Transcript No Slide Title

STEMI-WRAP on Evidence-Based
Management of STEMI:
The Emergency Department Perspective
Charles V. Pollack, Jr., M.A., M.D., FACEP, FAHA
Professor and Chair, Emergency Medicine, Pennsylvania Hospital
University of Pennsylvania Health System
Philadelphia
STEMI

Accounts for 15-20% of cases of ACS seen in ED;
UA/NSTEMI (collectively, NSTE ACS) account for
majority

High-visibility diagnosis because of its high
morbidity and mortality, patient and family fears and
expectations, and intensity of monitoring by
observers inside and outside the hospital—QI,
payors, JCAHO, P4P
STEMI

Pathophys: STEMI is caused by complete
obstruction of an epicardial vessel, which causes
angina or anginal equivalent and diagnostic ECG
changes of ST-segment elevation

Recognition of STEMI, which by GLs should occur
within 10 minutes of ED arrival, launches the EDcardiology team on a fast-moving track that
demands prompt stabilization, evidence-based
medical management, and quick decisions
regarding reperfusion therapy

Dx of STEMI is clinical + electrocardiographic and
DOES NOT require assessment of cardiac markers
STEMI

STEMI typically result from fissure or frank rupture
of an atherosclerotic plaque
 Stimulates local activation of:
• platelets
• coagulation cascade
• complement

Platelet aggregate forms over site of plaque injury
and as it matures (fibrinogen→fibrin) causes
complete obstruction of distal flow. To the extent that
collateral flow downstream is lacking, ischemia
quickly ensues and infarction starts to occur within
minutes
STEMI

Pharmacologic therapy in STEMI is therefore
directed at this triad of abnormal activity:
 Platelet activation—anti-activation and antiaggregation
• ASA and clopidogrel
• GPIs



Coagulation activation—anticoagulants
Complement activation—anti-inflammatories . . . ?
Statins
In preparation for reperfusion therapy by lysis or
angiography and primary PCI
Guidelines for STEMI diagnosis and
management

complex disease state with broad ranges of
presentation and a multitude of therapeutic options

Many important and pertinent clinical studies

Information overload!

Need evidence-based guidelines to promote
consistency of care and resulting better outcomes
Guidelines for STEMI management

ACC/AHA Joint Task Force: 1990, 1996, 1999

Last comprehensive update in 2004
 Widely read, lots of interest
 Clear evidence scoring, sensible recommendations,
temporal sequencing
• “soup to nuts”

Recapitulation, interpretation, and promulgation for
upstream providers in Annals of Emergency
Medicine
Guidelines for STEMI management

ACC/AHA Joint Task Force: presented “focused
update” in December 2007
 “focus” (from upstream perspective) on reperfusion
strategies and opportunities to minimize delays to
reperfusion
 Beta blockers
 Choices of anticoagulants
 New recommendations regarding clopidogrel
Applying Classification of
Recommendations
Class I
Class IIa
Class IIb
Class III
Benefit >>> Risk
Benefit >> Risk
Additional studies with
focused objectives
needed
Benefit ≥ Risk
Additional studies with
broad objectives needed;
Additional registry data
would be helpful
Risk ≥ Benefit
No additional studies
needed
Procedure/ Treatment
SHOULD be performed/
administered
IT IS REASONABLE to
perform
procedure/administer
treatment
should
is recommended
is indicated
is useful/effective/
beneficial
is reasonable
can be useful/effective/
beneficial
is probably recommended
or indicated
Procedure/Treatment
MAY BE CONSIDERED
may/might be considered
may/might be reasonable
usefulness/effectiveness is
unknown
/unclear/uncertain or not
well established
Procedure/Treatment
should NOT be performed/administered
SINCE IT IS NOT
HELPFUL AND MAY BE
HARMFUL
is not recommended
is not indicated
should not
is not useful/effective/
beneficial
may be harmful
“The Guidelines”
Weighing the Evidence

