Read 2011 ABSITE Keyword Manual, page 54 text version

54

2011 ABSITE Review Manual

Treatment of myocardial infarction

Given the progressive loss of functioning myocytes with persistent occlusion of the infarct-related artery in STEMI, the initial management aims to restore blood flow to the infarct zone. It is generally accepted that primary PCI is the preferred option. Most deaths associated with STEMI occur within the first hour of its onset and are usually caused by ventricular fibrillation. Review of previous studies have shown that early fibrinolysis is associated with a 17% reduction in mortality. · Supplemental oxygen: Supplemental oxygen should be administered to patients with arterial oxygen desaturation (i.e., Sao2 < 90%) (Class I; LOE, B), but it is reasonable to administer supplemental oxygen to all patients with uncomplicated STEMI during the first 6 hours (Class IIa; LOE, C). · Nitroglycerin: 0.4 mg every 5 minutes, for a total of three doses. Intravenous (IV) nitroglycerin is then indicated for relief of ongoing ischemic discomfort, control of hypertension, or management of pulmonary congestion (Class I; LOE, C). Nitrates should not be administered to patients with (SBP) < 90 mm Hg or SBP 30 mm Hg below baseline, severe bradycardia (<50 beats/min), tachycardia (>100 beats/min), or suspected right ventricular (RV) infarction (Class III; LOE, C). · Analgesia: Morphine sulfate (2 to 4 mg IV, with increments of 2 to 8 mg IV repeated at 5- to 15-minute intervals) is the analgesic of choice for management of pain associated with STEMI (Class I; LOE, C). · Aspirin: Aspirin should be chewed by patients who have not taken aspirin before presentation with STEMI (Class I). The initial dose should be 162 mg (LOE, A) to 325 mg (LOE, C). Nonenteric-coated aspirin provides more rapid buccal absorption. · Beta blockers: Oral beta blocker therapy should be initiated for patients who do not have any of the following: (1) signs of heart failure; (2) evidence of a low output state; (3) increased risk for cardiogenic shock; or (4) other relative contraindications (e.g., PR interval > 0.24 second, second- or third-degree atrioventricular (AV) block, or reactive airway disease) (Class I; LOE, B). 53

STEMI patient who is a candidate for reperfusion Initially seen at a PCI capable facility Initially seen at a non-PCI capable facility Selection of reperfusion strategy

Send to cath lab for primary PCI (Class I, LOE: A)

Transfer for Primary PCI (Class I, LOE: A)

Initial treatment with fibrinolytic High risk

Preparatory antithrombotic (anticoagulant plus antiplatelet) regimen Diagnostic angiography At PCI facility, evaluate for timing of diagnostic angio

Transfer to a PCI facility is reasonable for early diagnostic angio and possible PCI or CABG (Class IIa, LOE: B) High-risk patients as defined by 2007 STEMI Focused Update should undergo cath (Class I, LOE: B)

Transfer to a PCI facility may be considered (Cass IIb, LOE: C), especially if ischemic symptoms persist and failure to reperfuse is suspected

Medical therapy only

PCI with stent

CABG

American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 120:2271, 2009. Antman EM & Morrow DA. 2011. Bonow: Braunwald's Heart Disease A Textbook of Cardiovascular Medicine. 9th Edition. Chapter 55: Segment Elevation Myocardial Infarction: Management.

Information

2011 ABSITE Keyword Manual, page 54

1 pages

Find more like this

Report File (DMCA)

Our content is added by our users. We aim to remove reported files within 1 working day. Please use this link to notify us:

Report this file as copyright or inappropriate

100111