ACC AHA ST段抬高心梗2004指南解读

nullACC/AHA Guidelines for the Management of Patients With ST-Elevation Acute Myocardial Infarction- Focus Emergency CareACC/AHA Guidelines for the Management of Patients With ST-Elevation Acute Myocardial Infarction- Focus Emergency CareA 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 MembersWriting Committee & Task Force MembersWriting 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. OrnatoAMI StatsAMI StatsIncidence 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 InfarctionPathophysiology of ST-Elevation Myocardial InfarctionResults from stabilization of a platelet aggregate at site of plaque rupture by fibrin meshplateletRBCfibrin meshGP IIb-IIIaGenerally caused by a completely occlusive thrombus in a coronary arteryRecent Influences of PracticeRecent Influences of PracticeSuperiority 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 ½ 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 RecommendationsClassification of RecommendationsClass 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 EvidenceLevel of EvidenceLevel 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 PatencyAchieve Coronary PatencyInitial 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 STEMIImportance of Early Reperfusion Therapy in STEMIOutcomes Dependent Upon: Time to treatment-TIME IS STILL MUSCLE Early and full restoration in coronary blood flow Sustained restoration of flow Prehospital IssuesPrehospital IssuesEMS 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 contraindicatedAntman et al. JACC 2004;44:675-7.Initial Patient EvaluationInitial Patient EvaluationClass 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.nullPatients Transported by EMS After Calling 9-1-1Onset of STEMI SymptomsCall 911 Call Fast9-1-1 EMS DispatchEMS on-scene Encourage 12-lead ECG Consider prehospital fibrinolytic if capable and EMS-to-needle < 30 minEMS Triage PlanNot PCI Capable HospitalPCI Capable HospitalInterhospitalTransferHospital Fibrinolysis: Door-to-needle within<30 minEMS transport:EMS to Balloon within 90 minPatient self-transport: Hospital Door-to-Balloon within 90 minEMS transportEMS on scene Within 8 minDispatch1 minPatient5 min after Symptom onsetGoalsTotal ischemic time: Within 120 min** Golden hour = First 60 min Adapted from Panel A Figure 1 Antman et al. JACC 2004;44:676.null Adapted from Panel B Figure 1 Antman et al. JACC 2004;44:676.FibrinolysisNoninv. Risk StratificationLate Hospital Care & Secondary PreventionPCI or CABGPrimary PCIReceiving HospitalNot PCI Capable PCI CapableRescueIschemic drivenInitial Recognition & Management in the EDInitial Recognition & Management in the EDOptimal Strategies for the ED Triage Initial Patient Evaluation History Physical Exam ECG Laboratory Examinations Biomarkers of Cardiac Damage Imaging Routine MeasuresAntman et al. JACC 2004;44:677-9.Selection of Reperfusion Strategy Step 1: Assess Time and RiskSelection of Reperfusion Strategy Step 1: Assess Time and RiskTime 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 Antman et al. JACC 2004;44:682.Pharmacological ReperfusionPharmacological Reperfusion Available Resources Class I 1. STEMI patients presenting to a facility without the capability for expert, prompt intervention with primary PCI within 90 minutes of first medical contact should undergo fibrinolysis unless contraindicated. (Level of Evidence: A) Antman et al. JACC 2004;44:682.Fibrinolytic TherapyFibrinolytic TherapyClass I In the absence of contraindication, fibrinolytic therapy should be administered to STEMI patients with symptom onset within the prior 12 hours & ST elevation > 0.1mV in at least 2 contiguous precordial leads or at least 2 adjacent limb leads. 