Weight of evidence grades:
= Data from many large, randomized trials
= Data from fewer, smaller randomized trials, careful
analyses of nonrandomized studies, observational
registries
= Expert consensus
Lives saved/1000 patients
Time Delays and 30 Day Outcome in STEMI
40
3000
14,000
30
12,000
Loss of benefit
per hour of delay
1.6±0.6 lives per
1000 patients
9000
20
10
7000
0
0
6
12
18
Hours from onset of symptoms
to randomization
Collins. NEJM. 1997;336:847.
24
45,000 patients in
placebo controlled
lytic trials.
Time Delays and 30 Day Outcome in
STEMI: Primary PCI (NRMI-2)
Cannon C, et al. JAMA 2000;283:2941-2947
Time Delays and 30 Day Outcome in
STEMI: Primary PCI (NRMI-2)
Cannon C, et al. JAMA 2000;283:2941-2947
Prehospital Issues

EMS


Chest Pain Evaluation & Treatment


Emphasis on early defibrillation; AEDs; 911 dispatchers
training & use of national protocols; 12-lead ECGs
Emphasis on giving chewable ASA, unless contraindicated &
prehospital ECG & checklist
Prehospital Fibrinolysis

Upgraded to a Class IIa (Level B) Recommendation
• although not particularly likely in most systems

Prehospital Destination Protocols


Where to transport STEMI patients: a plan must be in place
Special considerations
• Cardiogenic Shock
• Fibrinolytic contraindicated
Patients Transported by EMS After Calling 9-1-1
Hospital Fibrinolysis:
Door-to-needle
within<30 min
Onset of
STEMI
Symptoms
9-1-1
EMS
Dispatch
EMS on-scene
• Encourage 12-lead ECG
• Consider prehospital fibrinolytic if
capable and EMS-to-needle < 30
min
PPCI:
Door-to-balloon
within<90 min
Goals
Patient
5’ after
sx onset
Dispatch
1 min
EMS on
scene
Within
8 min
Not PCI
Capable
Hospital
PCI
Capable
Hospital
EMS transport
EMS transport:EMS to Balloon within 90 min
Patient self-transport: Hospital Door-to-Balloon
within 90 min
Total ischemic time: Within 120 min*
ACC/AHA 2007 STEMI Focused Update:
Acute Medical Therapy
a
b
General treatment
measures

Aspirin, nitrates, oxygen, analgesicsa
(morphine)
Infarct size limitation

β-blockers (not for acute use in patients
with evidence of heart failure)
Reperfusion

Thrombolysis (within 30 min) or primary PCI
(within 90 min)
Anticoagulant
and antiplatelet
therapy

UFH or enoxaparin or fondaparinuxb
 Clopidogrel 75 mg/d added to aspirin for
patients undergoing fibrinolysis; 300 mg
loading dose for patients <75 y who receive
fibrinolytic therapy or who do not receive
reperfusion therapy
 If PCI: clopidogrel, GP IIb/IIIa inhibitors
Patients routinely taking NSAIDs (except for aspirin), both nonselective as well as COX-2 selective agents, before
STEMI should have those agents discontinued at the time of presentation with STEMI because of the increased risk
of mortality, reinfarction, hypertension, heart failure, and myocardial rupture associated with their use.
Because of the risk of catheter thrombosis, fondaparinux should not be used as the sole anticoagulant to support
PCI. An additional anticoagulant with anti-IIa activity should be administered.
Antman E, et al. J Am Coll Cardiol. doi:10.1016/j.jacc.2007.10.001.
2007 ACC/AHA STEMI Focused Update
Reperfusion Therapy for STEMI
Class I Modified Recommendations


