ST-segment elevation myocardial infarction

Diagnosis

1. ≥ 1-mm (0.1mV) ST-segment elevation in at least 2 anatomically contiguous limb leads (aVL to III, including -aVR)
2. ≥ 1-mm ST-segment elevation in a precordial lead V4 through V6
3. ≥ 2-mm (0.2mV) ST-segment elevation in V1 through V3
4. a new left bundle branch block

ACC/AHA, ESC

DDx

1. Myocardial ischemia or infarction
2. Noninfarction, transmural ischemia (Prinzmetal's angina pattern or acute takotsubo cardiomyopathy)
3. Acute myocardial infarction (MI)
4. Post-MI (ventricular aneurysm pattern)-Previous MI with recurrent ischemia in the same area-Acute pericarditis-Normal "early repolarization variants"
5. Left ventricular hypertrophy or left bundle branch block (only V1-V2 or V3)-Myocarditis (may look like myocardial infarction or pericarditis)
6. Brugada patterns (V1-V3 with right bundle branch block-appearing morphology)
7. Myocardial tumor
8. Myocardial trauma
9. Hyperkalemia (only leads V1 and V2)
10. Hypothermia (J wave/Osborn wave)

Treatment

Adjunctive

1. O2
   1. Esp for SpO2 <90%
2. ASA 162-325mg chewable or 600mg PR
3. Plavix
   1. Loading dose
      1. 300mg
      2. 600mg if PCI anticipated
      3. No loading dose if >75yr receiving fibrinolytics
4. NTG
5. Morphine
6. BBlocker:
   1. PO within 24 hours
   2. IV beta-blocker is reasonable for patients who are hypertensive in the absence of:
      1. signs of heart failure
      2. evidence of a low cardiac output state
      3. post beta-blocker cardiogenic shock risk factors (age > 70 years, systolic blood pressure < 120 mm Hg, sinus tachycardia > 110 bpm or heart rate < 60 bpm, increased time since onset of symptoms of STEMI)
      4. other relative contraindications to beta blockade (PR interval > 0.24 s, second- or third-degree heart block, active asthma, or reactive airway disease)

Anticoagulants

1. Heparin (UFH)
   1. Bolus 60U/kg (max: 4000U) followed by 12U/kg/h (max: 1000U/h)
   2. Titrate to PTT 1.5-2.5 x control
2. LMWH
   1. <75yo with serum Cr < 2.5 mg/dL (men) or < 2.0 mg/dL (women):
      1. 30mg IV bolus followed by 1mg/kg SC q12h
   2. ≥ 75yo
      1. 0.75mg/kg SC q12h
   3. CrCl < 30 mL/min
      1. 1mg/kg SC qd
3. Fondaparinux
   1. Cr < 3.0 mg/dL:
      1. 2.5mg IV bolus then 2.5mg SC qd started 24hr after bolus
   2. Monitor anti-Xa levels
4. Bivalirudin
   1. 0.75mg/kg IV bolus followed by 1.75 mg/kg/h
   2. CrCl < 30 mL/min
      1. 0.75mg/kg IV bolus followed by 1.0 mg/kg/h

Antiplatelet

1. GPIIB/IIIa Inhibitors (Abciximab, Eptifibatide)
   1. Defer to cardiologist
   2. Given right before PCI
2. Clopidogrel
   1. 300mg po x1
   2. 600mg po x1 (if PCI is anticipated)

Definitive

1. Fibrinolytics within 30mins
   1. Fibrinolytic tx w/in 3hr resulted in >30 lives saved per 1000 pts
2. PCI within 90mins (acceptable delay may be up to 120min)

Fibrinolysis

Indications

1. <12hr from onset of CP and:
   1. ST elevation of ≥1mm in 2 contiguous limb or precordial leads OR
   2. New left bundle branch block

Contraindications

1. Absolute contraindications
   1. Any prior ICH
   2. Known structural cerebral vascular lesion (AVM)
   3. Known intracranial neoplasm
   4. Ischemic stroke w/in 3 mo
   5. Active internal bleeding (excluding menses)
   6. Suspected aortic dissection or pericarditis
2. Relative contraindications
   1. Severe uncontrolled BP (>180/100)
   2. History of chronic severe poorly controlled HTN
   3. History of prior ischemic stroke >3 mo
   4. Known intracranial pathology not covered in absolute contraindications
   5. Current use of anticoagulants with known INR >2–3
   6. Known bleeding diathesis
   7. Recent trauma (past 2 wk)
   8. Prolonged CPR (>10 min)
   9. Major surgery (<3 wk)
   10. Noncompressible vascular punctures (e.g. IJ, subclavian)
   11. Recent internal bleeding (within 2–4 wk)
   12. Pts treated previously with streptokinase should not receive streptokinase a 2nd time
   13. Pregnancy
   14. Active peptic ulcer disease
   15. Other medical conditions likely to increase risk of bleeding (diabetic retinopathy, etc)

Source

ACC/AHA Practice Guidelines 2004/5

EBM 6/09