High Risk Acute Coronary Syndrome Management

Aka: High Risk Acute Coronary Syndrome Management, ST Elevation MI, Q-Wave MI, Myocardial Infarction Protocol

1. See Also
   1. MI Adjunctive Therapy
2. Indications: Myocardial Infarction
   1. ST Elevation 0.1 mV (1 mm) or more in 2 or more contiguous leads or
   2. True posterior Myocardial Infarction (only reason to use reperfusion therapy for ST depression)
3. Indications: Disproven (or in question)
   1. New (or presumed new) Left Bundle Branch Block
      1. No longer considered equivalent to STEMI
      2. Reperfusion therapy for this is in question (although still in the 2010 ACC guidelines)
      3. Consider Sgarbossa Criteria for risk stratification (but low Test Sensitivity)
   2. References
      1. Chang (2009) Am J Emerg Med 27(8): 916-21
      2. Jain (2011) Am J Cardiol 107(8): 1111-6
4. Management: Reperfusion
   1. Time from Chest Pain onset <12 hours
      1. Start MI Adjunctive Therapy (do not delay reperfusion)
      2. Immediate Reperfusion Strategy
         1. Angioplasty with cardiothoracic back-up
            1. Goal within 90 minutes of ED arrival
            2. Preferred over Thrombolysis only if center performs >36 procedures/year
            3. Rescue Angioplasty after failed Thrombolysis
               1. Moderate infarction area and <50% reduction in ST Elevation at 30 minutes
               2. Hemodynamically unstable from ventricular arrhythmia
               3. Cardiogenic Shock or severe Congestive Heart Failure
            4. Example medication protocol for inter-hospital transport to catheter lab (consult local experts)
               1. Clopidogrel (Plavix) 600 mg orally and
               2. Heparin bolus 70 units/kg up to 5000 units (no maintenance as delays transport)
         2. Thrombolytic therapy
            1. Goal within 30 minutes of ED arrival
            2. Indicated if not contraindicated and Angioplasty not available within 90 minutes
         3. Efficacy: Comparing Angioplasty with Thrombolytic
            1. Similar outcomes and complication rates
               1. Mehta (2002) J Am Coll Cardiol 40:1034-40
            2. Angioplasty preferred if transport delay <1 hour
               1. Andersen (2003) N Engl J Med 349:733-42
   2. Time from Chest Pain onset >12 hours
      1. Manage as Myocardial Ischemia Protocol
5. Management: Acute Medications
   1. See Post Myocardial Infarction Medications
   2. Beta Blockers are used selectively only
      1. Exercise caution with Beta Blockers following the acute phase post-STEMI
      2. See Post Myocardial Infarction Medications for contraindications
6. Management: Long-term Medications
   1. See Post Myocardial Infarction Medications
   2. Oral antiplatelet medications are used routinely following ST Elevation MI (especially after stenting)
      1. Clopidogrel (Plavix)
      2. Prasugrel (Effient)
7. Management: Contraindicated Medications
   1. NSAIDS are absolutely contraindicated in acute post-STEMI period
      1. See Post Myocardial Infarction Medications
8. References
   1. (2000) Circulation 102(suppl I):I-172 to I-203
   2. Antman (2008) Circulation 117(2): 296-329