1. health and fitness
2. therapy

PRCS GUIDELINES FOR THE MANAGEMENT OF PATIENTS
WITH ST-ELEVATION MYOCARDIAL INFARCTION
(STEMI)
THE PANEL
PRCS CARDIOLOGISTS
Dr. Kassem Soboh (Hamshary hospital)
Dr. Adnan Said (Nassra hospital)
Dr. Hassan Souleiman (Safad hospital)
PRCS PHARMACIST
Dr. Fadi Salam (Hamshary hospital)
PRCS GENERAL PRACTITIONERS
Dr. Emad Koussa (Nassra hospital)
PRCS CCU NURSES
Mr Khaled Sabbah, Hamshary
Mr Sulyman Khlaif, Nassra
Mr. Wissam Hourani, Safad
Mr. Alaa Rabah, Balsam
Mr. Jamal Maarouf, Haifa
ITALIAN SPECIALIST
Dr. Enrico Materia (MD and Public Health expert, ASP Lazio, Italy)
June 2006
QUALITY OF CARE AT PRCS HOSPITALS
TABLE OF CONTENT
1.
INTRODUCTION …………………………………………………………….. p. 3
2.
INITIAL RECOGNITION ……………………………………………………… p. 5
2.1
2.2
2.2
2.3
2.4
2.5
2.6
3.
MEDICAL MANAGEMENT ……………………………………………………p.
3.1
3.2
3.3
4.
Routine measures
a) Oxigen
b) Nitrates
c) Analgesia
d) Aspirin
e) Beta-blockers
f) ACE Inhibitors
g) Calcium Channel Blockers
h) Anxiolytics
i) Reperfusion with thrombolytic agents
j) Heparin
Coronary Angiography and Percutaneous Coronary Intervention
Strict glucose control during STEMI
Coronary Care Unit
Early general measures
HEMODYNAMIC DISTURBANCES ………...………………………………….. p. 11
5.1
5.2
5.3
5.4
5.5
6.
7
HOSPITAL MANAGEMENT …………………………………………………… p. 11
4.1
4.2
5.
Initial patient evaluation
History
Physical examination
Electrocardiogram
Laboratory examinations
Imaging
Recording of findings in clinical file
Hypotension
Low output status
Pulmonary congestion
Cardiogenic shock
Mechanical causes of Heart Failure
ARRHYTHMIAS AFTER STEMI………………………………………………p. 13
6.1 Ventricular Fibrillation
6.2 Ventricular Tachycardia
6.3 Ventricular premature beats and Accelerated Idioventricular or Junctional Rhythms
6.4 Supraventricular Arrhythmias and Atrial Fibrillation
6.5 Ventricular Asystole
6.6 Conduction Block associated with STEMI
7.
CONVALESCENCE, DISCHARGE AND POST STEMI CARE …………………….p.
15
7.1 Pericarditis after STEMI
7.2 Risk stratification at hospital discharge
7.3 Secondary prevention
8.
LIST OF ACRONYMS AND ABBREVIATIONS…………………………………..p.
18
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1. INTRODUCTION
The present guideline has been developed in the frame of the project "Hospital care quality
study, development of good practice guidelines and implementation strategies, training of
trainers”, financed by the Humanitarian Aid Department of the European Commission.
Current practice in the management of patients affected by acute coronary syndrome (ACS)
was evaluated with the aim of providing background information for adapting the
international guideline to PRCS context. The complete results can be found in the report
“Hospital care quality study”.
Coronary heart disease (CHD) is the leading cause of death worldwide both in developed and
developing countries, and acute coronary syndrome is one of the most frequent and
threatening clinical emergency, carrying a high risk of death.
There is evidence that Palestinians have a very high rate of CHD in comparison with other
world populations 1 .
ACS includes several conditions: acute ST-segment elevation myocardial infarction (STEMI),
non ST-segment elevation myocardial infarction (NSTEMI), and unstable angina (UA).