2. In the absence of contraindications, fibrinolytic therapy should be administered to STEMI patients with symptom onset within the prior 12 hours and new or presumably new LBBB.Antman et al. JACC 2004;44:682-3.Fibrinolytic TherapyFibrinolytic Therapy Class IIa In the absence of contraindication, fibrinolytic therapy it is reasonable to administer to STEMI patients with symptom onset within the prior 12 hours & 12-lead ECG findings consistent with a true posterior MI (Level C). 2. In the absence of contraindications, it is reasonable to administer to fibrinolytic therapy to patients with symptoms of STEMI beginning within the prior 12 hours to 24 hours who have continuing ischemic symptoms & ST elevation > 0.1mV in at least 2 contiguous precordial leads or at least 2 adjacent limb leads (Level B). Antman et al. JACC 2004;44:683.ACC/ AHA: Contraindications and Cautions for Fibrinolytic Use in STEMIACC/ AHA: Contraindications and Cautions for Fibrinolytic Use in STEMI Absolute Contraindications Any prior ICH Known structural cerebral vascular lesion -eg, AVM Known malignant intracranial neoplasm -primary or metastatic Ischemic stroke within 3 months -EXCEPT AIS within 3 hours Suspected aortic dissection Active bleeding or bleeding diathesis (does not include menses) Significant closed head or facial trauma within 3 months Antman et al. JACC 2004;44:683.Fibrinolytic Therapy Step 2: Determine Whether Fibrinolysis or an Invasive Strategy is Preferred Fibrinolytic Therapy Step 2: Determine Whether Fibrinolysis or an Invasive Strategy is Preferred Adapted from Figure 3; Antman et al. JACC 2004;44:682.If presentation is less than 3 hours and there is no delay to an invasive strategy, there is no preference for either strategy.Fibrinolysis is generally preferred if: Early presentation (3 hours or less from symptom onset & delay to invasive strategy; see below) Invasive strategy is not an option Catheterization lab occupied/not available Vascular access difficulties Lack of access to a skilled PCI lab- Operator experience > 75 PPCI cases per year/ Team experience >36 PPCI cases per year Delay to invasive strategy Prolonged transport (Door-to Balloon) – (Door-to- needle) time is > 1 HR Medical contact-to- balloon time is > than 90 min An invasive strategy is generally preferred if: Skilled PCI laboratory available with surgical backup Medical contact-to- balloon time is < than 90 min (Door-to Balloon) – (Door-to- needle time) is < 1 hr High risk from STEMI Cardiogenic shock Killip class greater than or equal to 3 Contraindications to fibrinolysis, including increased risk of bleeding and ICH Late presentation Symptom onset was more than 3 hours ago Diagnosis of STEMI is in doubtCAPTIM Comparison of Angioplasty and Prehospital Thrombolysis in Acute Myocardial InfarctionCAPTIM Comparison of Angioplasty and Prehospital Thrombolysis in Acute Myocardial InfarctionPrimary Composite Endpoint- Death, Reinfarction, Disabling StrokeBonnefoy E, et al. Lancet 2002;360:825-9CAPTIM -1Year Results Sx to Treatment AnalysisCAPTIM -1Year Results Sx to Treatment AnalysisTouboul P. Presented at: The 18th International Symposium on Thrombolysis and Interventional Therapy in Acute Myocardial Infarction - George Washington University Symposium; November 16, 2002; Chicago, Ill. Sx  2 h0.0DeathSx  2 h5.07.52.5Pre-hospital LysisPrimary PCI2.25.7DeathP=0.0570.07.510.02.5Pre-hospital LysisPrimary PCI5.93.7DeathP=0.475.0PercentComparison of Approved Fibrinolytic AgentsComparison of Approved Fibrinolytic AgentsAdapted from Table 15, pg 53.Accessed on August 6, 2004 http://www.acc.org/clinical/guidelines/stemi/index.pdf. Streptokinase Alteplase Reteplase Tenecteplase Dose 1.5 MU over Up to 100mg in 10U x 2 30-50mg 30-60 min 90 min (wt-based) each over 2 min based on weight Bolus Admin. No No Yes Yes Antigenic Yes No No No Allergic React Yes No No No Systemic Marked Mild Moderate Minimal Fibrinogen Depletion ~90-min patency 50 75 75? 