STEMI patients presenting to a hospital with PCI capability
should be treated with primary PCI within 90 minutes of first
medical contact as a systems goal (Level of Evidence: A)
STEMI patients presenting to a hospital without PCI
capability and who cannot be transferred to a PCI center
and undergo PCI within 90 minutes of first medical contact
should be treated with fibrinolytic therapy within 30 minutes
of hospital presentation as a systems goal unless fibrinolytic
therapy is contraindicated (Level of Evidence: B)
Antman E, et al. J Am Coll Cardiol. doi:10.1016/j.jacc.2007.10.001.
Determine Whether Fibrinolysis
or PCI Is Preferred
No Preference for Either Strategy If Presentation Is 3 hr
and There Is No Delay in Invasive Strategy
However, fibrinolysis generally preferred when
 Invasive strategy not an option

–
Vascular access difficulties
–
No access to skilled PCI lab
Delay to invasive strategy
–
Prolonged transport
–
Door-to-balloon time >90 min
–
>1 hr vs fibrinolysis
(fibrin-specific agent) now
Adapted with permission from Antman EM, et al. J Am Coll Cardiol. 2004;44:671-719.
Photo courtesy of ACC/AHA guidelines for STEMI slide set.
http://www.cardiosource.com/srch/results.asp?searchterm=STEMI+PowerPoint+
Slides&parsedquery+&x+10&y=5. Accessed January 10, 2008.
Determine Whether Fibrinolysis
or PCI Is Preferred (cont.)
No Preference for Either Strategy If Presentation Is 3 hr
and There Is No Delay in Invasive Strategy
However, invasive strategy generally preferred when

Skilled PCI lab is available with surgical backup
– Door-to-balloon time <90 min

High risk from STEMI
– Cardiogenic shock*, Killip class ≥III


Contraindications to fibrinolysis, including
increased risk of bleeding and ICH
Late presentation
– >3 hr from symptom onset

Diagnosis of STEMI is in doubt
*PCI strongly preferred, but if immediate PCI not available/transfer for PCI delayed and presentation ≤3
hours, treat with fibrinolytic therapy and transfer to a skilled PCI lab.
Adapted from Antman EM, et al. J Am Coll Cardiol. 2004;44:671-719.
Photo courtesy of ACC/AHA guidelines for STEMI slide set.
http://www.cardiosource.com/srch/results.asp?searchterm=STEMI+PowerPoint+
Slides&parsedquery+&x+10&y=5. Accessed January 10, 2008.
Primary PCI vs Thrombolysis in STEMI:
Quantitative Analysis (23 RCTs*, N=7739)
25
Frequency, %
20
Short-term
outcomes
(4–6 wk)
PCI
P<.0001
Thrombolytic
therapy
P<.0001
15
P=.0002
P<.0001
P=.032
10
5
0
P<.0001
Death
Nonfatal
MI
Recurrent
Ischemia
Hemorrhagic
Stroke
*The criterion for time to treatment was 6 h or less in 9 of the trials,
12 h in 13 trials, and up to 36 h in the SHOCK trial.
Adapted with permission from Keeley EC, et al. Lancet. 2003;361:13-20.
Major
Bleed
Death,
Nonfatal
Reinfarction,
or Stroke
NRMI: Advantage of PCI Compared With Fibrinolysis
Decreases as PCI-Related Delay Increases
PCI Better
1.5
1.25
1.0
Fibrinolysis Better
Odds of Death With Fibrinolysis
2.0
0.8
0.5
60
75
90
105 114
135
150
165
PCI-Related Delay (door-to-balloon–door-to-needle time), min
Adapted with permission from Pinto DS, et al. Circulation. 2006;114:2019-2025.
180
Door to Balloon (D2B):
An Alliance for Quality Campaign
Door to Balloon (D2B) Campaign—joint
program of ACC, AHA, and other health
organizations
 Aims to increase percentage of AMI patients
who receive primary angioplasty within 90
minutes of hospital presentation to 75%; current
figures indicate only 35% achieve this goal
 D2B implementation kit contains 6 evidencebased strategies for reducing door-to-balloon
D2B: An Alliance for Quality Web site. http://www.d2balliance.com. Accessed
times
December
27, 2007.

