisease&StrokeStatistics-2004Update**NRMI4QuarterlyData

Report(Nation).SouthSanFrancisco,Calif:GenentechInc;June,2004.PathophysiologyofST-Elevation

MyocardialInfarctionResultsfromstabilizationofa

plateletaggregateatsiteof

plaquerupturebyfibrinmeshplateletRBCfibrinmeshGPIIb-IIIaGenerallycausedbya

completelyocclusive

thrombusinacoronaryarteryRecentInfluencesofPracticeSuperiorityofPrimaryPercutaneousCoronaryIntervention(PPCI)overfibrinolysisifDoor-to-BallooncompletedinatimelyfashionAcknowledgementthatTimeMattersinPPCIRecommendationsfortimetoreperfusionupdatedStudiespublishedonCombinationTherapy

GPIIb/IIIareceptorantagonistsincombinationwith?dosefibrinolysisStudieswithLMWHintreatmentofSTEMI(enoxaparin+fulldoseTNK-tPA)EuropeanSTEMItrialsinfluencetheguidelinesPrehospital,TransferPCIPrehospitalDestinationProtocols5ClassificationofRecommendationsClassI: Conditionsforwhichthereisevidenceand/or

generalagreementthatagivenprocedureor treatmentis

beneficial,useful,andeffective.ClassII: Conditionsforwhichthereisconflictingevidence

and/oradivergenceofopinionaboutthe usefulness/efficacyofaprocedureortreatment.ClassIIa:Weightofevidence/opinionisinfavorof usefulness/efficacy.ClassIIb: Usefulness/efficacyislesswellestablishedby

evidence/opinion.ClassIII:Conditionsforwhichthereisevidenceand/or generalagreementthataprocedure/treatmentis

NOTuseful/effectiveandinsomecasesmaybe

harmful.LevelofEvidenceLevelofEvidenceA:Dataderivedfrommultiplerandomizedclinicaltrialsormeta-analyses.LevelofEvidenceB:Dataderivedfromasinglerandomizedtrial,ornonrandomizedstudies.LevelofEvidenceC:Onlyconsensusopinionofexperts,casestudies,orstandardofcare.7AchieveCoronaryPatencyInitialReperfusionTherapy

Definedastheinitialstrategyemployedtorestorebloodflowtotheoccludedcoronaryartery3MajorOptions:PharmacologicalReperfusionPCIAcuteSurgicalReperfusionUnderbothPharmacologicalandPCIarelistedseverallowerrecommendations&investigationalreperfusionstrategiesClassIAllpatientsshouldundergorapidevaluationforreperfusiontherapy&haveareperfusionstrategyimplementedpromptlyaftercontactwiththemedicalsystem Antmanetal.JACC2004;44:680.8ImportanceofEarly

ReperfusionTherapyinSTEMIOutcomesDependentUpon:Timetotreatment-TIMEISSTILLMUSCLE

EarlyandfullrestorationincoronarybloodflowSustainedrestorationofflow9PrehospitalIssuesEMSEmphasisonearlydefibrillation;AEDs;911dispatcherstraining&useofnationalprotocolsChestPainEvaluation&TreatmentEmphasisongivingchewableASA,unlesscontraindicated&prehospitalECG&checklistPrehospitalFibrinolysisUpgradedtoaClassIIa(LevelB)RecommendationPrehospitalDestinationProtocolsWheretotransportSTEMIpatients-HaveaplaninplaceSpecialconsiderationsCardiogenicShockFibrinolyticcontraindicatedAntmanetal.JACC2004;44:675-7.10InitialPatientEvaluationClassI

Delayinpatientcontact(arrivalattheEDorcontactwithparamedics)to:fibrinolytictherapylessthan30minutesPCIlessthan90mins

