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A 63-yo non-English-speaking woman comes to the ED b/c of severe, steady precordial discomfort that began 14 hours ago.

She thought that the CP may have been indigestion, but she had no relief with an antacid. She has a h/o HTN. She is taking no medication. Her HR is 92/min, and her BP is 150/90. Her chest and cardiac exam is normal. Her EKG shows 3-mm STE in V2-V6. She is given a chewable ASA, morphine 4mg IV, metoprolol 5mg IV, and NTG 20mcg/min IV w/ a decrease in her CP intensity from severe to moderate. A hospital in the next county (1.5h away by ambulance) recently established a program that provides 24h angioplasty services.

Which of the following should be considered in the decision of whether to refer this patient for treatment?
A) Angioplasty (with or without stenting) has a better outcome than thrombolysis in this patient B) Thrombolysis has a better outcome than angioplasty (with or without stenting) in this patient C) Thrombolysis and angioplasty (with or without stenting) are equivalent in outcome for this patient D) Neither thrombolysis nor angioplasty (with or without stenting) should be performed in this patient

74yo female is admitted w/ 3h of crushing substernal CP. She has a h/o L carotid occlusion w/ hemiparesis occurring 3 months ago. She also has a h/o mild HTN, hyperlipidemia, and DM complicated by neuropathy and retinopathy. Her meds include coumadin, atenolol, and pravastatin. In the ED, she has a Vfib arrest and is successfully converted to NSR after receiving 2 min of CPR. Her EKG shows SR w/ 3-mm STE in V2-V6. The results of initial laboratory tests are within normal limits, except for an elevated PT w/ and INR of 1.8.

Which of the following represent an absolute contraindication to the use of a thrombolytic agent in this patient?

A) L carotid occlusion w/ hemiparesis 3 months ago B) CPR for 2 minutes C) Patient age>70 years D) Patient on coumadin with an INR of 1.8 E) Diabetic retinopathy

Fibrinolytic Therapy in STEMI


June 6, 2007

90% of patients w/ acute STEMI have complete occlusion of culprit artery PCI preferred if performed w/in 90 minutes of presentation or if transfer to neighboring institution for PCI can occur w/in 30-60 min. Thombolytic therapy is the alternative treatment Not as effective in non-STEMI as the infarctrelated artery is not totally occluded in 60-85% of cases

EFFICACY
Benefit first demonstrated w/ streptokinase (GISSI-2 and ISIS-2 trials). ISIS-2 showed combination of ASA and streptokinase reduced mortality from 10.2% (placebo) to 7.2%. GUSTO-I: alteplase superior to streptokinase (although more expensive) ASSENT-2 and GUSTO-III: newer agents like tenecteplase, reteplase, lanoteplase as effective as alteplase but have significantly lower incidence of noncerebral bleeding complications and need for transfusion.

Time to presentation
Survival benefit greatest when lytics administered within first 4 hours after onset of symptoms, particularly within the first 70 minutes. Mortality benefit less likely at 13-18 hours. There MAY be benefit in patients presenting >12hours if patient has on-going stuttering chest pain. AHA recommendations (2004): administer lytics if no contraindications w/in 12 hr of symptom onset; reasonable to administer at 12-24 hr if continuing symptoms or persistent ST elevation on EKG.

Long-term survival
Long-term benefit primarily seen in patients who achieved TIMI 3 flow w/ lytic administration. Vessel opening (TIMI 2 or 3) reported in 60-87% of patients receiving lytics, but normalization (TIMI 3) in only 50-60% of arteries. Only TIMI 3 flow associated w/ improved LV function and survival.
***Note: TIMI 3 flow is achieved in ~90% of patients treated with primary PCI.

Other prognostic indicatorspositive predictors of one-year mortality


Demographics: older age (>55), lower weight (<80kg), previous MI, previous CABG Larger infarctions, anterior wall infarct, hypotension, tachycardia (>115), longer QRS (>125), lower EF/heart failure, cardiogenic shock Presence of cardiac risk factors such as smoking, HTN, prior CVA

CONTRAINDICATIONS It is estimated that 20-30% of patients ineligible for thrombolytic therapy


This is what we missed on the in-service!!

ABSOLUTE contraindications
Previous ICH Known structural cerebral vascular lesion Known malignant intracranial neoplasm Ischemic CVA within 3 months prior Suspected aortic dissection Active bleeding or bleeding diathesis Significant closed-head or facial trauma within 3 months prior
ADVANCED AGE IS NOT A MAJOR CONTRAINDICATION FOR THROMBOLYTICS!
although pts >75y/o may get less overall benefit.