75 rates (%) TIMI grade 3 flow, % 32 54 60 63Fibrinolytic Therapy Combination Therapy with GP IIb/IIIa Fibrinolytic Therapy Combination Therapy with GP IIb/IIIa Class IIb1. Combination pharmacological reperfusion with abciximab and half-dose reteplase or tenecteplase may be considered for prevention of reinfarction (Level of Evidence: A) and other complications of STEMI in selected patients: anterior location of MI, age less than 75 years, and no risk factors for bleeding. In two clinical trials of combination reperfusion, the prevention of reinfarction did not translate into a survival benefit at either 30 days or 1 year. (Level of Evidence: B) 2. Combination pharmacological reperfusion with abciximab and half-dose reteplase or tenecteplase may be considered for prevention of reinfarction and other complications of STEMI in selected patients (anterior location of MI, age less than 75 years, and no risk factors for bleeding) in whom an early referral for angiography and PCI (ie, facilitated PCI) is planned. (Level of Evidence: C)Antman et al. JACC 2004;44:684.GP IIb/IIIa As A Solo Reperfusion StrategyGP IIb/IIIa As A Solo Reperfusion Strategy “Studies evaluating the use of glycoprotein IIb/IIIa inhibitors as the sole means of reperfusion (i.e., without a fibrinolytic or in conjunction with PCI) do not suggest that the isolated use of a GP IIb/IIIa inhibitor restores TIMI 3 flow in a sufficient proportion of patients to make it a viable pharmacologic strategy”. -pg 54, Full Text GuidelinesFrom the TIMI-14, SPEED, INTRO-AMI data setsAccessed on August 6, 2004 http://www.acc.org/clinical/guidelines/stemi/index.pdf.Fibrinolytic Therapy Combination Therapy with GP IIb/IIIaFibrinolytic Therapy Combination Therapy with GP IIb/IIIaClass III 1. Combination pharmacological reperfusion with abciximab and half-dose reteplase or tenecteplase should not be given to patients aged greater than 75 years because of an increased risk of ICH. (Level of Evidence: B)Antman et al. JACC 2004; 44:683.Primary Percutaneous Coronary InterventionPrimary Percutaneous Coronary Intervention Class I 1. General considerations: If immediately available, primary PCI should be performed in patients with STEMI (including true posterior MI) or MI with new or presumably new LBBB who can undergo PCI of the infarct artery within 12 hours of symptom onset, if performed in a timely fashion (balloon inflation within 90 minutes of presentation) by persons skilled in the procedure (individuals who perform more than 75 PCI procedures per year). The procedure should be supported by experienced personnel in an appropriate laboratory environment (performs more than 200 PCI procedures per year, of which at least 36 are primary PCI for STEMI, and has cardiac surgery capability). (Level of Evidence: A) Antman et al. JACC 2004;44: 682.NRMI 2: Primary PCI Door-to-Balloon Time vs. MortalityNRMI 2: Primary PCI Door-to-Balloon Time vs. MortalityDoor-to-Balloon Time (minutes)MV Adjusted Odds of DeathP=0.01P=0.0007P=0.0003n = 2,2305,7346,6164,4612,6275,412Time from Symptom Onset to Treatment Predicts 1-year Mortality after Primary PCITime from Symptom Onset to Treatment Predicts 1-year Mortality after Primary PCIDe Luca et al, Circulation 2004;109:1223-1225The relative risk of 1-year mortality increases by 7.5% for each 30-minute delayn=1791Mortality rates with primary PCI as a function of PCI-related time delayMortality rates with primary PCI as a function of PCI-related time delayCircle sizes = sample size of the individual study. Solid line = weighted meta-regression. 