Door to Balloon (D2B): An Alliance for Quality Campaign
Strategies Associated With a Significant Reduction in DTB Time
Strategy
Mean reduction in
door-to-balloon time
(min)*
Having emergency medicine physicians activate the
cath lab
8.2
Having a single call to a central page
operator activate the cath lab
13.8
Having the ED activate the cath lab while
patient is still en route
15.4
Expecting staff to arrive at the cath lab within
20 minutes after page
19.3
Having an attending cardiologist always on site
14.6
Having staff in the ED and cath lab use and receive
real-time feedback
8.6
*P<.05 for all.
Bradley EH, et al. N Engl J Med. 2006;355:2308-2320.
2007 ACC/AHA STEMI Focused Update
Anticoagulants as Ancillary Therapy
to Reperfusion Therapy
New Class I Recommendation
●
Patients undergoing reperfusion with fibrinolytics should receive
anticoagulant therapy for a minimum of 48 hours
and preferably for the duration of the index hospitalization,
up to 8 days (regimens other than UFH are recommended
if anticoagulant therapy is given for more than 48 hours
because of the risk of heparin-induced thrombocytopenia
with prolonged UFH treatment)
●
Anticoagulants regimens with established efficacy include:
● UFH
● Enoxaparin
● Fondaparinux
Antman E, et al. J Am Coll Cardiol. doi:10.1016/j.jacc.2007.10.001.
2007 ACC/AHA STEMI Focused Update
Anticoagulants
●
Modified Class IIa Recommendation
It is reasonable for patients with STEMI who do not undergo
reperfusion therapy to be treated with anticoagulant therapy
(non-UFH regimen) for the duration of the index hospitalization,
up to 8 days (Level of Evidence: B). Convenient strategies that
can be used include those with LMWH (Level of Evidence: C) or
fondaparinux (Level of Evidence: B) using the same dosing
regimens as for patients who receive fibrinolytic therapy
Antman E, et al. J Am Coll Cardiol. doi:10.1016/j.jacc.2007.10.001.
Main Results From ExTRACT–TIMI 25
Main Secondary End Point:
Death, nonfatal re-MI, or urgent
revascularization by 30 days
Primary End Point:
Death or nonfatal re-MI by 30 days
UFH
12
12.0
15
9.9
12
ENOX
9
UFH
14.5
11.7
ENOX
9
%
RR=0.83
6
%
P<.001
3
3
0
0
0
0
5
10
15 20
Days
25
30
RR=0.81
6
P<.001
RR=0.88
P=.02
5
10
15 20
Days
• Major bleeding at 30 days: 1.4% with UFH vs 2.1% with enoxaparin (P<.001)
• ICH: 0.7% for UFH vs 0.8% for enoxaparin (P=.14)
Adapted with permission from Antman EM, et al. N Engl J Med. 2006;354:1477-1488.
25
30
ExTRACT–TIMI 25: For Every 1000
Patients Treated With Enoxaparin vs UFH
4
Events/1000 Patients
5
0
(No increase in
nonfatal ICH)
-5
-7
-10
-15
-20
-6
-15
Nonfatal
reMI
Urgent
Revasc.
Antman EM, et al. N Engl J Med. 2006;354:1477-1488.
Adapted with permission from clinicaltrialresults.org.
Death
Nonfatal TIMI
Major Bleed
OASIS-6 Trial: Study Design
12,092 patients presenting with STEMI within 24 hours of symptom onset
(shortened to 12 hours of symptom onset midway through trial)
Randomized. Blinded. Factorial.
28% female; mean age, 62 years; mean follow-up, 3-6 months
Stratum 1 (No UFH)
n=5658
Fondaparinux
n=2823
Placebo
n=2835
2.5 mg/day for up to 8 days or
hospital discharge