Acute myocardial infarction is an acute process of myocardial ischemia with sufficient
severity and duration to result in permanent myocardial damage. Clinically, the diagnosis of
permanent myocardial damage is typically made when there is a characteristic rise and fall in
cardiac biomarkers indicative of myocardial necrosis that may or may not be accompanied by
the development of Q waves on the ECG.
This practice guideline for managing patients who present to the ER with symptoms
suggestive of STEMI has been developed in May 2006 by a multidisciplinary team, including
cardiologists, emergency medicine doctors and CCU nurses working at PRCS/Lebanon
hospitals, adapting the guideline issued by the American College of Cardiology/American
Heart Association in collaboration with the Canadian Heart Association 2 .
The ACC/AHA guideline has been selected as the preferable in terms of quality and updating
among other similar documents. To make our guideline simple to use, the graded strength of
recommendations was not reported.
1
Kark JD, Fink R, Adler B, Goldberg N, Goldman S. The incidence of coronary heart disease
among Palestinians and Israelis in Jerusalem. Int J Epidemiol 2006; 35: 448-457.
2
ACC/AHA Guidelines for the Management of patients with ST-Elevation Myocardial Infarction.
Executive Summary. Circulation 2004; 110:588-636 (207 references).
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To provide clinicians with a set of recommendations that can easily be translated into the
practice of caring for patients with STEMI, this guidelines is organised around the chronology
of the interface between the patient and the clinicians.
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2. INITIAL RECOGNITION OF STEMI
2.1 INITIAL PATIENT EVALUATION
Æ The choice of initial STEMI treatment should be made by the emergency medicine
physician on duty based on this guidelines. For cases in which the initial diagnosis or
treatment plan is unclear to the emergency physician or is not covered directly by the
guideline, immediate cardiology consultation is advisable.
Æ All patients presenting to the ER with chest discomfort or other symptoms suggestive
of STEMI or UA should be considered high-priority triage cases and should be
evaluated and treated based on a predetermined chest pain protocol.
2.2 HISTORY
Æ The targeted history of STEMI patients taken in ER should ascertain whether the
patient has had prior episodes of myocardial ischemia, such as stable or unstable
angina, myocardial infarction, or coronary artery by-pass graft or percutaneous
coronary intervention.
Æ Evaluation of the patient’s complaints should focus on chest discomfort (including
type, duration and location), associated symptoms, age-related differences in
presentation, hypertension, diabetes mellitus, possibility of aortic dissection, risk of
bleeding, and clinical cerebrovascular diseases.
2.3 PHYSICAL EXAMINATION
Æ A physical examination should be performed to aid in the diagnosis and assessment
of the extent, location, and presence of complications of STEMI.
2.4 ELECTROCARDIOGRAM
Æ A 12-lead ECG should be performed and shown to an experienced physician within
10 min of ER arrival for all patients with chest discomfort or other symptoms
suggestive of STEMI.
Æ In patients with inferior STEMI, right precordial V4R ECG leads should be obtained
to detect ST elevation suggestive of right ventricular infarction.
Æ If the initial ECG is not diagnostic of STEMI but the patient remains symptomatic,
and there is a high clinical suspicion for STEMI, serial ECG at 10 min intervals, or
continuous 12-lead ST-segment monitoring, should be performed to detect the
potential development of ST elevation.
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2.5 LABORATORY EXAMINATIONS
Æ All patients with chest discomfort or other symptoms suggestive of ACS should be
tested for laboratory biomarkers of cardiac damage including: CK, CK-MB, GOT,
LDH.
Although cardiac specific troponin is the optimum marker (given its greater
sensitivity and specificity than CK-MB, its usefulness for the evaluation of patients
with STEMI who have coexistent skeletal muscle injury, and the possibility to
perform a qualitative assessment through a handheld bedside assay) CK-MB assay is
also acceptable.