62 minBenefit Favors PCIHarm Favors LysisFor Every 10 min delay to PCI: 1% reduction in mortality difference towards lyticsPrimary Percutaneous Coronary InterventionPrimary Percutaneous Coronary InterventionClass I 2. Specific Considerations: a. Primary PCI should be performed as quickly as possible, with a goal of a medical contact–to-balloon or door-to-balloon time of within 90 minutes. (Level of Evidence: B) b. If the symptom duration is within 3 hours and the expected door-to-balloon time minus the expected door-to-needle time is: i) within 1 hour, primary PCI is generally preferred. (Level of Evidence: B) ii) greater than 1 hour, fibrinolytic therapy (fibrin-specific agents) is generally preferred. (Level of Evidence: B) c. If symptom duration is greater than 3 hours, primary PCI is generally preferred and should be performed with a medical contact–to-balloon or door-to-balloon time as brief as possible, with a goal of within 90 minutes. (Level of Evidence: B)Antman et al. JACC 2004;44:684.Primary Percutaneous Coronary InterventionPrimary Percutaneous Coronary Intervention Class I 2. Specific Considerations (continued) d. Primary PCI should be performed for patients younger than 75 years old with ST elevation or LBBB who develop shock within 36 hours of MI and are suitable for revascularization that can be performed within 18 hours of shock, unless further support is futile because of the patient’s wishes or contraindications/unsuitability for further invasive care. (Level of Evidence: A) e. Primary PCI should be performed in patients with severe CHF and/or pulmonary edema (Killip class 3) and onset of symptoms within 12 hours. The medical contact–to-balloon or door-to-balloon time should be as short as possible (ie, goal within 90 min). (Level of Evidence: B) Antman et al. JACC 2004;44:684.Primary Percutaneous Coronary Intervention PPCI without On-Site Cardiac SurgeryPrimary Percutaneous Coronary Intervention PPCI without On-Site Cardiac Surgery Class IIb 1. Primary PCI might be considered in hospitals without on-site cardiac surgery, provided that there exists a proven plan for rapid transport to a cardiac surgery operating room in a nearby hospital with appropriate hemodynamic support capability for transfer. The procedure should be limited to patients with STEMI or MI with new, or presumably new, LBBB on ECG, and should be done in a timely fashion (balloon inflation within 90 minutes of presentation) by persons skilled in the procedure (at least 75 PCIs per year) and at hospitals that perform a minimum of 36 primary PCI procedures per year. (Level of Evidence: B)Antman et al. JACC 2004;44:686.Primary Percutaneous Coronary InterventionPrimary Percutaneous Coronary InterventionInterhospital Transfer for Primary PCI “To achieve optimal results, time from the first hospital door to the balloon inflation in the second hospital should be as short as possible, with a goal of within 90 minutes. Significant reductions in door-to-balloon times might be achieved by directly transporting patients to PCI centers rather than transporting them to the nearest hospital, if interhospital transfer will subsequently be required to obtain primary PCI”.Antman et al. JACC 2004;44:686.DANAMI-2: ResultsDANAMI-2: ResultsDeath/MI/Stroke (%)LyticPrimary PCIP=0.35Death02647.66.6LyticPrimary PCIP<0.0001Recurrent MI026846.31.6LyticPrimary PCIP=0.15Stroke026841.12.08Anderson HR, et al. NEJM 2003;349:733-42Door to Balloon Times Among Patients Transferred in NRMI 4Door to Balloon Times Among Patients Transferred in NRMI 4Door to Data: 50th: 9 Min. 25th: 4 Min. 75th: 16 Min.Data to Cath Lab Arrival: 50th: 132 Min. 25th: 88 Min. 75th: 219 Min.Cath Lab to Balloon: 50th: 37 Min. 25th: 28 Min 75th: 50 Min.913237Total Door 1 to Balloon Time: 185 minutes (25th: 137; 75th: 276) Percent of Patients with Door to Balloon Time < 90 Min.: 3.0%Sample Size: 1,346; Time Period: January 2002 – December 2002Acce