Acute MI management - ver 1.pptx

acute Myocardial infraction

1. Acute MI management subtitle

2. Definition

3. What is new?

4. Diagnosis and Risk Stratification

5. Antithrombotic treatment

6. Invasive treatment

7. Major Changes in Recommendations

8. Major Changes in Recommendations

9. Diagnostic algorithm and triage in acute coronary syndrome Initial Assessment Components: Integration of low likelihood and/or high likelihood features: Clinical context (symptoms, vital signs). 12-lead ECG findings. Cardiac troponin concentration at presentation and serially. "Other cardiac" conditions like myocarditis, Takotsubo syndrome, congestive heart failure. " Noncardiac " conditions: e.g., pneumonia, pneumothorax. Cardiac Troponin Interpretation: Troponin and its change over serial sampling as a quantitative marker. Higher "0 h" level or absolute change indicates higher likelihood of MI .

10. Diagnostic algorithm and triage in acute coronary syndrome Cardiac Arrest or Hemodynamic Instability: In cases of presumed cardiovascular origin: Echocardiography by trained physicians after a 12-lead ECG. Suspected Aortic Dissection or Pulmonary Embolism: If initial assessment suggests these conditions: Recommended to perform D-dimers and CCTA based on specific algorithms.

11. Value of high-sensitivity cardiac troponin. hs-cTn assays Value of High-Sensitivity Cardiac Troponin (hs-cTn): hs-cTn assays reported in ng/L, conventional assays in lg/L. Both assays provide identical information for substantially elevated concentrations (>100 ng/L). hs-cTn uniquely distinguishes "normal" from mildly elevated levels. Detection of Previously Undetectable Cases: hs-cTn identifies patients previously undetectable with conventional assays. Some have hs-cTn >99th percentile (possibly related to AMI).

12. Clinical implications of high-sensitivity cardiac troponin assays

13. 0 h/1 h rule-out and rule-in algorithm using high-sensitivity cardiac troponin assays 0 h/1 h Rule-out and Rule-in Algorithm: For haemodynamically stable patients with suspected non-ST-segment elevation acute coronary syndrome. "0 h" and "1 h" refer to time from first blood test. NSTEMI Rule-out: Very low hs-cTn concentration at presentation. Combination of low baseline levels and no relevant increase within 1 h (no 1hD). NSTEMI Rule-in: High likelihood if hs-cTn at presentation is moderately elevated. Clear rise in hs-cTn concentrations within the first hour (1hD ).

14. 0 h/1 h rule-out and rule-in algorithm using high-sensitivity cardiac troponin assays Assay-specific Cut-offs: Cut-offs for ruling in or out NSTEMI are specific to the assay used. Derived to achieve predefined sensitivity and specificity criteria for NSTEMI.

15. Differential diagnoses of acute coronary syndromes in the setting of acute chest pain Bold = common and/or important differential diagnoses. Dilated , hypertrophic and restrictive cardiomyopathies may cause angina or chest discomfort.

16. Timing of the blood draws and clinical decisions when using the European Society of Cardiology 0 h/1 h algorithm CPO = Chest Pain Onset CPR = Cardiopulmonary Resuscitation ECG = Electrocardiogram/Electrocardiography hs-cTn = High-Sensitivity Cardiac Troponin MACE = Major Adverse Cardiovascular Events MI = Myocardial Infarction Time Points and Blood Collection: "0 h" and "1 h" are blood collection time points. Turn-around Time: Time from blood draw to reporting results (usually 1 h). Includes transportation, scanning, centrifugation, analysis, and reporting. Consistency Across Assays: Turn-around time same for hs-cTn and conventional assays on automated platforms. Clinical Decision Time: Add local turn-around time to blood draw for earliest decision point. "0 h" blood: decision at 1 h with 1 h turn-around. "1 h" blood: results at 2 h (1 h + 1 h) with 1 h turn-around. European Heart Journal (2021) 42, 12891367

17. Timing of the blood draws and clinical decisions when using the European Society of Cardiology 0 h/1 h algorithm Abbreviations: CPO = Chest Pain Onset CPR = Cardiopulmonary Resuscitation ECG = Electrocardiogram/Electrocardiography hs-cTn = High-Sensitivity Cardiac Troponin MACE = Major Adverse Cardiovascular Events MI = Myocardial Infarction Time Points and Blood Collection: "0 h" and "1 h" are blood collection time points. Turn-around Time: Time from blood draw to reporting results (usually 1 h). Includes transportation, scanning, centrifugation, analysis, and reporting. Consistency Across Assays: Turn-around time same for hs-cTn and conventional assays on automated platforms. Clinical Decision Time: Add local turn-around time to blood draw for earliest decision point. "0 h" blood: decision at 1 h with 1 h turn-around. "1 h" blood: results at 2 h (1 h + 1 h) with 1 h turn-around.

