Alyssa Morris, R5
Thanks to Drs Rob Hall and Lisa Campfens






ASA
Plavix
BB
Morphine
Nitro
Heparin
 Reperfusion
CURE
CLARITY
SYNERGY
COMMIT
TACTICS
GUSTO
DANAMI
SHOCK
ISIS
CRUSADE
FRISC
38
NNT to prevent one
Death in STEMI with
ASA
35
NNT to prevent one
Death in STEMI with
streptokinase
NO Mortality decrease
AVOID
- Hypotension
- Cardiogenic Shock
CAUTION
- HR<50
- RV infarct
- Recent viagra or cialis

AHA guidelines state “reasonable”( II a)

CRUSADE study

AVOID
 hypotension, shock, tenuous respiratory status

Focus should be on other anti-ischemic
therapy!

Main evidence is for secondary
prevention of the next MI

Limited evidence from early 80s when
used as monotherapy

COMMIT TRIAL
5
fewer vfib episodes
5
fewer reinfarctions
11
more cardiogenic shock
NO Benefit of early IV beta-blockade
Rapid Atrial Fibrillation
Ventricular arrythmias
Hypertensive + Tachycardic
…….or just use iv nitro

Oral Beta-Blockade should be initiated
within 24 hours (Class I, Level B) as long as
none of:
 Signs of CHF
 2nd or 3rd degree heart block, PR. 0.24
 Low output states (shock, confusion, oliguria)
 Increased risk for cardiogenic shock (HR > 110, SBP < 120, age > 75)

IV Beta-Blockade is reasonable for control
of hypertension (not tachycardia alone) if
no contraindications are present

STEMI
 Fibrinolysis
▪ 300-600mg
 PCI
▪ 300- 600mg
 Clopidogrel should be held for 5, preferably 7
days before CABG




STEMIs got lytic, followed by cath b/w 2-8
days
Endpoint = death, recurrent MI, occluded
artery on angiography
21% - 15%, ARR 6%, NNT 16
Benefit was gained artery occlusion rates on
angiography not mortality or recurrent MI
rates

NOT a benign treatment
 NNH 50 for minor bleeding
 NNH 100 for major bleeding

NNT of 40-80 for benefits of composite end points of
recurrent angina, MI, death, urgent revascularization

NO benefit in low risk patients

STEMIs

Fondaparinux or UFH

PCI or Medical Mx

Reperfusion with fibrinolytics
 UFH 60U/kg max 4000U
 Enoxaparin 30mg IV bolus
 Fondaparinux 2.5mg IV

Reperfusion with PCI
 UFH
 Enoxaparin
 Fondaparinux






How long has the patient been symptomatic?
Are there absolute or relative
contraindications to lytic?
How long of a transport to PCI?
Is the patient in CHF, shock, arrhythmias
Is there a mechanical complication requiring
surgery?
How bad is this particular STEMI?



Mortality 75%
0.25 - 1%, NNH 100-400
Rates increase with number of risk factors





> 75 years old
< 70 kg
BP > 169/95
Prior CVA
Excessive anticoagulation

Inferior STEMI
 Mortality 5%

Inferior + RV STEMI
 Mortality 8%

Anterior STEMI
 Mortality 12%
20
New LBBB
27
Anterior MI
125
Inferior MI
Outcome
Lytic
PCI
ARR
NNT
Mortality
9%
7%
2%
50
Death/MI/
CVA
14%
8%
6%
16

PCI vs LYTIC

30d mortality
 46% vs 56%

6m mortality
 50% vs 63%

>30m chest pain

At least 1mm STE in at least 2 limb leads or

At least 1mm STE in 2 contiguous
precordial leads

New or presumed new LBBB

True posterior STEMI

ABSOLUTE







Prior ICH
Malignant intracranial neoplasm
Cerebral vascular lesion (AVM)
Ischemic CVA<3m
Ao Dissection
Active bleeding or bleeding
diathesis
 Sig CHI or Facial trauma <3m
RELATIVE
 Chronic, severe HTN
 SBP>180 DBP>110
 Hx ischemic stroke >3m,







dementia
Traumatic or prolonged CPR
Recent major surgery <3w
Recent internal bleeding <4w
Noncompressible vascular
puncture
Pregnancy
Active PUD
Current use of OAC: higher INR=
higher risk of bleeding
Door to Needle 30 min
Door to Balloon 90 min
DTB-DTN>1hr
Prolonged transport
DTB>90min

REACT trial

CARESS-AMI

TRANSFER-AMI

2009- TRANSFER TO PCI CENTER
 Lytic treated STEMI meeting high risk
criteria
 Non-high risk who received lytic may be
considered for transfer asap to a PCI center
for PCI prn

TNK 30-50mg single dose

ASA 162-325mg chewed

Plavix 300mg (or up to 600mg)

Heparin
 UFH
 Enoxaparin
 Fondaparinux

ASA 162-325mg chewed

Plavix 300-600mg

Heparin
 UFH*
 Enoxaparin
 Fondaparinux