Æ In patients with negative cardiac markers within 6 hours of the onset of pain, another
sample should be drawn in the 6- to 12-h time frame.
Æ Other laboratory tests which should be routinely performed for early risk stratification
in patients with symptoms suggestive of ACS include:
-
Complete blood counts (CBC)
-
Erithrocyte Sedimentation Rate (ESR)
-
Blood sugar (glucose)
-
BUN & Creatininemia
-
Electrolytes (Na, K)
-
Lipids: Cholesterol, Triglycerids, Low and High Density Lipoprotein
(LHL & HDL)
-
PT & PTT (Prothrombin Time and Partial Thromboplastin Time)
-
C-reactive protein (CRP) and when possible fibrinogen as indicators
of an increased risk of adverse outcome.
2. 6 IMAGING
Æ Patients with STEMI should have a portable chest-X ray, either in ER or in CCU - but
this should not delay implementation of reperfusion therapy, whenever it is possible
to perform.
Æ Portable echocardiography is reasonable to clarify the diagnosis of STEMI, allow
estimation of prognosis and risk stratification of patients on arrival in hospital,
especially if the diagnosis of STEMI is confounded by left bundle-branch block with
anterior ST depression.
2.7 RECORDING OF FINDINGS IN CLINICAL FILE
Æ Findings of diagnostic work-up including ECGs, laboratory tests and imaging notes
(chest X-ray and echocardiography) should be routinely recorded in the clinical file
by the doctors and/or nurses.
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3. MEDICAL MANAGEMENT
3.1 ROUTINE MEASURES
a) Oxigen
Æ Supplemental oxygen should be administered to patients with arterial oxygen
desaturation less than 90%.
Æ It is reasonable to administer supplemental oxygen to all patients with uncomplicated
STEMI during the first 6 hours.
b) Nitrates
Æ Patients with ongoing ischemic discomfort should receive sublingual nitrates
(isorbide dinitrate, Isordil ®) every 5 min for a total of 3 doses, after which an
assessment should be made about the need for intravenous nitroglycerin.
Æ Intravenous nitrates is indicated in the first 48 hours after STEMI for relief of
ongoing ischemic discomfort, control of hypertension, or management of pulmonary
congestion.
Æ Transdermal nitrates may be useful in case of transportation of the patients from
outdoor to hospital or from ER to CCU.
Æ Nitrates should not be administered to patients with systolic blood pressure less than
90 mm Hg or greater or equal to 30 mm Hg below baseline, or with sever bradycardia
(< 50 bpm) or tachycardia (>100 bpm).
Æ Nitrates may be administered to relief ischemic pain and are clearly indicated as a
vasodilator in patients with STEMI associated to left ventricular failure.
Æ In view of their marginal treatment benefits, nitrates should not be used if
hypotension limits the administration of beta-blockers, which have more powerful
salutary effects.
c) Analgesia
Æ Pethidin (bolus of 50 mg IV repeated after every 30 min up to 200 mg maximum) is
the analgesic of choice for management of pain associated with STEMI.
Alternatively, morphine sulphate (2 to 4 mg with increment of 2 to 8 mg IV repeated
at 5 to 15 intervals) can be used.
Æ Pentazocin (Sosagen ®) should be avoided when possible for its vasocostrictive
action.
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d) Aspirin
Æ Aspirin should be chewed by patients who have not taken aspirin before presentation
with STEMI. The initial dose should be from 160 mg to 325 mg (from half to one
tablet, better if not coated or buffered as it delay rapid buccal absorption). At this
dosage, aspirin produces a rapid clinical antithrombotic effect.
Æ Aspirin should be given as promptly as possible (certainly within 24 hours) and
continued indefinitely at a daily dose of 75 to 160 mg.
e) Beta-blockers
Æ Oral beta-blocker therapy should be administered promptly to those patients without a
contraindication, irrespective of concomitant fibrinolytic therapy.