18. Timing of the blood draws and clinical decisions when using the European Society of Cardiology 0 h/1 h algorithm Abbreviations: CPO = Chest Pain Onset CPR = Cardiopulmonary Resuscitation ECG = Electrocardiogram/Electrocardiography hs-cTn = High-Sensitivity Cardiac Troponin MACE = Major Adverse Cardiovascular Events MI = Myocardial Infarction Time Points and Blood Collection: "0 h" and "1 h" represent the time points for blood collection. Turn-around Time: Turn-around time is the duration from blood draw to reporting results to the clinician. Usually around 1 h using an automated platform in the central laboratory. Includes processes like blood tube transport, probe scanning, centrifugation, analysis, and result reporting to electronic records. Consistency Across Assays: Turn-around time remains the same for hs-cTn and conventional assays on automated platforms. Clinical Decision Time: Adding local turn-around time to blood draw time determines the earliest clinical decision point. For example, at the "0 h" time point, decision time is at 1 h if local turn-around time is 1 h. For blood drawn at "1 h," results arrive at 2 h (1 h + 1 h) with a 1-hour local turn-around time.

19. Acute Cardiac Care In Stable and Unstable ST-segment Elevation MI

20. STEMI Chain of Survival Early Symptom Recognitio n & Call for Help EM S Evaluation & Treatment Emergency Department Evaluatio n & Treatment Reperfusion Therapy Total Ischaemic Time Ibanez B, et al. Eur Heart J. 2018 Jan 7;39(2):119-177.

21. NEW The time point when the patient is either initially assessed by a physician , paramedic, nurse or other trained EMS personnel who can obtain and interpret the ECG, and deliver initial interventions (e.g. defibrillation). FMC can be either in the prehospital setting or upon patient arrival at the hospital (e.g. emergency department). Modes of patient presentation Ibanez B, et al. Eur Heart J. 2018 Jan 7;39(2):119-177. FMC: first Medical Contact EMS: Emergency Medical System PCI: Percutaneous Coronary Intervention

22. Initial diagnosis Ibanez B, et al. Eur Heart J. 2018 Jan 7;39(2):119-177.

23. In some cases the ECG diagnosis may be difficult : bundle branch block Stable STEMI Patients Ibanez B, et al. Eur Heart J. 2018 Jan 7;39(2):119-177. , FMC: first Medical Contact EMS: Emergency Medical System PCI: Percutaneous Coronary Intervention

24. Atypical electrocardiographic presentation Ibanez B, et al. Eur Heart J. 2018 Jan 7;39(2):119-177.

25. Atypical electrocardiographic presentation Ibanez B, et al. Eur Heart J. 2018 Jan 7;39(2):119-177.

26. Atypical electrocardiographic presentation

27. Modes of patient presentation Left and right bundle branch block are considered equal for recommending urgent angiography if ischaemic symptoms . bundle branch block, ventricular pacing, hyper-acute T waves, isolated depression in anterior leads, universal ST depression with elevation in aVR In these cases, and in the presence of symptoms , A primary PCI strategy (urgent angiography and PCI if indicated) should be followed.

28. Summary of indications for imaging and stress testing in ST-elevation myocardial infarction patients

29. www.escardio.org/guidelines 2017 ESC Guidelines for the Management of AMI-STEMI (European Heart Journal 2017 - doi:10.1093/eurheartj/ehx095) Relief of hypoxaemia and symptoms Recommendations Class Level Hypoxia Oxygen is indicated in patients with hypoxaemia (SaO2 <90% or PaO2 <60 mmHg). I C Routine oxygen is not recommended in patients with SaO2 ≥90%. III B Symptoms Titrated i.v. opioids should be considered to relieve pain. IIa C A mild tranquillizer (usually a benzodiazepine) should be considered in very anxious patients. IIa C NEW I  IIa

30. Stable STEMI Patients Modes of patient presentation, components of ischaemia time and flowchart for reperfusion strategy selection

31. FMC : EMS FMC : Non-PCI Center FMC : PCI Center <1 0’ <1 0’ <1 0’ Time t o PCI ≤ 120’ > 120’ Strategy (Wire crossing) Primary PCI <90’ Reperfusion Fibrinolysis <10’ Reperfusion strateg y (Lyti c bolus) Reperfusion (Wire crossing) Primary PCI <60’ Strategy Transfe r to PCI centre FMC: first Medical Contact EMS: Emergency Medical System PCI: Percutaneous Coronary Intervention Patient Delay System Delay Total ischaemic Time Stable STEMI Patients

32. Stable STEMI Patients Strategy Clock Time to PCI? ≤ 120’ > 120’ Alert & transfer to Primary PCI Fibrinolysis PCI Centre Strategy Strategy Reperfusion 1 0’ (Lyti c bolus) Transfe r t o 60-90 PCI centre ’ ≥ Reperfusion 9 0’ (Wir e 120 ’ crossing) Meet reperfusion Rescue PCI No criteria Yes 2hrs. Routine PCI 24hrs. Strategy NEW STEMI diagnosis (defined as the time at which the ECG of a patient with ischaemic symptoms is interpreted as presenting ST-segment elevation or equivalent) is the time zero in the reperfusion strategy clock.