(LevelofEvidence:B)ThechoiceofinitialSTEMItreatmentshouldbemadebyEDPhysicianondutybasedonapredetermined,institution-specific,writtenprotocol….Forunclearcases,notcoveredbytheprotocol,contactcardiologistimmediately.(LevelofEvidenceC).Antmanetal.JACC2004;44:677-8.PatientsTransportedbyEMSAfterCalling9-1-1OnsetofSTEMISymptomsCall911CallFast9-1-1EMSDispatchEMSon-sceneEncourage12-leadECGConsiderprehospitalfibrinolyticifcapableandEMS-to-needle<30minEMSTriagePlanNotPCICapableHospitalPCICapableHospitalInterhospitalTransferHospitalFibrinolysis:Door-to-needlewithin<30minEMStransport:EMStoBalloonwithin90minPatientself-transport:HospitalDoor-to-Balloonwithin90minEMStransportEMSonscene

Within8minDispatch1minPatient5minafterSymptomonsetGoalsTotalischemictime:Within120min**Goldenhour=First60min

AdaptedfromPanelAFigure1Antmanetal.JACC2004;44:676.

AdaptedfromPanelBFigure1Antmanetal.JACC2004;44:676.FibrinolysisNoninv.RiskStratificationLateHospitalCare&SecondaryPreventionPCIorCABGPrimaryPCIReceivingHospitalNotPCICapablePCICapableRescueIschemicdriven13InitialRecognition&ManagementintheEDOptimalStrategiesfortheEDTriageInitialPatientEvaluationHistoryPhysicalExamECGLaboratoryExaminationsBiomarkersofCardiacDamageImagingRoutineMeasuresAntmanetal.JACC2004;44:677-9.14SelectionofReperfusionStrategyStep1:AssessTimeandRiskTimefromOnsetofSymptomsDifferentiationmadeforearlypresentersRiskofSTEMIHighrisk(eg,cardiogenicshock)PPCIpreferredRiskofBleedingHighRiskofbleeding-PPCIPreferredTimeRequiredforTransporttoaSkilledPCILabAvailabilityofPCIlabsImportanceofreductionofrecurrentMITime-to-PCIminusTime-ToBalloonAntmanetal.JACC2004;44:682.15PharmacologicalReperfusion AvailableResourcesClassI1.STEMIpatientspresentingtoafacilitywithoutthecapabilityforexpert,promptinterventionwithprimaryPCIwithin90minutesoffirstmedicalcontactshouldundergofibrinolysisunlesscontraindicated.

(LevelofEvidence:A)Antmanetal.JACC2004;44:682.16FibrinolyticTherapyClassI

Intheabsenceofcontraindication,fibrinolytictherapy shouldbeadministeredtoSTEMIpatientswith symptomonsetwithintheprior12hours&STelevation >0.1mVinatleast2contiguousprecordialleadsorat least2adjacentlimbleads.2.Intheabsenceofcontraindications,fibrinolytictherapy shouldbeadministeredtoSTEMIpatientswith symptomonsetwithintheprior12hoursand

neworpresumablynewLBBB.Antmanetal.JACC2004;44:682-3.17FibrinolyticTherapy

ClassIIaIntheabsenceofcontraindication,fibrinolytictherapy itisreasonabletoadministertoSTEMIpatientswith symptomonsetwithintheprior12hours&12-leadECG findingsconsistentwithatrueposteriorMI(LevelC).2.Intheabsenceofcontraindications,itisreasonableto administertofibrinolytictherapytopatientswithsymptoms ofSTEMIbeginningwithintheprior12hoursto24hours

whohavecontinuingischemicsymptoms&STelevation

>0.1mV

inatleast2contiguousprecordialleadsoratleast2 adjacentlimbleads(LevelB).

Antmanetal.JACC2004;44:683.ACC/AHA:ContraindicationsandCautionsforFibrinolyticUseinSTEMIAbsoluteContraindicationsAnypriorICHKnownstructuralcerebralvascularlesion -eg,AVMKnownmalignantintracranialneoplasm-primaryormetastaticIschemicstrokewithin3months -EXCEPTAISwithin3hoursSuspectedaorticdissectionActivebleedingorbleedingdiathesis(doesnotincludemenses)Significantclosedheadorfacialtraumawithin3monthsAntmanetal.JACC

2004;44:683.19FibrinolyticTherapy

Step2:

DetermineWhetherFibrinolysisor

anInvasiveStrategyisPreferred

AdaptedfromFigure3;Antmanetal.JACC

2004;44:682.Ifpresentationislessthan3hoursandthereisnodelaytoaninvasivestrategy,thereisnopreferenceforeitherstrategy.Fibrinolysisisgenerallypreferredif:Earlypresentation(3hoursorlessfromsymptomonset&delaytoinvasivestrategy;seebelow)InvasivestrategyisnotanoptionCatheterizationlaboccupied/notavailableVascularaccessdifficultiesLackofaccesstoaskilledPCIlab-Operatorexperience>75PPCIcasesperyear/Teamexperience>36PPCIcasesperyearDelaytoinvasivestrategyProlongedtransport(Door-toBalloon)–(Door-to-needle)timeis>1HRMedicalcontact-to-balloontimeis>than90minAninvasivestrategyisgenerallypreferredif:

SkilledPCIlaboratoryavailablewithsurgicalbackupMedicalcontact-to-balloontimeis<than90min(Door-toBalloon)–(Door-to-needletime)is<1hr

HighriskfromSTEMICardiogenicshockKillipclassgreaterthanorequalto3Contraindicationstofibrinolysis,includingincreasedriskofbleedingandICHLatepresentationSymptomonsetwasmorethan3hoursagoDiagnosisofSTEMIisindoubt20CAPTIM

ComparisonofAngioplastyandPrehospitalThrombolysisinAcuteMyocardialInfarctionPrimaryCompositeEndpoint-Death,Reinfarction,DisablingStrokeBonnefoyE,etal.Lancet2002;360:825-921CAPTIM-1YearResults

SxtoTreatmentAnalysisTouboulP.Presentedat:The18thInternationalSymposiumonThrombolysisandInterventionalTherapyinAcuteMyocardialInfarction-GeorgeWashingtonUniversitySymposium;November16,2002;Chicago,Ill.Sx2h0.0DeathSx2h5.07.52.5Pre-hospitalLysisPrimaryPCI2.25.7DeathP=0.0570.07.510.02.5Pre-hospitalLysisPrimaryPCI5.93.7DeathP=0.475.0Percent22ComparisonofApprovedFibrinolyticAgentsAdaptedfromTable15,pg53.AccessedonAugust6,2004/clinical/guidelines/stemi/index.pdf.

Streptokinase Alteplase Reteplase TenecteplaseDose

1.5MUover Upto100mgin 10Ux2 30-50mg

30-60min 90min(wt-based)eachover2min basedonweightBolusAdmin.

No No Yes YesAntigenic

Yes No No NoAllergicReact

YesNo No NoSystemic

Marked Mild

Moderate MinimalFibrinogenDepletion~90-minpatency50 7575?

75

rates(%)TIMIgrade3flow,%32 54 60 6323FibrinolyticTherapy

CombinationTherapywithGPIIb/IIIaClassIIb1.Combinationpharmacologicalreperfusionwithabciximabandhalf-dosereteplaseortenecteplasemaybeconsideredforpreventionofreinfarction

(LevelofEvidence:A)andothercomplicationsofSTEMIinselectedpatients:anteriorlocationofMI,agelessthan75years,andnoriskfactorsforbleeding.Intwoclinicaltrialsofcombinationreperfusion,thepreventionofreinfarctiondidnottranslateintoasurvivalbenefitateither30daysor1year.(LevelofEvidence:B)2.Combinationpharmacologicalreperfusionwithabciximabandhalf-dosereteplaseortenecteplasemaybeconsideredforpreventionofreinfarctionandothercomplicationsofSTEMIinselectedpatients(anteriorlocationofMI,agelessthan75years,andnoriskfactorsforbleeding)inwhomanearlyreferralforangiographyandPCI(ie,facilitatedPCI)isplanned.(LevelofEvidence:C)Antmanetal.JACC