Patients with STEMI receiving beta-blockers promptly have shown a 14% reduction
in mortality at 7 days and a 23% reduction in long-term mortality.
Immediate beta-blocker therapy appears to reduce:
-
the magnitude of infarction and incidence of associated complications in
subjects not receiving concomitant fibrinolytic therapy;
-
the rate of reinfarction in patients receiving concomitant fibrinolytic therapy;
-
the frequency of life-threatening ventricular tachyarrhythmias.
Æ It is reasonable to administer IV beta-blockers promptly to STEMI patients without
contraindications, especially if a tachyarrhythmia or hypertension is present.
Æ Patients receiving beta-blockers within the 24 hours of STEMI without adverse
effects should continue to receive them during the early convalescence phase of
STEMI.
f)
Angiotensin Converting Enzyme Inhibitors
Æ An ACE inhibitor should be administered orally within the 24 hours of STEMI in the
absence of hypotension (SBP < 100 mmHg, or less than 100 mg or less than 30 mm
Hg below baseline) or known contraindications to that class of medication. The
benefit is higher for patients with left ventricular dysfunction (LVEF < 40 or with
pulmonary congestion) than for those without.
Æ Whenever possible, an angiotensin receptor blocker (ARB) should be administered to
STEMI patients who are intolerant to ACE inhibitors and who have either clinical or
radiological signs of heart failure or LVEF less than 0.40).
g) Calcium Channel Blockers
Æ It is reasonable to give verapamil or diltiazem to patients in whom beta-blockers are
ineffective or contraindicated (eg, bronchospastic disease) for relief of ischemia or
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control of rapid ventricular response with atrial fibrillation or flutter after STEMI in
absence of CHF, LV disfunction, or AV block.
h) Anxiolytics
Æ It is reasonable to use anxiolytic medications in STEMI patients to alleviate shortterm anxiety or altered behaviour related to hospitalisation for STEMI.
i)
Reperfusion with thrombolytic agents
Æ Whenever possible, all STEMI patients should undergo rapid evaluation for
reperfusion therapy and have a reperfusion strategy implemented promptly, as
expeditious restoration of flow in the obstructed artery after the onset of symptoms in
STEMI patients is a key determinant of short and long-term outcome.
Æ STEMI patients presenting to a hospital where streptokinase is available should
undergo to fibrinolysis unless contraindicated.
Æ In absence of contraindications, streptokinase should be administered to STEMI
patients with symptoms onset within the prior 12 hours and ST elevation greater than
0.1 mV in at least 2 contiguous precordial leads or at 2 adjacent limb leads, or new or
presumably new LBBB.
Æ Streptokinase should administered when appropriate at a dosage of 1.500.000 MU,
between 30 and 60 min.
Æ Contraindication to fibrinolytic therapy are: any history of intracranial hemorrhage;
significant close head or facial trauma within the past 3 months; uncontrolled or
poorly controlled hypertension; suspected aortic dissection; active bleeding or
bleeding diathesis; ischemic stroke within the past 3 months; dementia; intracranial
neoplasms; pregnancy; active peptic ulcer; current use of anticoagulants.
j)
Heparin
Æ It is reasonable that STEMI patients not undergoing reperfusion therapy who do not
have a contraindication to anticoagulation be treated with heparin. Intravenous
Unfractionated Heparin (UHF) should be administered with a bolus of 5.000 U IV
followed by 1.000 U per hour for at least 48 hours. Thereafter subcutaneous
administration with Low Molecular Weight Fractionated Heparin (LMWH) should be
given until the patient is ambulatory.
Æ Monitoring of coagulation parameters should be performed measuring PT once at the
first day of heparin therapy, and by daily measurement of PTT until heparin treatment
is administered.
