Evidence Based Strategies for

Acute Myocardial Infarction Care

Scott A. Sample DO, FACC
Cardiovascular Interventionist
April 2010
Why a Systems Approach to Acute
Coronary Syndrome Care?
Therapy for ACS has been well studied and validated.
Standardized protocols for treatment are evidence based
and readily available.
A systems approach results in improved adherence to
evidence based treatment strategies. These strategies
improve patient outcomes and survival.
A systems approach provides a scaffold for program
development and real time feedback measurements that
can be used to improve care.
A systems approach encourages providers across the
entire continuum of care to place focus on the patient.
Evidence Based Strategies for
Acute Myocardial Infarction Care
Pre-hospital Care/Diagnosing Acute Coronary Syndromes

Acute Myocardial Infarction in the rural hospital setting
STEMI Treatment/Transfer
Thrombolytics/Anticoagulants/Beta Blockers

Unstable Angina/Non-STEMI
Risk Scoring/Management/
Transfer Considerations

American College of Cardiology Website
ACC/AHA STEMI and non-STEMI guidelines

Pre-Hospital Care
Patients with chest pain suspicious for acute
coronary syndromes should undergo the
following:
Activation of EMS LOE* B
Aspirin 162-325mg chewed and swallowed (Unless
already self administered by patient) LOE A
12 Lead EKG, if available in the field LOE B
Rapid stabilization and transfer to Emergency
Department (Unless care pathways for Acute MI PCI
direct to the catheterization laboratory are in place)
LOE A
* LOE = Level of Evidence
ACS Recognition
Upon arrival to the Emergency Department, 12
lead EKG (10 minutes) LOE B
Initiate continuous EKG monitoring, oximetry,
and frequent vital sign monitoring LOE B
Establish IV access with two large bore
peripheral IVs
Once ACS is suspected/established, initiate
aspirin, oxygen, nitrates and morphine
ACS Risk Stratification
Obtain baseline laboratory markers
including a CBC, Metabolic Panel and
Cardiac Markers
If the initial EKG is nondiagnostic, repeat
every 15-30 minutes
Assess cardiac risk factors
Assessment of Risk
Identify chest pain into 4 groups
Non-cardiac Pain
Stable Angina
Possible Acute Coronary Syndrome
Definite Acute Coronary Syndrome
Evidence Based Strategies for
Acute Myocardial Infarction Care
Pre-hospital Care/Diagnosing Acute Coronary Syndromes

Acute Myocardial Infarction in the rural hospital setting
STEMI Treatment/Transfer
Thrombolytics/Anticoagulants/Beta Blockers

Unstable Angina/Non-STEMI
Risk Scoring/Management/
Transfer Considerations

American College of Cardiology Website
ACC/AHA STEMI and non-STEMI guidelines

Approach For Acute Coronary
Syndrome for Critical Access
Hospitals: STEMI
Patient presents with
Ischemic Chest Pain
Early EKG
STEMI ACS/NONSTEMI
Transfer to PCI Capable Hospital
If time to PCI is <90 minutes
Initiate Thrombolytic Therapy
Transfer to PCI Capable Hospital
After Thrombolytics are Initiated
Thrombolytic Therapy Indications
Presentation consistent with signs and
symptoms of AMI
Time of symptom onset 12 hours or less
ST elevation > 1mm in 2 or more
contiguous leads
New Left Bundle Branch Block
True Posterior Wall MI

