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ACC/AHA 2007 STEMI Guidelines

Focused Update Slide Set

Based on the 2007 Focused Update of the


ACC/AHA Guidelines for the Management of
Patients With ST-Elevation Myocardial
Infarction (STEMI): A Report of the ACC/AHA
Task Force on Practice Guidelines

ACC/AHA 2007 STEMI Guidelines Focused Update

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ACC/AHA 2007 STEMI Guidelines Focused Update
ACC/AHA 2007 STEMI Guidelines Focused Update
ACC/AHA 2007 STEMI Guidelines Focused Update
Ischemic Discomfort

Acute Coronary
Presentation Syndrome

Working Dx

ECG No ST Elevation ST
Elevation
Non-ST ACS
Cardiac
Biomarker UA NSTEMI

Unstable Myocardial Infarction


Final Dx
Angina NQMI Qw MI
Libby P. Circulation 2001;104:365, Hamm CW, Bertrand M, Braunwald E, Lancet 2001; 358:1533-1538; Davies MJ. Heart 2000; 83:361-366.
Anderson JL, et al. J Am Coll Cardiol. 2007;50:e1-e157, Figure 1. Reprinted with permission. ACC/AHA 2007 STEMI Guidelines Focused Update

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Hospitalizations in the U.S. Due to Acute
Coronary Syndromes (ACS)

Acute Coronary
Syndromes*

1.57 Million Hospital Admissions - ACS

UA/NSTEMI† STEMI

1.24 million .33 million


Admissions per year Admissions per year

Heart Disease and Stroke Statistics – 2007 Update. Circulation 2007;


115:69-171. *Primary and secondary diagnoses. †About 0.57 million
NSTEMI and 0.67 million UA. ACC/AHA 2007 STEMI Guidelines Focused Update

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Analgesia

ACC/AHA 2007 STEMI Guidelines Focused Update

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Analgesia

• Morphine remains Class I for STEMI


although may increase adverse events
in UA/NSTEMI
• NSAID medications increase mortality,
reinfarction, and heart failure in
proportion to degree of COX-2
selectivity
– Discontinue on admission for STEMI
– Do not initiate during acute phase of
management
ACC/AHA 2007 STEMI Guidelines Focused Update

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Beta-Blockers

ACC/AHA 2007 STEMI Guidelines Focused Update

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COMMIT: Study design

TREATMENT: Metoprolol 15 mg iv over 15 mins, then 200


mg oral daily vs matching placebo

INCLUSION: Suspected acute MI (ST change or LBBB)


within 24 h of symptom onset
EXCLUSION: Shock, systolic BP <100 mmHg, heart rate
<50/min or II/III AV block
1° OUTCOMES: Death & death, re-MI or VF/arrest up to 4
weeks in hospital (or prior discharge)
Mean treatment and follow-up: 16 days

ACC/AHA 2007 STEMI Guidelines Focused Update

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Effects of Metoprolol
COMMIT (N = 45,852) Totality of Evidence (N = 52,411)

Death
13%
P=0.0006

ReMI
Increased
22%
early risk of
P=0.0002
shock

VF
15%
P=0.002

Risk factors for cardiogenic shock :heart failure, age > 70 , systolic blood Lancet. 2005;366:1622.
pressure < 120, sinus tachycardia > 110 or heart rate < 60, increased time ACC/AHA 2007 STEMI Guidelines Focused Update
since onset of STEMI symptoms
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Beta-Blockers
I IIa IIb III Oral beta-blocker therapy should be initiated in the
first 24 hours 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 to beta blockade (PR interval >
0.24 sec, 2nd - or 3rd -degree heart block, active
asthma, or reactive airway disease).

ACC/AHA 2007 STEMI Guidelines Focused Update

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Primary PCI

ACC/AHA 2007 STEMI Guidelines Focused Update

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Options for Transport of Patients With
STEMI and Initial Reperfusion Treatment
Hospital fibrinolysis:
Door-to-Needle
within 30 min.
Not PCI
capable

Onset of 9-1-1 EMS on-scene EMS Inter-


symptoms of EMS • Encourage 12-lead ECGs. Triage Hospital
STEMI Dispatch • Consider prehospital fibrinolytic if Plan Transfer
capable and EMS-to-needle within
30 min.
PCI
capable
GOALS
5 8
min. EMS Transport
min.
Patient EMS Prehospital fibrinolysis EMS transport
EMS-to-needle EMS-to-balloon within 90 min.
within 30 min. Patient self-transport
Dispatch Hospital door-to-balloon
1 min. within 90 min.

