myocardial infarction treatment guidelines 2020

Table 1 is illustrative of the general relationships between clinical and ECG findings and the categorization of patients into those at a low, an intermediate, or a high level of risk of events. (Level of Evidence: C), c. Synchronized cardioversion with an initial monophasic shock of 200 J for atrial fibrillation and 50 J for flutter, preceded by brief general anesthesia or conscious sedation whenever possible. Because the various agents have not been compared directly with each other, their relative efficacy is not known. PCI for diabetic patients with 1-vessel disease and inducible ischemia. (Level of Evidence: A). 2003;107:2533–7.25, Patients with STEMI who have cardiogenic shock and are less than 75 years of age should be brought immediately or secondarily transferred to facilities capable of cardiac catheterization and rapid revascularization (percutaneous coronary intervention [PCI] or coronary artery bypass graft surgery [CABG]) if it can be performed within 18 hours of onset of shock. 1. It is recommended that the use of hormone therapy be discontinued in women who have STEMI.200–202. Although corticosteroids are effective for pain relief, their use is associated with an increased risk of scar thinning and myocardial rupture. Unauthorized It is reasonable to (re)administer fibrinolytic therapy to patients with recurrent ST elevation and ischemic-type chest discomfort who are not considered candidates for revascularization or for whom coronary angiography and PCI cannot be rapidly (ideally within 60 minutes from the onset of recurrent discomfort) implemented. (Level of Evidence: B), 4. Valsartan and candesartan have established efficacy for this recommendation. ICD-10-CM Official Guidelines for Coding and Reporting FY 2020 (October 1, 2019 - September 30, 2020) Narrative changes appear in bold text . OR indicates odds ratio. (Level of Evidence: C), Nursing care should be provided by individuals certified in critical care, with staffing based on the specific needs of patients and provider competencies, as well as organizational priorities. In patients with secondary angina, factors that increase myocardial oxygen demand or decrease oxygen delivery to the heart may provoke or exacerbate ischemia in the presence of significant underlying CAD. (Level of Evidence: A), It is reasonable to administer IV beta-blockers promptly to STEMI patients without contraindications, especially if a tachyarrhythmia or hypertension is present. Bedside Testing for Serum Cardiac Biomarkers 596, • Patients With STEMI Not Receiving Reperfusion 605, 3. However, even less severe disease can have a substantial negative affect on the quality of life. Short-term (4 to 6 weeks; top left) and long-term (top right) outcomes for various end points shown are plotted for STEMI patients randomized to PCI or fibrinolysis for reperfusion in 23 trials (n=7739). Patients with early contraindications within the first 24 hours of STEMI should be reevaluated for candidacy for beta-blocker therapy. Coronary arteriography, if available, for patients who have ST-segment depression or isolated T-wave changes not known to be old and who are unresponsive to NTG and calcium antagonists. Cardiac rehabilitation/secondary prevention programs, when available, are recommended for patients with STEMI, particularly those with multiple modifiable risk factors and/or those moderate- to high-risk patients in whom supervised exercise training is warranted. Patients with severe hypotension (systolic arterial pressure less than 80 mm Hg). Evaluation begins in these patients by obtaining information from the history, physical examination, and ECG (Table 1) to be used to confirm or reject the diagnosis of UA/NSTEMI. (Level of Evidence: C), 2. (Level of Evidence: C), 12. These data strongly support the approach that patients younger than 75 years with STEMI complicated by cardiogenic shock should undergo emergency revascularization and support measures. It is recommended that postmenopausal women on HRT continue but that HRT not be initiated for the secondary prevention of coronary events. Usually, a calcium antagonist at a high dose (verapamil 240 to 480 mg/d, diltiazem 120 to 360 mg/d, nifedipine 60 to 120 mg/d) is started. On the basis of the data in the HERO-2 trial, the Writing Committee believed that bivalirudin could be considered an acceptable alternative to UFH in those STEMI patients who receive fibrinolysis with streptokinase, have heparin-induced thrombocytopenia, and who, in the opinion of the treating physician, would benefit from anticoagulation. It is reasonable to evaluate all patients who have an indication for permanent pacing after STEMI for biventricular pacing (cardiac resynchronization therapy). (Level of Evidence: B). It is reasonable to perform primary PCI for fibrinolytic-ineligible patients with onset of symptoms within the prior 12 to 24 hours and 1 or more of the following: Randomized controlled trials evaluating the outcome of PCI for patients who present with STEMI but who are ineligible for fibrinolytic therapy have not been performed. Low sensitivity in very early phase of MI (<6 h after symptom onset) and requires repeat measurement at 8–12 h, if negative 2. (Level of Evidence: B), Intravenous UFH (bolus of 60 U/kg, maximum 4000 U IV; initial infusion 12 U/kg per hour, maximum of 1000 U/h) or LMWH should be used in patients after STEMI who are at high risk for systemic emboli (large or anterior MI, atrial fibrillation, previous embolus, known LV thrombus, or cardiogenic shock). Careful monitoring has refuted this concept, and treatment of these rhythm disturbances is not recommended unless they lead to hemodynamic compromise. Patients who arrive at a medical facility in a pain-free state, have unchanged or normal ECGs, are hemodynamically stable, and do not have elevated cardiac markers represent more of a diagnostic than an urgent therapeutic challenge. The American College of Cardiology (ACC) and the American Heart Association (AHA) have updated guidelines for the management of myocardial infarction. (Level of Evidence: B), It is reasonable to perform routine PCI in patients with LV ejection fraction (LVEF) less than or equal to 0.40, CHF, or serious ventricular arrhythmias. Acute myocardial infarction is myocardial cell death that occurs because of a prolonged mismatch between perfusion and demand. There was a trend toward a reduction in death as well. If the patient is at low risk (Table 1) and does not experience any further ischemic discomfort and his or her follow-up 12-lead ECG and cardiac marker measurements after 6 to 8 hours of observation remain normal, the patient may be considered for an early stress test to provoke ischemia. Abbreviations and acronyms 3 2. Intensive medical and interventional management of ACS may be undertaken but with close observation for adverse effects of these therapies. Start warfarin concurrently with LMWH and titrate to INR of 2 to 3. (Level of Evidence: C), A brief, focused, and limited neurological examination to look for evidence of prior stroke or cognitive deficits should be performed on STEMI patients before administration of fibrinolytic therapy. One or more of these pharmacological agents may be used: i. The clinical applicability of these tests to the post-STEMI patient is in a state of evolution. (Level of Evidence: C), 1. A follow-up visit should delineate the presence or absence of cardiovascular symptoms and functional class. (Level of Evidence: B), During the acute phase (first 24 to 48 hours) of the management of STEMI in patients with hyperglycemia, it is reasonable to administer an insulin infusion to normalize blood glucose, even in patients with an uncomplicated course. Figure 2 shows the short- and long-term outcomes of patients with STEMI treated by fibrinolysis versus PCI and the number of patients who need to be treated to prevent 1 event or cause 1 harmful complication when selecting PCI instead of fibrinolysis as the reperfusion strategy (Figure 2).76 Of note, when primary PCI is compared with tissue plasminogen activator (tPA) and the SHOCK trial is excluded, the mortality rate is 5.5% versus 6.7% (odds ratio 0.81%, 95% confidence interval [CI] 0.64 to 1.03, P equals 0.081.76a, There is serious and legitimate concern that a routine policy of primary PCI for patients with STEMI will result in unacceptable delays in achieving reperfusion in a substantial number of cases and produce less than optimal outcomes if performed by less-experienced operators.

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