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3.2 CORONARY ANGIOGRAPHY AND PERCUTANEOUS CORONARY INTERVENTIONS
Æ Whenever possible, transfer of STEMI patients to other hospital for a diagnostic
coronary angiography should be performed in:
-
candidates for primary PCI;
-
patients with cardiogenic shock who are candidates for revascularization;
-
candidates for surgical repair of ventricular septal rupture or severe mitral
regurgitation;
-
patients with persistent hemodynamic and/or electrical instability.
Æ Coronary angioplasty should not be performed in patients with extensive
comorbidities in whom the risks of revascularization are likely to outweigh the
benefits.
Æ Potential candidates of primary PCI include:
-
fibrinolysis-inelegible patients who present STEMI within 12 hours of
symptoms;
-
patients with ST elevation or new LBBB who develop shock within 36 hours
of MI;
-
patients with severe Cardiac Heart Failure (CHF) and/or pulmonary edema
and onset of symptoms within 12 hours.
Æ Primary PCI should not be performed in asymptomatic patients more than 12 hours
onset
of
STEMI
if
they
are
hemodynamically
and
electrically
stable.
In fact, PCI appears to have its greatest mortality benefit in high risk patients. In
cardiogenic shock a 9% reduction in 30-day mortality is obtained with coronary
revascularization compared to immediate medical stabilization.
3.3 STRICT GLUCOSE CONTROL DURING STEMI
Æ An insulin infusion to normalise blood glucose is recommended for patients with
STEMI during the acute phase (first 24 to 48 hours).
Æ After the acute phase of STEMI, it is reasonable to individualise treatment of
diabetics, selecting a combination of insulin, and oral hypoglycaemic agents that
achieve the best glycemic control.
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4. HOSPITAL MANAGEMENT
4.1 CORONARY CARE UNIT
Æ STEMI patients should be admitted to a quiet and comfortable environment that
provide for continuous monitoring of ECG and pulse oximetry and defibrillation.
Æ The patient’s medication regimen should be reviewed to confirm the administration
of aspirin and beta-blockers in an adequate dose to control heart rate and to assess the
need for IV nitrates for control of angina, hypertension or heart failure.
Æ Nursing care should be provided by individual certified in critical care.
4.2 EARLY GENERAL MEASURES
Æ Patients with STEMI who are free of symptoms should not be on bed rest for more
than 12 to 24 hours, being limited movements around the bed allowed.
Æ Patients with STEMI should be prescribed a diet which focuses on reduced intake of
fats and cholesterol, and on a restricted sodium intake when hypertension or heart
failure is present.
Æ Patients counselling to maximize adherence to post-STEMI treatments (e.g:
compliance with taking medication, exercise prescription, and smoking cessation)
should begin during the early phase of hospitalisation and occur intensively at followup visits.
5. HEMODYNAMIC DISTURBANCES
5.1 HYPOTENSION
Æ Rapid volume loading with an IV infusion should be administered to patients without
clinical evidence for volume overload.
Æ Vasopressor support should be given for hypotension that does not resolve after
volume loading (dopamine, dobutamine).
5.2 LOW-OUTPUT STATE
Æ Recommended treatment for low-output states - defined as a left ventricular ejection
fraction < 0.40 - whenever possible to assess, include measures either available or not
at PRCS hospitals:
-
Inotropic support (dopamine, dobutamine)
-
Intra-aortic counterpulsation
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-
Mechanical reperfusion with PCI or CABG
-
Surgical correction of mechanical complications (to be assessed through
echocardiography)
Æ Beta-blockers or calcium channel antagonists should not be administered to patients
in a low-output state due to pump failure.
5. 3 PULMONARY CONGESTION
Æ Recommended treatment for low-output state include the following measures:
-
Oxygen supplementation
-
Morphine sulfate
-
ACE inhibitors
-
Nitrates
-
Diuretics (furosemide)
-
Beta-blockade (to be initiate before discharge for secondary prevention)
-
Long-term aldosterone blockade (in post-STEMI patients without significant
renal dysfunction)
Æ Beta-blockers or calcium blockers should not be administered acutely to STEMI
patients with frank cardiac failure evidenced by pulmonary congestion or signs of a
low-output state.