Golden Hour = first 60 min. Total ischemic time: within 120 min.
Antman EM, et al. J Am Coll Cardiol 2008. Published ahead of print on December 10, 2007. Available at
http://content.onlinejacc.org/cgi/content/full/j.jacc.2007.10.001. Figure 1. ACC/AHA 2007 STEMI Guidelines Focused Update

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Facilitated PCI

ACC/AHA 2007 STEMI Guidelines Focused Update

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Facilitated PCI
A planned reperfusion strategy using full-dose
fibrinolytic therapy followed by immediate PCI
is not recommended and may be harmful.

Facilitated PCI using regimens other than full-


dose fibrinolytic therapy might be considered
as a reperfusion strategy when all of the
following are present:
a. Patients are at high risk,
b. PCI is not immediately available within 90
minutes, and
c. Bleeding risk is low (younger age, absence of
poorly controlled hypertension, normal body
weight). ACC/AHA 2007 STEMI Guidelines Focused Update

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Rescue and Late PCI

ACC/AHA 2007 STEMI Guidelines Focused Update

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Rescue PCI
A strategy of coronary angiography with
intent to
perform PCI (or emergency CABG) is
recommended in patients who have received
fibrinolytic therapy and have:

a. Cardiogenic shock in patients < 75 years


who are suitable candidates for
revascularization

b. Severe congestive heart failure and/or


pulmonary edema (Killip class III)

c. Hemodynamically compromising
ACC/AHA 2007 STEMI Guidelines Focused Update

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Anticoagulants

ACC/AHA 2007 STEMI Guidelines Focused Update

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Anticoagulants
Patients undergoing reperfusion with
fibrinolytics should receive anticoagulant
therapy for a minimum of 48 hours (Level of
Evidence: C) and preferably for the duration of
the index hospitalization, up to 8 days. (Level
of Evidence: A)

Anticoagulant regimens with established


efficacy include:
♥ UFH (LOE: C)
♥ Enoxaparin (LOE:A)
♥ Fondaparinux (LOE:B)

ACC/AHA 2007 STEMI Guidelines Focused Update

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Unfractionated Heparin

Advantages Disadvantages
 Immediate  Indirect thrombin
anticoagulation inhibitor so does not
inhibit clot-bound
 Multiple sites of action thrombin
in coagulation cascade  Nonspecific binding to:
― Serine proteases
 Long history of
― Endothelial cells
successful clinical use
(can lead to variability
 Readily monitored by in level of
aPTT and ACT anticoagulation)

 Reduced effect in ACS


― Inhibited by PF-4
 Causes platelet
aggregation

 Nonlinear
Hirsh J, et al. Circulation. 2001;103:2994-3018. aPTT = activated partial thromboplastin time; ACT = activated coagulation time; PF-4 =
platelet factor 4; HIT = heparin-induced thrombocytopenia. ACC/AHA 2007 STEMI Guidelines Focused Update
pharmacokinetics
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ExTRACT-TIMI 25: Primary End Point (ITT)
Death or Nonfatal MI
15

UFH
Primary End Point

12 12.0
17% RRR
%
9.9%
9
Enoxaparin
(%)

6
Relative Risk
0.83 (95% CI, 0.77 to
0.90)
3 P<.001

Lost to follow-up = 3
0
0 5 10 15 20 25 30
Days after
Randomization
Adapted with permission from Antman EM, et al. N Engl J Med. 2006;354:1477-1488. ACC/AHA 2007 STEMI Guidelines Focused Update