2004;44:684.24GPIIb/IIIaAsASoloReperfusionStrategy“StudiesevaluatingtheuseofglycoproteinIIb/IIIainhibitorsasthesolemeansofreperfusion(i.e.,withoutafibrinolyticorinconjunctionwithPCI)donotsuggestthattheisolateduseofaGPIIb/IIIainhibitorrestoresTIMI3flowinasufficientproportionofpatientstomakeitaviablepharmacologicstrategy”. -pg54,FullTextGuidelinesFromtheTIMI-14,SPEED,INTRO-AMIdatasetsAccessedonAugust6,2004/clinical/guidelines/stemi/index.pdf.25FibrinolyticTherapy

CombinationTherapywithGPIIb/IIIaClassIII1.Combinationpharmacologicalreperfusionwithabciximabandhalf-dosereteplaseortenecteplaseshouldnotbegiventopatientsagedgreaterthan75yearsbecauseofanincreasedriskofICH.(LevelofEvidence:B)Antmanetal.JACC

2004;44:683.26PrimaryPercutaneousCoronaryIntervention

ClassI

1.Generalconsiderations:Ifimmediatelyavailable,primaryPCIshouldbeperformedinpatientswithSTEMI(includingtrueposteriorMI)orMIwithneworpresumablynewLBBBwhocanundergoPCIoftheinfarctarterywithin12hoursofsymptomonset,ifperformedinatimelyfashion(ballooninflationwithin90minutesofpresentation)bypersonsskilledintheprocedure(individualswhoperformmorethan75PCIproceduresperyear).Theprocedureshouldbesupportedbyexperiencedpersonnelinanappropriatelaboratoryenvironment(performsmorethan200PCIproceduresperyear,ofwhichatleast36areprimaryPCIforSTEMI,andhascardiacsurgerycapability).(LevelofEvidence:A)

Antmanetal.JACC

2004;44:682.27NRMI2:PrimaryPCIDoor-to-BalloonTimevs.MortalityDoor-to-BalloonTime(minutes)MVAdjustedOddsofDeathP=0.01P=0.0007P=0.0003n=2,2305,7346,6164,4612,6275,41228TimefromSymptomOnsettoTreatment

Predicts1-yearMortalityafterPrimaryPCIDeLucaetal,Circulation2004;109:1223-1225Therelativeriskof1-yearmortalityincreasesby7.5%foreach30-minutedelayn=1791MortalityrateswithprimaryPCIasafunctionofPCI-related

timedelayP=0.0060 20 40 60 80 100PCI-RelatedTimeDelay(door-to-balloon-doortoneedle)AbsoluteRiskDifferenceinDeath(%) -5 0 5 10 15Circle

sizes= samplesizeofthe individualstudy.Solidline = weightedmeta-regression.NallamothuBK,BatesER.AmJCardiol.2003;92:824-662minBenefit

FavorsPCIHarm

FavorsLysisForEvery10mindelaytoPCI:1%reductioninmortalitydifferencetowardslytics30PrimaryPercutaneousCoronaryInterventionClassI

2.SpecificConsiderations:a.PrimaryPCIshouldbeperformedasquicklyaspossible,withagoalofamedicalcontact–to-balloonordoor-to-balloontimeofwithin90minutes.(LevelofEvidence:B)b.Ifthesymptomdurationiswithin3hoursandtheexpecteddoor-to-balloontimeminustheexpecteddoor-to-needletimeis:i)within1hour,primaryPCIisgenerallypreferred.(LevelofEvidence:B)ii)greaterthan1hour,fibrinolytictherapy(fibrin-specificagents)isgenerallypreferred.(LevelofEvidence:B)c.Ifsymptomdurationisgreaterthan3hours,primaryPCIisgenerallypreferredandshouldbeperformedwithamedicalcontact–to-balloonordoor-to-balloontimeasbriefaspossible,withagoalofwithin90minutes.(LevelofEvidence:B)Antmanetal.JACC