5.4 CARDIOGENIC SHOCK
Æ Recommended treatment for cardiogenic shock include measures either available or
not at PRCS hospitals for which transfer of the patients to a tertiary care facility
should be made whenever possible:
- Inotropic agents (dopamine, dobutamine)
- Intraortic balloon counterpulsation
- Early revascularization either with PCI or CABG.
5.5 MECHANICAL CAUSES OF HEART FAILURE
Æ Mitral valve regurgitation, ventricular septal rupture after STEMI, and left ventricular
free-wall rupture, which may be indicated by a new cardiac murmur, and should be
confirmed by echocardiography, should be transferred to a tertiary care hospital and
considered for urgent cardiac surgery repair. CABG should be undertaken at the same
time of surgical repair.
Æ Left ventricular aneurysm associated with intractable ventricular tachyarrythmias
and/or pump failure, should be transferred to a tertiary care hospital and considered
for LV aneurysmectomy and CABG surgery.
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6. ARRHYTHMIAS AFTER STEMI
6.1 VENTRICULAR FIBRILLATION
Æ Ventricular fibrillation or pulseless Ventricular tachycardia should be treated with an
unsynchronised electric shock with an energy of 200 J; if unsuccessful, a second
shock of 200 to 300 J should be given, and than if necessary, a third shock of 360 J.
Æ A VF or or pulseless VT that is refractory to electric shock should be treated with
amiodarone (300 mg IV bolus) followed by a repeat unsynchronised electric shock.
Æ It is reasonable to correct electrolyte and, if possible, acid-base disturbances (K
greater than 4.0 mEq/L) to prevent recurrent episodes of VF.
Æ There is no convincing evidence that the prophylactic use of lidocaine reduce
mortality, and the prior practice of routine (prophylactic) administration of lidocaine
with STEMI has been largely abandoned.
6.2 VENTRICULAR TACHICARDIA
Æ Sustained (more than 30 seconds or causing hemodynamic collapse) VT should be
treated with an unsynchronised electric shock with an energy of 200 J; if unsuccessful,
a second shock of 200 to 300 J should be given, and than if necessary, a third shock of
360 J.
Æ Episodes of sustained monomorphic VT associated with angina, pulmonary edema, or
hypertension should be treated initially with an unsynchronised electric shock of 100
J. Brief anesthesia is desiderable if hemodynamically tolerable.
Æ Sustained monomorphic VT not associated with angina, pulmonary edema, or
hypertension should be treated with:
-
Amiodarone (150 mg infused over 10 minutes, repeated every 10 to 15
minutes, if necessary)
-
Synchronised electric cardioversion starting at energy of 50 J (brief anesthesia
is necessary).
6.3 VENTRICULAR PREMATURE BEATS AND ACCELERATED IDIOVENTRICULAR OR
JUNCTIONAL RHYTHMS
Æ Treatment of isolated ventricular premature beats, couplets, runs of accelerated
idioventricular rhythm, accelerated junctional rhythm, or nonsustained VT, is not
recommended, unless they lead to hemodynamic compromise.
Æ The routine use of prophylactic antiarrhythmic drugs (ie: lidocaine) is not indicated
for suppression of isolated ventricular premature beats, couplets, runs of accelerated
idioventricular rhythm, or nonsustained VT.
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6.4 SUPRAVENTRICULAR ARRHYTHMIAS AND ATRIAL FIBRILLATION
Æ Sustained atrial fibrillation and atrial flutter in patients with hemodynamic
compromise or ongoing ischemia should be treated with one or more of the following:
-
Syncronized cardioversion with an initial monophasic shock of 200 J for atrial
fibrillation and 50 J for flutter (brief general anesthesia or conscious sedation
whenever possible);
-
Intravenous amiodarone;
-
Intravenous digoxin for rate control principally for patients with severe LV
dysfunction and heart failure.