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Low-Molecular-Weight Heparin
Advantages Disadvantages
 Increased anti-Xa to anti-IIa  Indirect thrombin inhibitor
activity → inhibits thrombin  Less reversible
generation more effectively  Difficult to monitor
 Induces ↑ release of TFPI vs (no aPTT or ACT)
UFH  Renally cleared
 Not neutralized by platelet
 Long half-life
factor 4
 Risk of HIT
 Less binding to plasma
proteins (eg, acute-phase
reactant proteins) → more
consistent anticoagulation
 Lower rate of HIT vs UFH
 Lower fibrinogen levels
 Easy to administer (SC
administration)
 Long history of clinical
studies and experience, FDA-
Hirsh J, et approved indications
al. Circulation. 2001;103:2994-3018. TFPI = tissue factor pathway inhibitor; UFH = unfractionated heparin;
SC = subcutaneous; aPTT
 Monitoring typically = activated partial thromboplastin time;
ACT = activated coagulation time. ACC/AHA 2007 STEMI Guidelines Focused Update
unnecessary 23
Thienopyridines

ACC/AHA 2007 STEMI Guidelines Focused Update

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CLARITY-TIMI 28 Primary Endpoint:
Occluded Artery (or D/MI thru Angio/HD)

Odds
Odds Ratio
Ratio 0.64
0.64
Occluded Artery or Death/MI (%)

25 36%
36% 21.7
Odds
Odds (95%
(95% CI
CI 0.53-0.76)
0.53-0.76)
Reduction
Reduction
20
P=0.00000036
15.0
15

10

n=1752 n=1739 0.4 0.6 0.8 1.0 1.2 1.6


0
Clopidogrel Placebo
Clopidogrel Placebo better better
LD 300 mg Sabatine N Eng J Med 2005;352:1179.
MD 75 mg STEMI, Age 18-75ACC/AHA 2007 STEMI Guidelines Focused Update
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COMMIT: Effect of CLOPIDOGREL on
Death In Hospital
Placebo + ASA:
1,846 deaths (8.1%)
Clopidogrel + ASA:
1,728 deaths (7.5%)
0.6% ARD
7% RRR
Dead
(%)

P = 0.03

N = 45,852
No Age limit ; 26% > 70 y
Lytic Rx 50%
No LD given

Chen ZM, et al. Lancet. 2005;366:1607.

Days Since Randomization (up to 28 days) ACC/AHA 2007 STEMI Guidelines Focused Update

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Thienopyridines

Clopidogrel 75 mg per day orally should be


added to aspirin in patients with STEMI
regardless of whether they undergo
reperfusion with fibrinolytic therapy or do
not receive reperfusion therapy.

ACC/AHA 2007 STEMI Guidelines Focused Update

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Secondary Prevention and
Long-Term Management

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Secondary Prevention

• Ask, advise, assess, and assist patients to


stop smoking – I (B)
• Clopidogrel 75 mg daily:
– PCI – I (B)
– no PCI – IIa (C)
• Statin goal:
– LDL-C < 100 mg/dL – I (A)
– consider LDL-C < 70 mg/dL – IIa (A)
• Daily physical activity 30 min 7 d/wk,
minimum 5 d/wk – I (B)
• Annual influenza immunization – I (B)

ACC/AHA 2007 STEMI Guidelines Focused Update

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Secondary Prevention and Long Term Management

Goals Class
• Status I Recommendations
of tobacco use should be asked at
every visit.
Smoking
• Every tobacco user and family member
2007 Goal:
who smoke should be advised to quit at
Complete
every visit.
cessation.
• The tobacco user’s willingness to quit
No exposure to
should be assessed.
environmental NEW
• The tobacco user should be assisted by
tobacco smoke.
counseling and developing a plan for
quitting.
• Follow-up, referral to special programs,
or pharmacotherapy (including nicotine
replacement and pharmacological rx)
should be arranged.
• Exposure to environmental tobacco NEW
smoke at home and work should beFocused Update
ACC/AHA 2007 STEMI Guidelines

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Secondary Prevention and Long Term Management
Goals Class I Recommendations
If blood pressure is ≥ 140/90 mm Hg or
Blood ≥ 130/80 mm Hg for patients with
pressure chronic kidney disease or diabetes:
control:
2007 Goal: • It is recommended to initiate or maintain
< 140/90 mm lifestyle modification (weight control, ↑
Hg or <130/80 physical activity, alcohol moderation, sodium
mm Hg if ↓, and emphasis on ↑ consumption of fresh
chronic kidney
fruits, vegetables, and low-fat dairy
disease or
diabetes products). CHANGED
TEXT
• It is useful as tolerated, to add blood
pressure medication, treating initially with
beta-blockers and/or ACE inhibitors, with the
addition of other drugs such as thiazides as
needed to achieve goal ACC/AHA
BP. 2007 STEMI Guidelines Focused Update
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Secondary Prevention and Long Term Management