Stratum 2 (UFH)
n=6434
Fondaparinux
n=3213
UFH
n=3221
2.5 mg/day for up to 8 days or
hospital discharge
Primary end point: composite of death or reinfarction at 30 days
Secondary end point: composite of death or reinfarction at 9 days and at final followup
Yusuf S, et al. JAMA. 2006;295:1519-1530.
Adapted with permission from www.clinicaltrialresults.org.
OASIS-6 Trial: Results
14%
Primary End Point: Death/Reinfarction (%)
12%
14.8%
15%
6%
9.7%
Frequency
8%
11.2%
9%
8.9%
4%
7.4%
2%
0%
6%
3%
P=.008
P=.003
14%
P=.008
12%
0%
30 days
11.2%
10%
13.4%
12%
Reduction in Death/MI at 30 days:
Stratum 1 (No UFH Indicated)
P<.05
14%
9 days
Fondaparinux (n=6036)
3-6 months
10%
Control (n=6056)
Fondaparinux
Placebo
Reduction in Death/MI: Stratum 2
(UFH Indicated)
P=NS
8.3%
8%
8.7%
p=0.9
7
6%
4%
Severe Bleeding at
9 Days
Fonda-
Placebo/U
FH
HR
P
2%
0%
All cases
1.0%
1.3%
0.77
.13
Stratum 1 vs
placebo
1.0%
1.6%
0.63
.06
Stratum 2 vs UFH
1.1%
1.1%
0.95
.82
Fondaparinux
Yusuf S, et al. JAMA.
2006;295:1519-1530.
Adapted with permission
from clinicaltrialresults.org.
UFH
OASIS-6: PCI Substudy at 30 Days
8%
6%
Primary End Point of Death or MI
in Primary PCI Cohort (%)
P=.04
6.0%
4.9%
4%
2%
0%
Fondaparinux
Control
Yusuf S, et al. JAMA. 2006;295:1519-1530.
Adapted with permission from www.clinicaltrialresults.org.
 Guiding catheter
thrombosis in the primary
PCI cohort occurred more
often with fondaparinux
compared with control
(n=22 vs n=0, P<.001)
HORIZONS AMI: Bivalirudin vs Heparin + GP IIb/IIIa
for Primary PCI in STEMI
Bivalirudin monotherapy (n=1800)
Heparin + GP IIb/IIIa inhibitor (n=1802)
30-day event rates (%)
20
15
10
Diff = -2.9% [-4.9, -0.8]
RR = 0.76 [0.63, 0.92]
Diff = -3.3% [-5.0, -1.6]
RR = 0.60 [0.46, 0.77]
Diff = 0.0% [-1.6, 1.5]
RR = 0.99 [0.76, 1.30]
PNI ≤ .0001
Psup = .006
PNI ≤ .0001
Psup ≤ .0001
Psup = 1.00
12.1
9.2
5
4.9
1 end point
1 end point
Net adverse
clinical events
Major bleedinga
0
aNot
8.3
5.5
5.4
MACEb
related to CABG; bMACE = All-cause death, reinfarction, ischemic TVR or stroke.
Stone GW, et al. Presented at: Transcatheter Cardiovascular Therapeutics 2007; October 20-25,
2007; Washington, DC.
2007 ACC/AHA STEMI Focused Update
Thienopyridines
New Class I Recommendation
●
Clopidogrel 75 mg per day orally should be added to aspirin
in patients with STEMI regardless of whether they undergo reperfusion
with fibrinolytic therapy or do not receive reperfusion therapy.
Treatment with clopidogrel should continue for at least 14 days
2004 Class I Recommendation (remains current)
●
In patients taking clopidogrel in whom CABG is planned, the drug
should be withheld for at least 5 days, and preferably for 7 days,
unless the urgency for revascularization outweighs the risks of excess
bleeding
Antman E, et al. J Am Coll Cardiol. doi:10.1016/j.jacc.2007.10.001.
2007 ACC/AHA STEMI Focused Update
Thienopyridines (cont.)
New Class IIa Recommendations
●
●
In patients less than 75 years of age who receive fibrinolytic
therapy or who do not receive reperfusion therapy, it is