Æ Sustained atrial fibrillation and atrial flutter in patients with ongoing ischemia but
without hemodynamic compromise should be treated with one or more of the
following:
-
Beta-adrenergic blocked is preferred, unless contraindicated;
-
Intravenous diltiazem or verapamil;
-
Syncronized cardioversion with an initial monophasic shock of 200 J for atrial
fibrillation and 50 J for flutter (brief general anesthesia or conscious sedation
whenever possible).
Æ Reentrant paroxysmal tachycardia, because of its rapid rate, should be treated with the
following in the sequence shown:
-
Carotid sinus massage
-
IV beta-adrenergic blockade with metoprolol, atenolol or propanolol
-
IV diltiazem
-
IV digoxin
Æ Treatment of atrial premature beats is not indicated
6.5 VENTRICULAR ASYSTOLE
Æ Cardiopulmonary resuscitation measures, including chest compression, atropine,
vasopressin, and epinephrine, should be administered promptly to treat ventricular
asystole.
6.6 CONDUCTION BLOCK ASSOCIATED WITH STEMI
Æ Transfer to a specialised hospital is necessary to implant a permanent ventricular
pacing for third degree AV block after STEMI, second degree Mobitz type II, or
persistent second degree AV block with bilateral bundle-branch block, or transient
advanced second or third degree AV block and associated bundle-branch block.
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7. CONVALESCENCE, DISCHARGE AND POST STEMI CARE
7. 1 PERICARDITIS AFTER STEMI
Æ Asprin is recommended for treatment of pericarditis after STEMI, at dosage as high as
650 mg orally (coated) every 6 hours.
Æ Anticoagulation should be immediately discontinued if pericardial effusion develops
or increases.
Æ For pericarditis after STEMI not adequately controlled with aspirin it is reasonable to
administer one or more of the following:
-
Colchicine (0.6 mg every 12 hours, orally)
-
Acetominophen (paracetamol) (500 mg orally every 6 hours)
Æ Non-steroidal anti-inflammatory drugs may be considered for pain relief; however,
they should not used for extended periods because their continuous effect on platelet
function, and increased risk to expand the infarction or cause a myocardial scar
thinning.
Æ Ibuprofen should not to be used because for pain relief because it blocks the
antiplatelet effect of aspirin and can cause myocardial scar thinning and infarct
expansion.
7.2 RISK STRATIFICATION AT HOSPITAL DISCHARGE
Æ Whenever possible, patients discharged after STEMI should be advised to perform
risk stratification including one or more investigations (echocardiography, exercise
testing and coronary arteriography), according to a detailed approach conducive to
revascularization through catheterisation or cardiac surgery, or to medical therapy (see
pag 623 of ACC/AHA Practice Guidelines, used as best reference for this PRCS
guideline).
Æ Patients who have been stabilised (no ongoing ischemia, hemodynamic compromise,
or life-thretening arrhytmia) after STEMI and have incurred a significant fall in LV
function should have their surgery delayed to allow myocardial recovery to occur.
Æ Stable STEMI patients with preserved LV function can undertake CABG with several
days of the infarction without an increased risk.
7.3 SECONDARY PREVENTION
Æ Patients who survive the acute phase of STEMI should have plans initiated for
secondary prevention therapy, an essential part of the management of all patients with
STEMI.
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Æ Before hospital discharge, all STEMI patients should be educated about and actively
involved in planning for adherence to the life-style changes and drug therapies that are
important for secondary disease.
Æ A detailed and appealing leaflet describing the relevant measures for secondary
prevention should be available to be given to all patient at discharge after STEMI.
Æ Active counselling should focus on the goals reported in the following table.
