ST-segment elevation myocardial infarction: Difference between revisions

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


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


 
==Treatment==
-Myocardial ischemia or infarction
===Adjunctive===
 
#O2
-Noninfarction, transmural ischemia (Prinzmetal's angina pattern or acute takotsubo cardiomyopathy)
#ASA 162, 325chewable PO or 600mg PR; Plavix 300 or 600mg if ASA allergy
 
#NTG
-Acute myocardial infarction (MI)
#Morphine
 
#BBlocker:
-Post-MI (ventricular aneurysm pattern)-Previous MI with recurrent ischemia in the same area-Acute pericarditis-Normal "early repolarization variants"
##PO within 24 hours
 
##IV beta-blocker is reasonable for patients who are hypertensive in the absence of:
-Left ventricular hypertrophy or left bundle branch block (only V1-V2 or V3)-Myocarditis (may look like myocardial infarction or pericarditis)
###signs of heart failure
 
###evidence of a low cardiac output state
-Brugada patterns (V1-V3 with right bundle branch block-appearing morphology)
###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)
 
###other relative contraindications to beta blockade (PR interval > 0.24 s, second- or third-degree heart block, active asthma, or reactive airway disease)
-Myocardial tumor
 
-Myocardial trauma
 
-Hyperkalemia (only leads V1 and V2)
 
-Hypothermia (J wave/Osborn wave)
 
 
Treatment===Adjunctive===
 
 
O2
 
ASA 162, 325chewable PO or 600mg PR; Plavix 300 or 600mg if ASA allergy
 
NTG
 
Morphine
 
BBlocker:
 
-PO within 24 hours;
 
-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===
===Anticoagulants===
 
#Heparin (UFH)
 
##Bolus 60U/kg (max: 4000U)
Heparin (UFH)
##12U/kg/h (max: 1000U/h)
 
##NB: monitor PTT: 50-70s
-Bolus 60U/kg (max: 4000U)
#LMWH
 
##<75yo with serum Cr < 2.5 mg/dL (men) or < 2.0 mg/dL (women):
-12U/kg/h (max: 1000U/h)
###30mg IV bolus, followed by 1mg/kg SC q12h
 
##≥ 75yo: 0.75-mg/kg SC q12h
NB: monitor PTT: 50-70s
##CrCl < 30 mL/min: 1mg/kg SC qd
 
##NB: note renal clearance
#Fondaparinux
 
##Cr < 3.0 mg/dL: 2.5mg IV bolus, then 2.5-mg SC qd, started 24 hr after bolus
LMWH
##NB: monitor anti-Xa levels
 
#Bivalirudin
<75yo with serum Cr < 2.5 mg/dL (men) or < 2.0 mg/dL (women):
##0.75-mg/kg IV bolus, followed by 1.75 mg/kg/h
 
##CrCl < 30 mL/min: 0.75-mg/kg IV bolus, followed by 1.0 mg/kg/h
-30mg IV bolus, followed by 1mg/kg SC q12h
 
≥ 75yo: 0.75-mg/kg SC q12h
 
CrCl < 30 mL/min: 1mg/kg SC qd
 
NB: note renal clearance
 
 
Fondaparinux
 
-Cr < 3.0 mg/dL: 2.5mg IV bolus, then 2.5-mg SC qd, started 24 hr after bolus
 
NB: monitor anti-Xa levels
 
 
Bivalirudin
 
-0.75-mg/kg IV bolus, followed by 1.75 mg/kg/h
 
-CrCl < 30 mL/min: 0.75-mg/kg IV bolus, followed by 1.0 mg/kg/h
 


===Antiplatelet===
===Antiplatelet===
 
#GPIIB/IIIa Inhibitors: Abciximab (ReoPro®), Eptifibatide (Integrilin®), Tirofiban (Aggrastat®)
 
##Given right before PCI
GPIIB/IIIa Inhibitors: Abciximab (ReoPro®), Eptifibatide (Integrilin®), Tirofiban (Aggrastat®)
##Defer to cardiologist
 
#Clopidogrel (Plavix®)
-Given right before PCI
##300mg po x1 (onset 2h, peak 6-15h)
 
##600mg po x1 (faster onset)
-Defer to cardiologist
 
 
Thienopyridines
 
Clopidogrel (Plavix®)
 
-300mg po x1 (onset 2h, peak 6-15h)
 
-600mg po x1 (faster onset)
 


==Definitive==
==Definitive==
Fibrinolytics within 30mins
Fibrinolytics within 30mins


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PCI within 90mins
PCI within 90mins


==Source ==
==Source ==
DONALDSON (adapted from ACC/AHA Practice Guidelines 2004/5), EBM 6/09
DONALDSON (adapted from ACC/AHA Practice Guidelines 2004/5), EBM 6/09


[[Category:Cards]]
[[Category:Cards]]

Revision as of 16:54, 12 March 2011

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
  2. ASA 162, 325chewable PO or 600mg PR; Plavix 300 or 600mg if ASA allergy
  3. NTG
  4. Morphine
  5. 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)
    2. 12U/kg/h (max: 1000U/h)
    3. NB: monitor PTT: 50-70s
  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: 0.75-mg/kg SC q12h
    3. CrCl < 30 mL/min: 1mg/kg SC qd
    4. NB: note renal clearance
  3. Fondaparinux
    1. Cr < 3.0 mg/dL: 2.5mg IV bolus, then 2.5-mg SC qd, started 24 hr after bolus
    2. NB: monitor anti-Xa levels
  4. Bivalirudin
    1. 0.75-mg/kg IV bolus, followed by 1.75 mg/kg/h
    2. CrCl < 30 mL/min: 0.75-mg/kg IV bolus, followed by 1.0 mg/kg/h

Antiplatelet

  1. GPIIB/IIIa Inhibitors: Abciximab (ReoPro®), Eptifibatide (Integrilin®), Tirofiban (Aggrastat®)
    1. Given right before PCI
    2. Defer to cardiologist
  2. Clopidogrel (Plavix®)
    1. 300mg po x1 (onset 2h, peak 6-15h)
    2. 600mg po x1 (faster onset)

Definitive

Fibrinolytics within 30mins

OR

PCI within 90mins

Source

DONALDSON (adapted from ACC/AHA Practice Guidelines 2004/5), EBM 6/09

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