Goals Class I Recommendations


• Starting dietary therapy in all patients is
Lipid recommended. ↓ intake of sat. fats (< 7% of
management: total calories), trans fatty acids and cholesterol
2007 goal: (< 200 mg/d).
LDL-C << than
100 mg/dL (if • Adding plant stanol/sterols (2 g/d) and/or
TG ≥ 200 viscous fiber (> 10 g/d) is reasonable to further
mg/dL, non– lower LDL-C. (Class IIa; LOE:A)
NEW
HDL-C < 130
• Promotion of daily physical activity and weight
mg/dL
management is recommended.

• It may be reasonable to encourage ↑


consumption of omega-3 fatty acids in the form
of fish or in capsule form (1 g/d) for risk
reduction. For treatment of elevated TG, higher
doses are usually necessary for risk reduction.
(Class IIb; LOE: B) ACC/AHA 2007 STEMI Guidelines Focused Update

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Secondary Prevention and Long Term Management

Goals Class I Recommendations


• A fasting lipid profile should be assessed in all
Lipid patients and within 24 hours of hospitalization for
management: those with an acute cardiovascular or coronary
2007 goal: event. For hospitalized patients, initiation of lipid-
LDL-C << than lowering medication is indicated as recommended
100 mg/dL (if below before discharge according to the following
schedule:
TG ≥ 200
mg/dL, non– • LDL-C should be < 100 mg/dL.
HDL-C < 130 • Further reduction to < 70 mg /dL is reasonable.
mg/dL (Class IIa; LOE:
NEWA)
• If baseline LDL-C is ≥ 100 mg/dL, LDL-lowering
drug rx should be initiated.
• If on-treatment LDL-C is ≥ 100 mg/dL
intensify LDL-lowering drug rx (may require LDL-
lowering combination is recommended.
• If baseline LDL-C is 70 to 100 mg/dL, it is
reasonable to treat to LDL-C < 70 mg/dL. (Class
IIa; LOE: B) NEW ACC/AHA 2007 STEMI Guidelines Focused Update

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Secondary Prevention and Long Term Management
Goals Class I Recommendations
If TG are ≥ 150 mg per dL or HDL-C < 40 mg per dL,
Lipid weight management, physical activity, and smoking cessation
should be emphasized.
managemen
t: If TGs are 200 to 499 mg per dL, non–HDL-C target should be
(TG 200 less than 130 mg per dL.
mg/dL or If TGs are 200 to 499 mg/dL, non–HDL-C target is < 130
greater) mg/dL. (Class I; LOE: B); further reduction of non–HDL-C to <
Primary goal: 100 mg dL is reasonable. (Class IIa; LOE: B)
Non–HDL-C < Therapeutic options to reduce non–HDL-C include:
130 mg/dL •More intense LDL-C-lowering rx is indicated NEW
•Niacin (after LDL-C-lowering rx) can be beneficial (Class IIa;
LOE B)
•Fibrate therapy (after LDL-C-lowering rx) can be beneficial
(Class IIa; LOE B)

If TG are ≥ 500 mg/dL, therapeutic options indicated


and useful to prevent pancreatitis are fibrate or niacin
before LDL-lowering rx; and treat LDL-C to goal after TG-
lowering rx. Achieving non–HDL-C < 130 mg/dL is
recommended. ACC/AHA 2007 STEMI Guidelines Focused Update

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Secondary Prevention and Long Term Management

Goals Class I Recommendations


• For all patients, it is recommended that risk be
Physical assessed with a physical activity history and/or an
activity: exercise test to guide prescription.
2007 Goal:
30 min 7 d per • For all patients, encouraging 30 to 60 min of
wk; minimum moderate-intensity aerobic activity, such as brisk
5 d per wk walking, on most, preferably all, days of the week,
supplemented by an increase in daily lifestyle
activities (e.g., walking breaks at work, gardening,
household work).