reasonable to administer an oral loading dose of clopidogrel 300
mg (No data are available to guide decision making regarding an
oral loading dose
in patients 75 years of age or older)
Long-term maintenance therapy (eg, 1 year) with clopidogrel (75
mg per day orally) is reasonable in STEMI patients regardless of
whether they undergo reperfusion with fibrinolytic therapy or do
not receive
reperfusion therapy
Antman E, et al. J Am Coll Cardiol. doi:10.1016/j.jacc.2007.10.001.
CLARITY- TIMI 28 Trial: Study Design
Double-blind, randomized, placebo-controlled trial in
3491 patients, aged 18-75 yrs, with STEMI <12 hours
Fibrinolytic, ASA, Heparin
Randomized
Clopidogrel
300 mg + 75 mg qd
Placebo
Study
Drug
Coronary Angiogram
(2-8 days)
Open-label
clopidogrel
per MD in
both groups
30-day clinical follow-up
Sabatine MS, et al. N Engl J Med. 2005;352:1179-1189.
Primary end point:
Occluded artery (TIMI
flow grade 0/1) or
death/MI
by time of angio
CLARITY–TIMI 28: Clopidogrel 300 mg/75 mg qd
vs Placebo With Thrombolysis for STEMI (n = 3491)
Primary End Point: Occluded Artery
(or Death/MI Through Angio/HD)
25
36%
21.7
15
Odds Reduction
Placebo
20
15
20%
End Point, %
Occluded Artery or Death/MI, %
CV Death, MI, RI  Urg Revasc
15.0
10
10
Clopidogrel
Odds Ratio: 0.80
(95% CI, 0.65-0.97)
P=.03
5
5
0
0
n=1752
n=1739
Clopidogrel
Placebo
0
5
10
15
Days
P <.001
Adapted with permission from Sabatine MS, et al. N Engl J Med. 2005;352:1179-1189.
20
25
30
COMMIT/CCS-2:
Effect of Clopidogrel 75 mg qd vs Placebo (n = 45,852)
Death, Re-MI, or Stroke
Death in the Hospital
Placebo + ASA: 1845
deaths (8.1%)
Placebo + ASA: 2310
events (10.1%)
9
8
7
Clopidogrel + ASA:
2121 events (9.2%)
6
Clopidogrel + ASA: 1726
deaths (7.5%)
6
5
4
9% (SE 3) relative risk
reduction (P=.002)
3
Mortality, %
Event, %
7
5
4
7% (SE 3) relative risk
reduction (P=.03)
3
2
2
1
0
0
7
14
21
28
Days Since Randomization (up to 28 days)
a
1
0
0
7
14
21
28
Days Since Randomization (up to 28 days)
All patients received aspirin 162 mg/d.
SE = standard error.
Adapted with permission from COMMIT Collaborative Group. Lancet. 2005;366:1607-1621.
CLARITY–TIMI 28 and COMMIT/CCS-2:
Intracranial Hemorrhage and Major Bleeding
Clopidogrel
n=1733 (%)
Placebo
n=1719 (%)
P Value
8 (0.5)
12 (0.7)
.38
Major Bleeding
23 (1.3)
19 (1.1)
.64
30-day Major Bleeding
33 (1.9)
30 (1.7)
.80
Clopidogrel
n=22,961 (%)
Placebo
n=22,891 (%)
P Value
55 (0.2)
56 (0.2)
.90
134 (0.6)
125 (0.5)
.59
CLARITY–TIMI 281
ICH
COMMIT-CCS-22
ICH
Major Bleeding
1. Sabatine MS, et al. N Engl J Med. 2005;352:1179-1189.
2. Chen Z, et al. Lancet. 2005;366:1607-1621.
COMMIT/CCS-2: Metoprolol Results
End Point (%)
Metoprolol,
n=22,929
Placebo,
n=22,923
P
Death, reinfarction, or
cardiac arrest
9.4
9.9
.10
All-cause mortality
7.7
7.8
.69
Reinfarction
2.0
2.5
.001
Ventricular fibrillation
2.5
3.0
.001
Other cardiac arrest
3.0
2.8
.14
Cardiogenic shock
5.0
3.9
<.00001
COMMIT = ClOpidogrel & Metoprolol in Myocardial Infarction Trial.
Adapted with permission from Chen ZM, et al. Lancet. 2005;366:1622-1632.
Implications for the ED