Contraindications to Thrombolytics
Known prior hemorrhagic CVA
IC trauma
Active internal bleeding
Suspected aortic dissection
Cautions to Thrombolytics
Persistent BP 180/110mmHG
Prior cerebrovascular
accident/intracerebral pathology
Current use of anticoagulants in
therapeutic doses
Trauma or surgery within 2 weeks
Noncompressible vascular punctures
Recent (within 2-4 weeks) internal
bleeding
Pregnancy
Active peptic ulcer disease
History of chronic severe hypertension
Cautions to Thrombolytics cont.
Thrombolytic Agents
Alteplase
15mg bolus
Then 0.75mg/kg IV drip over 30 minutes (not
to exceed 50mg)
Then 0.5mg/kg over next 60 minutes (not to
exceed 35mg)
Maximum dose 100mg
This agent requires concurrent administration
of heparin or alternative agent
Thrombolytic Agents
Reteplase
First bolus 10U over 2 minutes
30 minutes later, second bolus 10U over 2
minutes
Heparin (or alternative agent) and aspirin
required adjuncts
Thrombolytic Agents
Tenecteplase
30-50mg weight adjusted IV bolus; see
package insert for dosing scale
Heparin (or alternative agent) and aspirin are
required adjuncts
STEMI Unfractionated Heparin
Adjunctive Therapy
Initial bolus 60 IU/kg, Maximum 4,000 IU
12 IU/kg/hr drip, Maximum 1,000 IU/hr
Monitor PTT, Hemoglobin, Hematocrit and
Platelet count per institutional protocol
STEMI Low Molecular Weight
Heparin Adjunctive Therapy
Enoxaparin
Age <75 with normal creatinine clearance:
bolus 30mg IV; 15 minutes later, 1mg/kg SQ
every 12 hours
Age >75 no IV bolus; 0.75mg/kg SQ every 12
hours
Creatinine Clearance <30mL/min, regardless
of age, 1mg/kg SQ every 24 hours
Monitor Hemoglobin, Hematocrit and Platelets
STEMI Fondaparinux Adjunctive
Therapy
Initial Dose 2.5mg/kg IV
Subsequent dose 2.5mg/kg SQ every 24
hours for up to 8 days
Do not use in patients with creatinine
clearance of less than 30mL/min
Do not use as monotherapy in patients
undergoing PCI
STEMI Beta Blocker Use
Class Ib
Oral beta blocker (ie metoprolol 25 mg po) unless
contraindicated by the following
Acute heart failure
Low cardiac output state
Increased risk of cardiogenic shock
PR interval >0.24 seconds, second degree or third degree
heart block
Class II
IV beta blocker for hypertensive patients that do not
have the above exclusion criteria

Additional Therapeutics
Aspirin 162-325mg, if not already given
Nitrates, preferably IV
Antiarrhythmics, if indicated
Transport with defibrillator patches
attached, if possible
Clopidogrel can be given with high level of
evidence to support use; however, if
surgical disease is present, surgery will be
delayed
Transfer Considerations
Establish contact with accepting hospital
Accepting Physician
Administrative Acceptance
Establish safest method of transfer
Arrange for copies of transfer documents
Copies of all pertinent clinical material

Evidence Based Strategies for
Acute Myocardial Infarction Care
Pre-hospital Care/Diagnosing Acute Coronary Syndromes

Acute Myocardial Infarction in the rural hospital setting
STEMI Treatment/Transfer
Thrombolytics/Anticoagulants/Beta Blockers

Unstable Angina/Non-STEMI
Risk Scoring/ Management/
Transfer Considerations

American College of Cardiology Website
ACC/AHA STEMI and non-STEMI guidelines

Approach For Acute Coronary
Syndrome for Critical Access
Hospitals: ACS/Non-STEMI
Patient presents with
Ischemic Chest Pain
Early EKG
STEMI ACS/NONSTEMI
Transfer to PCI Capable Hospital
If time to PCI is <90 minutes
Initiate Thrombolytic Therapy
Transfer to PCI Capable Hospital
After Thrombolytics are Initiated
NONSTEMI Care for Critical
Access Hospitals
NONSTEMI by EKG
Low Risk Features High Risk Features
Conservative Treatment
If Risk Stratification Is Suggestive
Of Higher Risk, Transfer to PCI Site
Initiate Early Transfer
To PCI Capable Site
Risk Stratification
Assessment of risk with readily available clinical and
demographic features of patients has been validated.
One such tool is the Thrombolysis in Myocardial
Infarction (TIMI) risk score.
The score is based on 7 features of patients with
suspected ACS.
Positive answers to the risk elements result in 1 point per
element. The maximum score is 7.
The higher the score, the greater the risk of mortality for
the patient. Use of this score may aid in determining
therapy for the patient as well as determining which
patients may benefit from elevation of care and early
transfer.
TIMI Risk Score for UA/NSTEMI
Historical Points

Age > 65 yrs 1
> 3 CAD Risk Factors 1
Known CAD ( > 50% Stenosis) 1
ASA use in past 7 days 1