2004;44:684.31PrimaryPercutaneousCoronaryIntervention

ClassI

2.SpecificConsiderations(continued)d.PrimaryPCIshouldbeperformedforpatientsyoungerthan75yearsoldwithSTelevationorLBBBwhodevelopshockwithin36hoursofMIandaresuitableforrevascularizationthatcanbeperformedwithin18hoursofshock,unlessfurthersupportisfutilebecauseofthepatient’swishesorcontraindications/unsuitabilityforfurtherinvasivecare.(LevelofEvidence:A)e.PrimaryPCIshouldbeperformedinpatientswithsevereCHFand/orpulmonaryedema(Killipclass3)andonsetofsymptomswithin12hours.Themedicalcontact–to-balloonordoor-to-balloontimeshouldbeasshortaspossible(ie,goalwithin90min).(LevelofEvidence:B)Antmanetal.JACC

2004;44:684.32PrimaryPercutaneousCoronaryIntervention

PPCIwithoutOn-SiteCardiacSurgery

ClassIIb

1.PrimaryPCImightbeconsideredinhospitalswithouton-sitecardiacsurgery,providedthatthereexistsaprovenplanforrapidtransporttoacardiacsurgeryoperatingroominanearbyhospitalwithappropriatehemodynamicsupportcapabilityfortransfer.TheprocedureshouldbelimitedtopatientswithSTEMIorMIwithnew,orpresumablynew,LBBBonECG,andshouldbedoneinatimelyfashion(ballooninflationwithin90minutesofpresentation)bypersonsskilledintheprocedure(atleast75PCIsperyear)andathospitalsthatperformaminimumof36primaryPCIproceduresperyear.(LevelofEvidence:B)Antmanetal.JACC

2004;44:686.33PrimaryPercutaneousCoronaryInterventionInterhospitalTransferforPrimaryPCI“Toachieveoptimalresults,timefromthefirsthospitaldoortotheballooninflationinthesecondhospitalshould

beasshortaspossible,withagoalofwithin90minutes.Significantreductionsindoor-to-balloontimesmightbeachievedbydirectlytransportingpatientstoPCIcentersratherthantransportingthemtothenearesthospital,ifinterhospitaltransferwillsubsequentlyberequiredtoobtainprimaryPCI”.Antmanetal.JACC

2004;44:686.34DANAMI-2:ResultsDeath/MI/Stroke(%)LyticPrimaryPCIP=0.35Death02647.66.6LyticPrimaryPCIP<0.0001RecurrentMI026846.31.6LyticPrimaryPCIP=0.15Stroke026841.12.08AndersonHR,etal.NEJM2003;349:733-42DoortoBalloonTimesAmongPatients

TransferredinNRMI4DoortoData:50th:9Min.25th:4Min.75th:16Min.DatatoCathLabArrival:50th:132Min.25th:88Min.75th:219Min.CathLabtoBalloon:50th:37Min.25th:28Min75th:50Min.913237TotalDoor1toBalloonTime:185minutes(25th:137;75th:276)PercentofPatientswithDoortoBalloonTime<90Min.:3.0%SampleSize:1,346;TimePeriod:January2002–December2002AccessedonAugust6,2004/clinical/guidelines/stemi/index.pdf.pg.61

36PrimaryPercutaneousCoronaryIntervention PrimaryStentingPrimarystentinghasbeencomparedwithprimaryangioplastyin9studies.Therewerenodifferencesinmortality(3.0%versus2.8%)orreinfarction(1.8%versus2.1%)rates.However,majoradversecardiaceventswerereduced,drivenbythereductioninsubsequenttarget-vesselrevascularizationwithstenting.Preliminaryreportssuggestthatcomparedwithconventionalbaremetalstents,drug-elutingstentsarenotassociatedwithincreasedriskwhenusedforprimaryPCIinSTEMIpatients.Postprocedurevesselpatency,biomarkerrelease,andtheincidenceofshort-termadverseeventsweresimilarinpatientsreceivingsirolimus(nequals186)orbaremetal(nequals183)stents.Thirty-dayeventratesofdeath,reinfarction,orrevascularizationwere7.5%versus10.4%,respectively(Pequals0.4).Antmanetal.JACC

2004;44:686.37DefinitionofTerms:

NomenclatureforfPCIFacilitatedPCI(fPCI)-fibrinolyticsorotherpharmacologics‘facilitate’PCIPharmacoinvasiveRecanalization-capiltalizesontherapidityofinitiation&widespreadfeasibilityofpharmacologicthrombolysistopromptlyrestore‘some’myocardialbloodflow,coupledwiththemorecompleterestorationachievablewithsubsequentPCIDauerman&Sobel,JACC2003;42:646-5138PrimaryPercutaneousCoronaryIntervention

FacilitatedPCI

ClassIIbFacilitatedPCImightbeperformedasareperfusionstrategyinhigher-riskpatientswhenPCIisnotimmediatelyavailableandbleedingriskislow.(LevelofEvidence:B)Thetextmentionsallpharmacologicaloptionstofacilitate,PCIincluding;full-dosefibrinolysis,?dosefibrinolysis,&aGPIIb-IIIa.Thestrategyholdspromiseforhigher-riskAMIwhenPPCIisnotreadilyavailable.Antmanetal.JACC

2004;44:686.39PrimaryPercutaneousCoronaryIntervention

RescuePCI

ClassIRescuePCIshouldbeperformedinpatientslessthan75yearsoldwithSTelevationorLBBBwhodevelopshockwithin36hoursofMIandaresuitableforrevascularizationthatcanbeperformedwithin18hoursofshock,unlessfurthersupportisfutilebecauseofthepatient’swishesorcontraindications/unsuitabilityforfurtherinvasivecare.(LevelofEvidence:B)2.RescuePCIshouldbeperformedinpatientswithsevereCHFand/orpulmonaryedema(Killipclass3)andonsetofsymptomswithin12hours.(LevelofEvidence:B)Antmanetal.JACC

2004;44:686.40PrimaryPercutaneousCoronaryIntervention

RescuePCI

ClassIIa1.RescuePCIisreasonableforselectedpatients75yearsorolderwithSTelevationorLBBBorwhodevelopshockwithin36hoursofMIandaresuitableforrevascularizationthatcanbeperformedwithin18hoursofshock.Patientswithgoodpriorfunctionalstatuswhoaresuitableforrevascularizationandagreetoinvasivecaremaybeselectedforsuchaninvasivestrategy.(LevelofEvidence:B)2.ItisreasonabletoperformrescuePCIforpatientswith1ormoreofthefollowing: a.Hemodynamicorelectricalinstability

(LevelofEvidence:C) b.Persistentischemicsymptoms.(LevelofEvidence:C)Antmanetal.JACC

2004;44:687.41PercutaneousCoronaryIntervention

AfterFibrinolysisClassI1.Inpatientswhoseanatomyissuitable,PCIshouldbeperformedwhenthereisobjectiveevidenceofrecurrentMI.(LevelofEvidence:C)2.Inpatientswhoseanatomyissuitable,PCIshouldbeperformedformoderateorseverespontaneousorprovocablemyocardialischemiaduringrecoveryfromSTEMI.(LevelofEvidence:B)3.Inpatientswhoseanatomyissuitable,PCIshouldbeperformedforcardiogenicshockorhemodynamicinstability.(LevelofEvidence:B)Antmanetal.JACC

2004;44:687.42PercutaneousCoronaryIntervention

AfterFibrinolysis-continued

ClassIIa1.ItisreasonabletoperformroutinePCIinpatientswithLVejectionfraction(LVEF)lessthanorequalto0.40,CHF,orseriousventriculararrhythmias.(LevelofEvidence:C)2.ItisreasonabletoperformPCIwhenthereisdocumentedclinicalheartfailureduringtheacuteepisode,eventhoughsubsequentevaluationshowspreservedLVfunction(LVEFgreaterthan0.40).(LevelofEvidence:C)ClassIIb(New,previouslyClassIII)1.RoutinePCImightbeconsideredaspartofaninvasivestrategyafterfibrinolytictherapy.(LevelofEvidence:B)Antmanetal.JACC