Lytics are underused, even when preference
for PPCI is accepted
Lytic therapy can be optimized with proper
use of adjunctive medications
– Enoxaparin
– Clopidogrel

Beta blockers should be used appropriately
2007 ACC/AHA STEMI Focused Update
-Blockers
Modified Class I Recommendation

Oral -blocker therapy should be initiated in the first 24 hours for
patients who do not have any of the following:
– Signs of heart failure
– Evidence of a low output state
– Increased riska for cardiogenic shock
– Other relative contraindications to -blockade (PR interval >0.24
second, second- or third-degree heart block, active asthma, or
reactive airway disease)
a Risk
factors for cardiogenic shock: age >70 years, systolic blood pressure <120 mm Hg, sinus
tachycardia >110 bpm or heart rate <60 bpm, and increased time since onset of symptoms of STEMI.
Antman E, et al. J Am Coll Cardiol. doi:10.1016/j.jacc.2007.10.001.
2007 ACC/AHA STEMI Focused Update
-Blockers (cont.)
New Class III Recommendation

IV -blockers should not be administered to STEMI patients who
have any of the following:
– Signs of heart failure
– Evidence of a low output state
– Increased riska for cardiogenic shock,
– Other relative contraindications to -blockade (PR interval >0.24
second, second- or third-degree heart block, active asthma, or
reactive airway disease)
a
Risk factors for cardiogenic shock: age >70 years, systolic blood pressure <120 mm Hg, sinus
tachycardia >110 bpm or heart rate <60 bpm, and increased time since onset of symptoms of STEMI.
Antman E, et al. J Am Coll Cardiol. doi:10.1016/j.jacc.2007.10.001.
2007 ACC/AHA STEMI Focused Update
Anticoagulants as Ancillary Therapy
to Reperfusion Therapy in PCI
New Class I Recommendation
●
For patients undergoing PCI after having received an anticoagulant regimen,
the following dosing recommendations should be followed:
● For prior treatment with UFH, administer additional boluses of UFH as needed to
support the procedure, taking into account whether GP IIb/IIIa receptor
antagonists have been administered. Bivalirudin may also be used in patients
treated previously with UFH
● For prior treatment with enoxaparin, if the last SC dose was administered within
the prior 8 hours, no additional enoxaparin should be given; if the last SC dose
was administered at least 8 to 12 hours earlier, an IV dose of 0.3 mg per kg of
enoxaparin should be given
● For prior treatment with fondaparinux, administer additional IV treatment with an
anticoagulant possessing anti-IIa activity, taking into account whether GP IIb/IIIa
receptor antagonists have been administered
Antman E, et al. J Am Coll Cardiol. doi:10.1016/j.jacc.2007.10.001.
2007 ACC/AHA STEMI Focused Update
PCI After Fibrinolysis or for Patients
Not Undergoing Primary Reperfusion