Presentation

Recent ( < 24H) severe angina 1
Elevated Cardiac Markers 1
ST deviation > 0.5mm 1



Risk Score = total points (0-7)
TIMI Score Risk of mortality/
recurrent ischemic event


0-1 4.7%

2 8.3%

3 13.2%

4 19.9%

5 26.2%

6-7 40.9%

Antman et al J AMA 2000
www.timi.org
low (0-2; 5-8% risk)
intermediate (3-4; 13-20% risk)
high (5-7; 26-41% risk)
Further Assessment
Admit for observation
Check serial enzymes
Continuous EKG monitoring
For high risk patients with multiple cardiac
risk factors, consider early transfer to PCI
capable hospitals
Optimal Medical Management
Vasodilators
Anti-Platelet therapy
Anti-Thrombotic therapy
Anti-Ischemic agents
Lipid Lowering therapy
General Medical therapy


Vasodilators
Nitroglycerin
Sublingual Initially
Intravenous
Transdermal
Anti-Platelet Agents
Aspirin 162-325mg daily
Clopidogrel 75mg daily (loading dose of
150-300mg)
Ticlopidine 250mg twice daily (loading
dose of 500mg)
IIb/IIIa glycoprotein inhibitors bolus and
continuous infusion per protocol driven
dosing schedules
IIb/IIIa Glycoprotein Inhibitors
Abciximab (Reopro) indicated in patients
anticipated to go to the catheterization
laboratory within 12 hours. Bolus and drip
Integrilin indicated in patients anticipated
to go to the catheterization laboratory or
for patients treated with medical
management for up to 72 hours. Bolus and
drip
Anti-Thrombotic Therapy
Unfractionated Heparin
Low Molecular Weight Heparin
Fondaparinux
Lepirudin

NONSTEMI Beta Blocker
Class I
Oral beta blocker therapy is indicated in all
patients recovering from NONSTEMI unless
contraindicated by other medical condition
indefinitely
Recovering NONSTEMI patients with
moderate to severely depressed left
ventricular systolic function should be treated
with beta blockers with a careful dose titration
strategy.

Lipid Lowering Therapy
Early initiation of statin type lipid lowering
agents has been shown to be beneficial in
the treatment of acute coronary
syndromes
The most studied agents include
pravastatin, simvastatin and atorvastatin

General Medical Management
Oxygen therapy
Analgesics
Stool softeners
Antacids
Other medical therapies for co-morbid
conditions
Risk Stratification
Recommendations
1. Noninvasive stress testing is recommended in low and intermediate-risk
patients who have been free of ischemia at rest or with low-level activity and of
heart failure for a minimum of 12 to 24 h.
2. Choice of stress test is based on the resting EKG, ability to perform exercise,
local expertise, and technologies available. Treadmill exercise is useful in
patients able to exercise in whom the EKG is free of baseline ST-segment
abnormalities, bundle-branch block, left ventricular (LV) hypertrophy,
intraventricular conduction defect, paced rhythm, preexcitation, and digoxin
effect.
3. An imaging modality should be added in patients with resting ST-segment
depression (greater than or equal to 0.10 mV). LV hypertrophy, bundle-branch
block, intraventricular conduction defect, preexcitation, or digoxin who are able
to exercise. In patients undergoing a low-level exercise test, an imaging
modality can add sensitivity.
4. Pharmacological stress testing with imaging is recommended when physical
limitations (e.g., arthritis, amputation, severe peripheral vascular disease,
severe chronic obstructive pulmonary disease).
Transfer Considerations
Establish contact with accepting hospital
Accepting Physician
Administrative Acceptance
Establish safest method of transfer
Arrange for copies of transfer documents
Copies of all pertinent clinical material

Summary:
Evidence Based Strategies for
Acute Myocardial Infarction Care
Pre-hospital Care/Diagnosing Acute Coronary Syndromes

Acute Myocardial Infarction in the rural hospital setting
STEMI Treatment/Transfer
Thrombolytics/Anticoagulants/Beta Blockers

Unstable Angina/Non-STEMI
Risk Scoring/Management/
Transfer Considerations

American College of Cardiology Website
ACC/AHA STEMI and non-STEMI guidelines