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ACC/AHA ST段抬高心梗2004指南解读

ACCAHA ST段抬高心梗2004指南解读

ACC/AHA Guidelines for the Management of Patients With ST-Elevation Acute Myocardial Infarction-    Focus Emergency Care
A Report of the American College of Cardiology/American Heart Association
Task Force on Practice Guidelines (Writing Committee to Revise the 1999
Guidelines for the Management of Patients with Acute Myocardial Infarction)
Available as full text or executive versions at http://www.acc.org

Antman et al. JACC 2004;44:671-719.
Writing Committee & Task Force Members
Writing Committee Members
Elliott M. Antman, Chair
 Daniel T. Anbe, Paul Wayne Armstrong, Eric R. Bates, Lee A. Green, Mary Hand, Judith S. Hochman, Harlan M. Krumholz, Frederick G. Kuschner, Gervasio A. Lamas, Charles J. Mullany, Joseph P. Ornato, David L. Pearle, Michael A. Sloan, Sidney C. Smith, Jr.
Task Force Members
Elliott M. Antman, Chair
Sidney C Smith, Jr.Vice Chair Joseph S. Alpert, Jeffery L. Anderson, David P. Faxon, Valentin Fuster, Raymond J. Gibbons, Gabriel Gregoratos, Jonathan L Halperin, Loren F. Hiratzka, Sharon Ann Hunt, Alice K. Jacobs, Joseph P. Ornato
AMI Stats
Incidence in the United States*
Estimated 900,000 will suffer AMI this year
~565,000 will be new attacks (avg. age- 65.8yrs/males, 70.4yrs/female)
~300,000 will be recurrent attacks
42% of AMI pts will die within 1 year
Approximately half of these deaths occur before reaching the emergency department
Most cardiac deaths are the result of fatal arrhythmias
Types of arrival/discharge AMIs**
Upon arrival: STEMI on 1st ECG-26%; STEMI on 1st or subsequent ECG-35%; NSTEMI-65%
Non-Q-wave: 75%   Q-wave: 25%

*American Heart Association. Heart Disease & Stroke Statistics-2004 Update
**NRMI 4 Quarterly Data Report (Nation). South San Francisco, Calif: Genentech Inc; June, 2004.

Pathophysiology of ST-Elevation Myocardial Infarction
Results from stabilization of a platelet aggregate at site of plaque rupture by fibrin mesh
platelet
RBC
fibrin mesh
GP IIb-IIIa
Generally caused by a completely occlusive thrombus in a coronary artery
Recent Influences of Practice
Superiority of Primary Percutaneous Coronary Intervention (PPCI) over fibrinolysis if Door-to-Balloon completed in a timely fashion
Acknowledgement that Time Matters in PPCI
Recommendations for time to reperfusion updated
Studies published on Combination Therapy
GP IIb/IIIa receptor antagonists in combination with ? dose fibrinolysis
Studies with LMWH in treatment of STEMI (enoxaparin + full dose TNK-tPA)
European STEMI trials influence the guidelines
Prehospital, Transfer PCI?Prehospital Destination Protocols
Classification of Recommendations
Class I:  Conditions for which there is evidence and/or  general agreement that a given procedure or  treatment is beneficial, useful, and effective.
Class II:  Conditions for which there is conflicting evidence  and/or a divergence of opinion about the  usefulness/efficacy of a procedure or treatment.
Class IIa: Weight of evidence/opinion is in favor of  usefulness/efficacy.
Class IIb: Usefulness/efficacy is less well established by  evidence/opinion.
Class III: Conditions for which there is evidence and/or    general agreement that a procedure/treatment is  NOTuseful/effective and in some cases may be  harmful.
Level of Evidence
Level of Evidence A: Data derived from multiple randomized clinical trials or meta-analyses.
Level of Evidence B: Data derived from a single randomized trial, or nonrandomized studies.
Level of Evidence C: Only
consensus opinion
of experts, case
studies, or
standard
of
care.
Achieve Coronary Patency
Initial Reperfusion Therapy
Defined as the initial strategy employed to restore blood flow to the occluded coronary artery
3 Major Options:
Pharmacological Reperfusion
PCI
Acute Surgical Reperfusion
Under both Pharmacological and PCI are listed several lower recommendations & investigational reperfusion strategies

Class I  All patients should undergo rapid evaluation for reperfusion therapy & have a reperfusion strategy implemented promptly after contact with the medical system  
Antman et al. JACC 2004;44:680.
Importance of Early Reperfusion Therapy in STEMI
Outcomes Dependent Upon:
Time to treatment-TIME IS STILL MUSCLE
 
Early and full restoration in coronary blood flow

Sustained restoration of flow
Prehospital Issues
EMS
Emphasis on early defibrillation; AEDs; 911 dispatchers training & use of national protocols
Chest Pain Evaluation & Treatment
Emphasis on giving chewable ASA, unless contraindicated & prehospital ECG & checklist
Prehospital Fibrinolysis
Upgraded to a Class IIa (Level B) Recommendation
Prehospital Destination Protocols
Where to transport STEMI patients-Have a plan in place
Special considerations
Cardiogenic Shock
Fibrinolytic contraindicated
Antman et al. JACC 2004;44:675-7.
Initial Patient Evaluation
Class I 
Delay in patient contact (arrival at the ED or contact with paramedics) to:
fibrinolytic therapy less than 30 minutes
PCI less than 90 mins
 (Level of Evidence: B)
The choice of initial STEMI treatment should be made by ED Physician on duty based on a predetermined, institution-specific, written protocol…. For unclear cases, not covered by the protocol, contact cardiologist immediately.
(Level of Evidence C).

Antman et al. JACC 2004; 44:677-8.
Patients Transported by EMS After Calling 9-1-1
Onset of
STEMI
Symptoms
Call 911
Call Fast
9-1-1
EMS
Dispatch
EMS on-scene
Encourage 12-lead ECG
Consider prehospital fibrinolytic if capable and EMS-to-needle < 30 min
EMS  Triage Plan
Not PCI
Capable
Hospital
PCI
Capable
Hospital
Interhospital
Transfer
Hospital Fibrinolysis:
Door-to-needle
within<30 min
EMS transport:EMS to Balloon within 90 min
Patient self-transport: Hospital Door-to-Balloon within 90 min
EMS transport
EMS on
scene
Within
 8 min
Dispatch
1 min
Patient
5 min after
Symptom onset
Goals
Total ischemic time: Within 120 min*
* Golden hour = First 60 min
 Adapted from Panel A Figure 1
 Antman et al. JACC 2004;44:676.
 Adapted from Panel B Figure 1
 Antman et al. JACC 2004;44:676.
Fibrinolysis
Noninv. Risk
Stratification
Late Hospital Care
& Secondary Prevention
PCI or
CABG
Primary
PCI
Receiving
Hospital
Not PCI
Capable
PCI
Capable
Rescue
Ischemic driven
Initial Recognition & Management in the ED
Optimal Strategies for the ED Triage
Initial Patient Evaluation
History
Physical Exam
ECG
Laboratory Examinations
Biomarkers of Cardiac Damage
Imaging
Routine Measures
Antman et al. JACC 2004;44:677-9.
Selection of Reperfusion Strategy Step 1: Assess Time and Risk
Time from Onset of Symptoms
Differentiation made for early presenters
Risk of STEMI
High risk (eg, cardiogenic shock) PPCI preferred
Risk of Bleeding
High Risk of bleeding-PPCI Preferred
Time Required for Transport to a Skilled PCI Lab
Availability of PCI labs
Importance of reduction of recurrent MI
Time-to-PCI minus Time-To Balloon


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