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Goals
SMOKING
Complete cessation
Interventions Recommendations
Assess tobacco use. Strongly encourage
patients and family to stop smoking.
ƒ
BLOOD PRESSURE
CONTROL
Less than 140/90
ƒ
LIPID MANAGEMENT
PHYSICAL ACTIVITY
WEIGHT
MANAGEMENT
DIABETES
MANAGEMENT
ANTIPLATELET
AGENTS/ANTICOAGUL
ANT
RENIN-ANGIOTENSINALDOSTERONE
SYSTEM BLOCKERS
BETA-BLOCKERS
Initiate lifestyle modification (weight
control, physical activity, alcohol
moderation, moderate sodium
restriction, emphasis on fruits,
vegetables and low-fat dairy products) in
all patients.
Use drugs, especially beta-blockers and
ACE inhibitors
Start dietary therapy in all patients (low
saturated, animal fats). Promote physical
activity and weight management;
TG less than 200
Assess fasting lipid profile in all patients
mg/dl
CHOL less than 200 preferably within 24 hours of STEMI;
mg/dl LDL less than Add statins when no sufficient response to
100 mg
diet, or in case of metabolic syndrome
(obesity, diabetes type II, and hypertension)
Minimum: 30 min
3/4 days per week
Optimal: daily
Waist
circumference=
Women: < 35 inches
Males: < 40 inches
Normal fasting
plasma glucose
(or HbA1c less than
7%, whenever
possible to measure)
Assess risk, preferably with exercise test,
whenever possible.
Encourage walking or other aerobic activity,
supplemented by an increase of in daily
lifestyle activities (walking breaks at work,
household work)
Start weight management and physical
activity as appropriate
Appropriate hypoglicemic therapy.
Treatment of other risk (physical activity,
weight management, blood pressure, and
cholesterol management)
Start and continue indefinitely aspirin 75 to
160 mg/dl if not contraindicated. Consider
clopidogel 75 mg/d or warfarin or coumadin
(monitoring PT) if aspirin is contraindicated
ACE inhibitors in all patients indefinitely.
ARBs in patients who are intolerant to ACEI
Aldosterone blockade in patient without
significant renal disfunctions or
hyperkaliemia already receiving ACEI, with
LVEF < 0.40, diabetes or heart failure
Start in all patients. Continue indefinitely.
Observe usual contraindications.
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LIST OF ACRONYMS AND ABBREVIATIONS
ACC/AHA
American College of Cardiology / American Heart Association
ACEI
Angiotensin Converting Enzymes Inhibitors
ARB
Angiotensin Receptor Blockers
AV
Atrio-Ventricular
CABG
Coronary Artery Bypass Graft surgery
CCU
Critical Care Unit (Intensive Care Unit)
CHF
Congestive Heart Failure
CK
Creatin kinase
CHD
Coronary Heart Disease
CHF
Congestive Heart Failure
CRP
C-reactive protein
CHOL
Cholesterol
EBM
Evidence based medicine
ECG
Electrocardiogram
ER
Emergency Room
GP
General Practitioner
HbA1c
Glycosylated Hemoglobin
HDL
High-density lipoprotein
IV
Intravenous
LBBB
Left Bundle Branch Block
LDL
Low-density lipopretein
LMWH
Low Molecular Weight Heparin (subcutaneous)
LV
Left Ventricular
LVEF
Left Ventricular Ejection Fraction
MI
Myocardial Infarction
NSTEMI
Non-ST-Segment Elevation Myocardial Infarction
PCI
Percutaneous Coronary Intervention (angioplasty with or without stents)
PRCS
Palestinian Red Crescent Society
PT
Prothrombin Time
PTT
Partial Thromboplastin Time
STEMI
ST-Segment Elevation Myocardial Infarction
TG
Triglicerids
UA
Unstable Angina
VF
Ventricular fibrillation
VT
Ventricular tachycardia
UHF
Intravenous Unfractionated Heparin
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