RELATIVE contraindications
Poorly controlled or chronic sustained HTN Ischemic CVA >3 months prior Dementia Traumatic or prolonged CPR or major surgery within <3 wk prior Recent (within 2-4 wk) internal bleeding Noncompressible vascular puncture Allergy to lytic agents Pregnancy Active peptic ulcer Current use of anti-coagulants

Adjunctive anti-coagulation
Thrombin inhibition enhances coronary thrombolysis and limits reocclusion; therefore anti-coagulation is administered to most patients receiving lytics. Alteplase, reteplase, tenecteplase: UFH at 60units/kg bolus followed by 12u/kg/hr gtt; maintain PTT b/w 50-70 sec for 48hr. LMWH also effective w/ tenecteplase, although dont use it in pts>75 y/o (increased risk of ICH) or those w/ Cr>2.5 in men or Cr>2.0 in women. ? benefit of UFH or LMWH in streptokinase, anistreplase, urokinase.

Plavix
CLARITY-TIMI 28 and COMMIT/CCS-2 demonstrated improved outcomes when plavix given before thrombolytic therapy. 300mg loading dose followed by 75mg daily In patients>75, risk of ICH not clear with 300mg loading dose vs 75mg loading dose

GP IIb/IIIa inhibitors
Two large trials failed to shows survival benefit with combination therapy (GP IIb/IIIa with thrombolytics) compared to conventional thrombolytic therapy, and bleeding was increased. DO NOT administer concurrent GP IIb/IIIa inhibitors with thrombolytics!

Assessment of response
Relief of symptoms Maintenance or restoration of hemodynamic and/or electrical stability Reduction of at least 50% of initial ST segment injury pattern on a follow-up EKG 60-90 min after initiation of therapy Serial measurements of cardiac biomarkers

PCI after thrombolytics???


This issue remains unresolved 3 possible scenarios *Facilitated PCIlytic drug given prior to planned PCI in attempt to achieve an open infarct-related artery before arrival of cath lab *Adjunctive PCIPCI performed within hours after thrombolysis *Early elective PCIPCI performed within a few days after thrombolysis

A 63-yo non-English-speaking woman comes to the ED b/c of severe, steady precordial discomfort that began 14 hours ago. She thought that the CP may have been indigestion, but she had no relief with an antacid. She has a h/o HTN. She is taking no medication. Her HR is 92/min, and her BP is 150/90. Her chest and cardiac exam is normal. Her EKG shows 3-mm STE in V2-V6. She is given a chewable ASA, morphine 4mg IV, metoprolol 5mg IV, and NTG 20mcg/min IV w/ a decrease in her CP intensity from severe to moderate. A hospital in the next county (1.5h away by ambulance) recently established a program that provides 24h angioplasty services.

Which of the following should be considered in the decision of whether to refer this patient for treatment?
A) Angioplasty (with or without stenting) has a better outcome than thrombolysis in this patient B) Thrombolysis has a better outcome than angioplasty (with or without stenting) in this patient C) Thrombolysis and angioplasty (with or without stenting) are equivalent in outcome for this patient D) Neither thrombolysis nor angioplasty (with or without stenting) should be performed in this patient

Which of the following should be considered in the decision of whether to refer this patient for treatment? A) Angioplasty (with or without stenting) has a better outcome than thrombolysis in this patient

74yo female is admitted w/ 3h of crushing substernal CP. She has a h/o L carotid occlusion w/ hemiparesis occurring 3 months ago. She also has a h/o mild HTN, hyperlipidemia, and DM complicated by neuropathy and retinopathy. Her meds include coumadin, atenolol, and pravastatin. In the ED, she has a Vfib arrest and is successfully converted to NSR after receiving 2 min of CPR. Her EKG shows SR w/ 3-mm STE in V2-V6. The results of initial laboratory tests are within normal limits, except for an elevated PT w/ and INR of 1.8.

Which of the following represent an absolute contraindication to the use of a thrombolytic agent in this patient?

A) L carotid occlusion w/ hemiparesis 3 months ago B) CPR for 2 minutes C) Patient age>70 years D) Patient on coumadin with an INR of 1.8 E) Diabetic retinopathy

Which of the following represent an absolute contraindication to the use of a thrombolytic agent in this patient?

A) L carotid occlusion w/ hemiparesis 3 months ago