2004;44:687.43Kaplan-Meiersurvivalestimates,byPCI

AfterLysisin20,101Patients

Years00.511.5NoPCIPCILogrankp<0.0001SurvivalGibsonCMetal,JACC200344AcuteSurgicalReperfusionClassIEmergencyorurgentCABGinpatientswithSTEMIshouldbeundertakeninthefollowingcircumstances:FailedPCIwithpersistentpainorhemodynamicinstabilityinpatientswithcoronaryanatomysuitableforsurgery. (LevelofEvidence:B)b.Persistentorrecurrentischemiarefractorytomedicaltherapyinpatientswhohavecoronaryanatomysuitableforsurgery,haveasignificantareaofmyocardiumatrisk,andarenotcandidatesforPCIorfibrinolytictherapy. (LevelofEvidence:B)Antmanetal.JACC

2004;44:688.45AcuteSurgicalReperfusion

(continued)ClassIc.Atthetimeofsurgicalrepairofpostinfarctionventricularseptalrupture(VSR)ormitralvalveinsufficiency.

(LevelofEvidence:B)d.Cardiogenicshockinpatientslessthan75yearsoldwithSTelevation,LBBB,orposteriorMIwhodevelopshockwithin36hoursofSTEMI,haveseveremultivesselorleftmaindisease,andaresuitableforrevascularizationthatcanbeperformedwithin18hoursofshock,unlessfurthersupportisfutilebecauseofthepatient’swishesorcontraindications/unsuitabilityforfurtherinvasivecare.(LevelofEvidence:A)e.Life-threateningventriculararrhythmiasinthepresenceofgreaterthanorequalto50%leftmainstenosisand/ortriple-vesseldisease.(LevelofEvidence:B)Antmanetal.JACC

2004;44:688.46AncillaryTherapy-Antithrombins

Heparin-UFH

ClassI1.PatientsundergoingpercutaneousorsurgicalrevascularizationshouldbegivenUFH.(LevelofEvidence:C)2.UFHshouldbegivenintravenouslytopatientsundergoingreperfusiontherapywithalteplase,reteplase,ortenecteplase,withdosingasfollows:bolusof60U/kg(maximum4000U)followedbyaninitialinfusionof12U/kgperhour(maximum1000U/hr)adjustedtomaintainactivatedpartialthromboplastintime(aPTT)at1.5to2.0timescontrol(approximately50to70seconds).(LevelofEvidence:C)3.UFHshouldbegivenintravenouslytopatientstreatedwithnonselectivefibrinolyticagents(streptokinase,anistreplase,orurokinase)whoareathighriskforsystemicemboli(largeoranteriorMI,atrialfibrillation,previousembolus,orknownLVthrombus).(LevelofEvidence:B)4.PlateletcountsshouldbemonitoreddailyinpatientsAntmanetal.JACC

2004;44:688.47AncillaryTherapy-Antithrombins

Heparin-UFHClassIIb1.ItmaybereasonabletoadministerUFHintravenouslytopatientsundergoingreperfusiontherapywithstreptokinase.(LevelofEvidence:B)Antmanetal.JACC

2004;44:689.48AncillaryTherapy-Antithrombins

Low-Molecular-Weight-HeparinClassIIb1.LMWHmightbeconsideredanacceptablealternativetoUFHasancillarytherapyforpatientslessthan75years

ofagewhoarereceivingfibrinolytictherapy,providedthatsignificantrenaldysfunction(serum

creatininegreaterthan2.5mg/dLinmenor2.0mg/dLinwomen)isnotpresent.Enoxaparin(30mgIVbolusfollowedby1.0mg/kgsubcutaneousinjectionevery12withfull-dosetenecteplaseisthemostcomprehensivelystudiedregimeninpatientslessthan75yearsofage.(LevelofEvidence:B)Antmanetal.JACC

2004;44:689.49AncillaryTherapy-Antithrombins

Direct-ActingAntithrombinsClassIIa1.Inpatientswithknownheparin-inducedthrombocytopenia,itisreasonabletoconsiderbivalirudin

asausefulalternativetoheparintobeusedinconjunctionwithstreptokinase.DosingaccordingtotheHERO(HirulogandEarlyReperfusionorOcclusion)-2regimen(abolusof0.25mg/kgfollowedbyanintravenousinfu