Modified Class IIb Recommendation
PCI of a hemodynamically significant stenosis in a patent
infarct artery >24 hours after STEMI may be considered as
part of an invasive strategy
New Class III Recommendation
PCI of a totally occluded infarct artery >24 hours after
STEMI is not recommended in asymptomatic patients with
1- or 2-vessel disease if they are hemodynamically and
electrically stable and do not have evidence of severe
ischemia
Antman E, et al. J Am Coll Cardiol. doi:10.1016/j.jacc.2007.10.001.
2007 ACC/AHA/SCAI PCI Focused Update
Antiplatelet Therapy: Clopidogrel
Modified Class I Recommendations
●
A loading dose of clopidogrel, generally 600 mg, should
be administered before or when PCI is performed
●
In patients undergoing PCI within 12 to 24 hours of
receiving fibrinolytic therapy, a clopidogrel oral loading
dose of 300 mg may be considered
King SB III, et al. J Am Coll Cardiol. doi:10.1016/j.jacc.2007.10.002.
2007 ACC/AHA/SCAI PCI Focused Update
Antiplatelet Therapy: Clopidogrel (cont.)
Modified Class IIa Recommendation
●
●
If clopidogrel is given at the time of the procedure,
supplementation with GP IIb/IIIa receptor antagonists
can be beneficial
Class IIa Recommendation (No Change)
For patients with an absolute contraindication to aspirin,
it is reasonable to give a 300 mg to 600 mg loading dose of
clopidogrel, administered at least 6 hours before PCI, and/or GP
IIb/IIIa antagonists, administered at the time
of PCI
King SB III, et al. J Am Coll Cardiol. doi:10.1016/j.jacc.2007.10.002.
DES vs BMS in STEMI: Meta-analysis
Primary Efficacy End Point: Reintervention
13.3%
13.3%
5.0%
5.0%
Reintervention = target lesion revascularization.
Reproduced with permission from Kastrati A, et al. Eur Heart J. 2007;28:2706-2713.
DES vs BMS in STEMI: Meta-analysis
Primary Safety End Point: Stent Thrombosis
Reproduced with permission from Kastrati A, et al. Eur Heart J. 2007;28:2706-2713.
2007 ACC/AHA STEMI Focused Update
Antiplatelet Therapy for Post-PCI Patients
Class I Recommendations

PCI without stenting
– ASA 75-162 mg/d indefinitely
and
– Clopidogrel 75 mg/d for at least 14 d

Bare-metal stent
– ASA 162-325 mg/d for at least 1 mo, 75-162 mg/d indefinitely
and
– Clopidogrel 75 mg/d for at least 1 mo, ideally up to 1 y

Drug-eluting stent
– ASA 162-325 mg/d for at least 3 (sirolimus) to 6 (paclitaxel) mo,
75-162 mg/d indefinitely
and
– Clopidogrel 75 mg/d for at least 1 y
Antman E, et al. J Am Coll Cardiol. doi:10.1016/j.jacc.2007.10.001.
2007 ACC/AHA STEMI Focused Update
Secondary Prevention: Clopidogrel


New Class I Recommendation
For all STEMI patients not undergoing stenting (medical
therapy alone or PTCA without stenting), treatment with
clopidogrel should continue for at least 14 days
New Class IIa Recommendation
Long-term maintenance therapy (eg, 1 year) with clopidogrel
(75 mg per day orally) is reasonable in STEMI patients
regardless of whether they undergo reperfusion with
fibrinolytic therapy or do not receive reperfusion therapy
Antman E, et al. J Am Coll Cardiol. doi:10.1016/j.jacc.2007.10.001.
2007 ACC/AHA STEMI Focused Update
Secondary Prevention:
Additional Recommendations

Smoking cessation
– At each visit, every tobacco user and family members who smoke should be
advised to quit (Class I, B)
– Exposure to environmental tobacco smoke at work and at home
should be avoided (Class I, B)

Statin goal
– LDL-C <100 mg/dL (Class I, A)
– Consider LDL-C <70 mg/dL (Class IIa, A)

Daily physical activity 30 min/d, min 5 d/wk (Class I, B)

Annual influenza immunization (Class I, B)
Antman E, et al. J Am Coll Cardiol. doi:10.1016/j.jacc.2007.10.001.
Conclusion: STEMI
Optimal medical care of STEMI begins in the
prehospital setting, continues in the ED, and
culminates in a prompt and informed
decision about reperfusion strategy.
Optimal outcomes in STEMI can be achieved
only with a multidisciplinary approach. The
ACC/AHA GLs invest initial decisionmaking
authority in the emergency physician.
Summary
● Acute therapy in STEMI focuses on reperfusion and
antithrombotic therapy – new ACC/AHA guidelines provide
current recommendations
● Long-term treatment involves aggressive multifactorial
lifestyle modification and both antithrombotic and antiischemic therapies