• Advising medical supervised programs (cardiac


rehabilitation) for high-risk patients (e.g., recent
acute coronary syndrome or revascularization, HF)
is recommended.

NEW • Encouraging resistance training 2 d per week


may be reasonable (Class ACC/AHA 2007 STEMI Guidelines Focused Update
IIb; LOE: C)
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Secondary Prevention and Long Term Management
It is useful to assess body mass index and/or
Goals waist circumference on each visit and
Class I Recommendations
consistently
Weight encourage weight maintenance/reduction
through an appropriate balance of physical
management:
activity, caloric
Goal: intake, and formal behavioral programs when
BMI 18.5 to 24.9 indicated to maintain/achieve a body mass index
kg/m2 between 18.5 and 24.9 kg/m2.

Waist The initial goal of weight loss therapy should be


circumference: to
Women: < 35 in. reduce body weight by approximately 10% from
(102 cm) baseline. With success, further weight loss can
be
Men: < 40 in. (89
attempted if indicated through further
cm) assessment.

If waist circumference (measured horizontally at


the iliac crest) is ≥ 35 inches (102 cm) in women
and ≥ 40
inches (89 cm) in men, itACC/AHA
is useful to initiate
2007 STEMI Guidelines Focused Update

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Secondary Prevention and Long Term Management

Goals Class I Recommendations


Diabetes It is recommended to initiate lifestyle
manageme and
nt: pharmacotherapy to achieve near-
Goal: normal HbA1c.
HbA1c < 7%
Beginning vigorous modification of
other risk factors (e.g., physical activity,
weight management, BP control, and
cholesterol management as
recommended above) is beneficial.

Coordination of diabetic care with


patient’s primary care physician or
NEW
endocrinologist is beneficial.
ACC/AHA 2007 STEMI Guidelines Focused Update

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Secondary Prevention and Long Term Management

Goals Class I Recommendations

Antiplatelet For all post-PCI STEMI stented patients


agents/ without aspirin resistance, allergy, or
anticoagulan increased risk of bleeding, aspirin 162 to
ts: Aspirin 325 mg daily should be given for at least
1 month after bare-metal stent
implantation, 3 months after sirolimus-
eluting stent implantation, and 6 months
after paclitaxel-eluting stent
implantation, after which long-term
aspirin use should be continued
indefinitely at a dose of 75 to 162 mg
CHANGED
TEXT
daily.
ACC/AHA 2007 STEMI Guidelines Focused Update

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Secondary Prevention and Long Term Management

Goals ForClass I Recommendations


all post-PCI patients who receive a drug-
eluting
stent (DES), clopidogrel 75 mg daily should
Antiplatelet
be
agents/ given for at least 12 months if patients are
anticoagulan not at
ts: high risk of bleeding.
Clopidogrel
For post-PCI patients receiving a bare metal
stent
(BMS), clopidogrel should be given for a
minimum
of 1 month and ideally up to 12 months
(unless the
CHANGED patient is at increased risk of bleeding; then
TEXT it
should be given for a minimum of 2 weeks).
ACC/AHA 2007 STEMI Guidelines Focused Update

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Secondary Prevention and Long Term Management
Goals Class I Recommendations
ACE inhibitors should be started and continued
Renin- indefinitely in all patients recovering from STEMI with
Angiotensi LVEF ≤ 40% and for those with hypertension,
n- diabetes, or chronic kidney disease, unless
contraindicated. CHANGED
Aldosteron TEXT
e System ACE inhibitors should be started and continued
Blockers: indefinitely in patients recovering from STEMI who
ACE are not lower risk (lower risk defined as those with
Inhibitors
NEW normal LVEF in whom cardiovascular risk factors are
REC well controlled and revascularization has been
performed), unless contraindicated.