33. (NEW) (NEW)

34. Ic  IIb IIa  IIb

35. NEW

36. NEW NEW NEW! Strategy should be guided as in other STEMI patients (if time from STEMI diagnosis to wire crossing is >120min  immediate fibrinolysis & transfer to PCI center. Urgent angiography upon arrival regardless time from lytics.

37. IIa  IIb IIa  IIb IIb  III

38. www.escardio.org/guidelines 2017 ESC Guidelines for the Management of AMI-STEMI (European Heart Journal 2017 - doi:10.1093/eurheartj/ehx095) Acute Heart Failure and Cardiogenic shock Opiates to relief dyspnea and anxiety IIbB IC Inotropic/vasopresor agents IIbC IIaC Ultrafiltration IIbB IIaB Mechanical support IIbC IIbC IABP IIbB routine Mechanical complications IIIB IIaC

39. www.escardio.org/guidelines 2017 ESC Guidelines for the Management of AMI-STEMI (European Heart Journal 2017 - doi:10.1093/eurheartj/ehx095) Cardiac arrest Recommendations Class Leve l A primary PCI strategy is recommended in patients with resuscitated cardiac arrest and an ECG consistent with STEMI. I B Targeted temperature management is indicated early after resuscitation of cardiac arrest patients who remain unresponsive. I B It is indicated that healthcare systems implement strategies to facilitate transfer of all patients in whom a myocardial infarction is suspected directly to the hospital offering 24/7 PCI-mediated reperfusion therapy via one specialized EMS. I C 22 NEW

40. Cardiac Arrest Patients Recommendations Class a Level b A primar y PC I strateg y i s recommende d i n patient s wit h I B resuscitated cardiac arrest and an ECG consistent with STEMI. Targete d temperatur e managemen t d i s indicate d earl y after I B resuscitation of cardiac arrest patients who remain unresponsive. It is indicated that healthcare In cases systems implement without strategies ST-segment to I elevation C on post- facilitate that all patients resucitation in whom a myocardial ECG infarction but is with a high suspicion of suspected are transferred directly ongoing to the hospital myocardial offering 24/7 ischaemia, urgent reperfusion therapy (preferably angiography primary PCI) via should one specialized be done < 2 hours after a EMS. quick evaluation to exclude non-coronary causes. It is indicated that all medical and paramedical personnel caring I C for suspected myocardial infarction have access to defibrillation equipment and are trained in basic cardiac life support. Urgen t angiograph y (an d PC I i f indicated ) shoul d b e considere d II a C in patients with resuscitated cardiac arrest without diagnostic ST-segment elevation but with a high suspicion of ongoing myocardial ischemia. Prehospital cooling using a rapid infusion of large volumes of cold III B i.v. fluid immediately after return of spontaneous circulation is not recommended. NEW NEW

41. www.escardio.org/guidelines 2017 ESC Guidelines for the Management of AMI-STEMI (European Heart Journal 2017 - doi:10.1093/eurheartj/ehx095) Management of atrial fibrillation Recommendations Class Level Acute rate control of AF Intravenous beta-blockers are indicated for rate control if necessary and there are no clinical signs of acute heart failure or hypotension. I C Intravenous amiodarone is indicated for rate control if necessary in the presence of concomitant acute heart failure and no hypotension. I C Intravenous digitalis should be considered for rate control if necessary in the presence of concomitant acute heart failure and hypotension. Ila B Cardioversion Immediate electrical cardioversion is indicated when adequate rate control cannot be achieved promptly with pharmacological agents in patients with AF and ongoing ischaemia, severe haemodynamic compromise or heart failure. I C A -> C B -> C I -> IIa

42. www.escardio.org/guidelines 2017 ESC Guidelines for the Management of AMI-STEMI (European Heart Journal 2017 - doi:10.1093/eurheartj/ehx095) Management of atrial fibrillation Recommendations Class Level Intravenous amiodarone is indicated to promote electrical cardioversion and/or decrease risk for early recurrence of AF after electrical cardioversion in unstable patients with recent onset AF. I C In patients with documented de novo AF during the acute phase of STEMI, long-term oral anticoagulation should be considered depending on CHA 2 DS 2 -VASc score and taking concomitant antithrombotic therapy into account. IIa C Digoxin is ineffective in converting recent onset AF to sinus rhythm and is not indicated for rhythm control. III A Calcium channel blockers and beta-blockers including sotalol are ineffective in converting recent onset AF to sinus rhythm. III B Prophylactic treatment with antiarrhythmic drugs to prevent AF is not indicated. III B A -> C NEW

43. www.escardio.org/guidelines 2017 ESC Guidelines for the Management of AMI-STEMI (European Heart Journal 2017 - doi:10.1093/eurheartj/ehx095) Recommendations Class Level Intravenous beta-blocker treatment is indicated for patients with polymorphic VT and/or VF unless contra-indicated. I B Prompt and complete revascularization is recommended to treat myocardial ischaemia that may be present in patients with recurrent VT and/or VF. I C Intravenous amiodarone is recommended for treatment of recurrent polymorphic VT. I C Correction of electrolyte imbalances (especially hypokalaemia and hypomagnesemia) is recommended in patients with VT and/or VF. I C Management of ventricular arrhythmias and conduction disturbances in the acute phase

44. www.escardio.org/guidelines 2017 ESC Guidelines for the Management of AMI-STEMI (European Heart Journal 2017 - doi:10.1093/eurheartj/ehx095) Recommendations Class Level In cases of sinus bradycardia with haemodynamic intolerance or high degree AV block without stable escape rhythm: i.v. positive chronotropic medication (epinephrine, vasopressin and/or atropine) is indicated, I C temporary pacing is indicated in cases of failure to respond to positive chronotropic medication, I C urgent angiography with a view to revascularization is indicated if the patient has not received previous reperfusion therapy. I C Management of ventricular arrhythmias and conduction disturbances in the acute phase

45. www.escardio.org/guidelines 2017 ESC Guidelines for the Management of AMI-STEMI (European Heart Journal 2017 - doi:10.1093/eurheartj/ehx095) Recommendations Class Level Intravenous amiodarone should be considered for recurrent VT with haemodynamic intolerance despite repetitive electrical cardioversion. IIa C Transvenous catheter pace termination and/or overdrive pacing should be considered if VT cannot be controlled by repetitive electrical cardioversion. IIa C Radiofrequency catheter ablation at a specialized ablation centre followed by ICD implantation should be considered in patients with recurrent VT, VF, or electrical storm despite complete revascularization and optimal medical therapy. IIa C Management of ventricular arrhythmias and conduction disturbances in the acute phase NEW

46. www.escardio.org/guidelines 2017 ESC Guidelines for the Management of AMI-STEMI (European Heart Journal 2017 - doi:10.1093/eurheartj/ehx095) Recommendations Class Level Recurrent VT with haemodynamic repercussion despite repetitive electrical cardioversion may be treated with lidocaine if beta-blockers, amiodarone, and overdrive stimulation are not effective/applicable. IIb C Prophylactic treatment with antiarrhythmic drugs is not indicated and may be harmful. III B Asymptomatic and haemodynamically irrelevant ventricular arrhythmias should not be treated with antiarrhythmic drugs. III C Management of ventricular arrhythmias and conduction disturbances in the acute phase NEW NEW IIa -> IIb

47. www.escardio.org/guidelines 2017 ESC Guidelines for the Management of AMI-STEMI (European Heart Journal 2017 - doi:10.1093/eurheartj/ehx095) 2017 NEW / REVISED CONCEPTS STRATEGY SELECTION AND TIME DELAYS: Clear definition of first medical contact (FMC). Definition of “time 0” to choose reperfusion strategy (i.e. the strategy clock starts at the time of “STEMI diagnosis”). Selection of PCI over fibrinolysis: when anticipated delay from “STEMI diagnosis” to wire crossing is ≤120 min. Maximum delay time from “STEMI diagnosis” to bolus of fibrinolysis agent is set in 10 min. “Door-to-Balloon” term eliminated from guidelines. ELECTROCARDIOGRAM AT PRESENTATION: Left and right bundle branch block considered equal for recommending urgent angiography if ischaemic symptoms. TIME TO ANGIOGRAPHY AFTER FIBRINOLYSIS: Timeframe is set in 2-24h after successful fibrinolysis. What is new in 2017 Guidelines on AMI-STEMI 30

48. Title and Content Layout with List Add your first bullet point here Add your second bullet point here Add your third bullet point here

49. Title and Content Layout with Chart

50. Two Content Layout with Table First bullet point here Second bullet point here Third bullet point here Class Group A Group B Class 1 82 95 Class 2 76 88 Class 3 84 90

51. Two Content Layout with SmartArt First bullet point here Second bullet point here Third bullet point here

52. Add a Slide Title - 1

53. Add a Slide Title - 2

54. Add a Slide Title - 3

55. Add a Slide Title - 4

56. Add a Slide Title - 5