Among lower risk patients recovering from STEMI


NEW
REC (i.e., those with normal LVEF in whom cardiovascular
risk factors are well controlled and revascularization
has been performed) use of ACE inhibitors is
ACC/AHA 2007 STEMI Guidelines Focused Update
reasonable. (Class IIa; LOE: B)
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Secondary Prevention and Long Term Management

Goals Class I Recommendations


Use of ARBs is recommended in patients
Renin- who are intolerant of ACE inhibitors and
Angiotensi have HF or have had a STEMI with LVEF ≤
n- 40%. CHANGED
Aldosteron TEXT

e System
Blockers: It is beneficial to use ARB therapy in other
ARBs NEW patients who are ACE-inhibitor intolerant
REC and have hypertension.

Considering use in combination with ACE


NEW
REC
inhibitors
in systolic dysfunction HF may be
reasonable. ACC/AHA 2007 STEMI Guidelines Focused Update

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Secondary Prevention and Long Term Management

Goals Class I Recommendations

Beta- It is beneficial to start and continue beta-


Blockers blocker therapy indefinitely in all patients
who have had MI, acute coronary
syndrome, or left ventricular dysfunction
with or without HF symptoms, unless
contraindicated.
CHANGED
TEXT

ACC/AHA 2007 STEMI Guidelines Focused Update

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CARDIAC REHBILITATION

ACC/AHA 2007 STEMI Guidelines Focused Update

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Coronary Artery Disease
 MI is the single leading cause of death in America
– 47% of all MIs expected this year will result in death
1200000
Number of Heart Attacks

1000000

800000

600000 Non-fatal
Fatal
400000

200000

0
47%
2003

ACC/AHA 2007 STEMI Guidelines Focused Update


CAD Disease Risk Factors
Controllable Uncontrollable

 Tobacco  Age
 Lipids (Cholesterol)  Gender
 Blood pressure  Heredity
 Physical inactivity
 Excess body weight
 Diabetes
 Stress

ACC/AHA 2007 STEMI Guidelines Focused Update


What is Cardiac
Rehabilitation?
Exercise and lifestyle
modification
Supervised by nurses and
requires physician referral
An outpatient service at
Madison County Memorial
Hospital
Meets two to three times
a week

ACC/AHA 2007 STEMI Guidelines Focused Update


Components
of Cardiac Rehab?
Supervised
progressive
exercise/activity
Nutrition
recommendations
Blood pressure and
cholesterol control

ACC/AHA 2007 STEMI Guidelines Focused Update


More …

Smoking cessation
Stress management
Weight management
Diabetes control

ACC/AHA 2007 STEMI Guidelines Focused Update


Benefits of Participation
• Improved functional abilities

• Improved quality of life

• Reduction of lifestyle related risks

• Increased knowledge of disease process and prevention


strategies

• Improved ability to perform daily life activities

ACC/AHA 2007 STEMI Guidelines Focused Update


More benefits of participation...

Increased knowledge of
heart disease

Increased self-esteem and


confidence

Improved adherence to
healthy lifestyle choices
ACC/AHA 2007 STEMI Guidelines Focused Update
Who Is Eligible for
Cardiac Rehab?
For those who have had any of the following:
– Heart attack
– Bypass surgery
– Angina
– Angioplasty with or without stent placement
– Heart valve replacement surgery

ACC/AHA 2007 STEMI Guidelines Focused Update


What is the cost of
cardiac rehab?
Most charges for outpatient cardiac rehab are
covered by insurance
Staff will assist in evaluating coverage and
calculating out of pocket costs (if any) prior to
starting
“Maintenance” programs are designed to help
patients continue their commitment to
exercise. These programs are not covered by
insurance.
ACC/AHA 2007 STEMI Guidelines Focused Update
Cardiac Rehab Professionals:
Cardiac Rehab Partnership:
– Medical Director
– Referring Physicians
– Nurses
– Exercise Physiologists
– Dietitians/Nutritionists
– Social Services
– Psychosocial Services
– Pharmacists
ACC/AHA 2007 STEMI Guidelines Focused Update
Why is Cardiac Rehab
Important?

Cardiac Rehab will give you the tools, knowledge, and


motivation needed to fight the progression of
cardiovascular disease with your
“heart and soul”!

ACC/AHA 2007 STEMI Guidelines Focused Update


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ACC/AHA 2007 STEMI Guidelines Focused Update
ACC/AHA 2007 STEMI Guidelines Focused Update
ACC/AHA 2007 STEMI Guidelines Focused Update