Regionalization of STEMI care
· Within
10 minutes: first medical contact (FMC) to ECG and diagnosis
· The
development of a heart attack network of care that incorporates the use of
prehospital catheterization laboratory activation, single-call patient transfer
protocols, and in-field bypass of non-PCI centers to minimize FMC-to-device
times for patients who are treated with primary PCI (pPCI)
· The
use of protocols to minimize time to fibrinolysis as well as the development of
a formal relationship with a PCI center to enable adjunctive PCI for patients
who are treated with fibrinolysis within a STEMI ( ST elevation MI) network.
· Hospitals
and emergency medical services (EMS) within STEMI networks maintain written,
updated STEMI management protocols, and audit treatment delays, reperfusion
rates and false activation rates to monitor quality metrics.
Management of STEMI patients
diagnosed in the prehospital setting
· EMS
personnel obtain an ECG in the field to identify STEMI and alert STEMI care
teams of a patient's imminent arrival.
· If
pPCI is used as a default reperfusion strategy for suspected STEMI patients in
the field, it is recommended that patients bypass non-PCI-capable centers and
instead be transported to the nearest PPCI center with the goal of achieving a
maximum FMC-to-device time of ≤120 minutes (ideal FMC-to-device time ≤90
minutes in urban settings). Consider fibrinolytic therapy if this timeline
cannot be achieved.
Management of STEMI patients
diagnosed in non-PCI-capable centers
· For
patients with STEMI identified at a non-PCI-capable center, if primary PCI is
used as the default reperfusion strategy, it is recommended that STEMI networks
target a total FMC-to-device time (including interfacility transfer) of ≤120
minutes. Consider fibrinolytic therapy if this timeline cannot be achieved.
· If
pPCI is used as a default reperfusion strategy, target a door-in–door-out time
at the transferring hospital of ≤30 minutes.
· If
fibrinolysis is used as a default reperfusion strategy, it is recommended that
STEMI networks target a total FMC-to-needle time of ≤30 minutes.
· Routine
rapid transfer to PCI centers after fibrinolysis, immediate PCI for patients
with failed reperfusion, and routine angiography with or without PCI within 24
hours after successful fibrinolysis are recommended.
· When
access to cardiac catheterization is available within 120 minutes of FMC, it
is not recommended that a strategy of pharmacologic facilitation be
used with full-dose fibrinolysis or a combination of fibrinolysis and
glycoprotein inhibitor (GPI) or GPI.
Management of STEMI patients
at PCI-capable centers
· For
patients with STEMI identified at a primary PCI center, it is recommended that
STEMI networks target a FMC-to-device time of ≤90 minutes.
· In
STEMI patients with cardiogenic shock and multivessel disease, non-culprit
lesion PCI is not recommended during the initial primary PCI
procedure.
· Routine
upfront thrombectomy is not recommended in patients with STEMI who
undergo pPCI.
· Transradial
access is recommended over transfemoral access as the preferred access site in
STEMI patients undergoing PCI when it can be performed by an experienced radial
operator.
· Use
of unfractionated heparin (UFH) is recommended for procedural anticoagulation
in patients with STEMI undergoing pPCI.
· Use
of bivalirudin is preferred over UFH or low molecular-weight heparin (LMWH) for
procedural anticoagulation in patients with STEMI undergoing pPCI who have a
history of heparin-induced thrombocytopenia or a very high risk of bleeding.
· Fondaparinux
is not recommended for procedural anticoagulation in patients with
STEMI undergoing primary PCI.
·
It is not recommended that intravenous (IV) or
intracoronary (IC) GPI be routinely used for primary PCI.
Dr KK Aggarwal
Padma Shri Awardee
President Elect Confederation of
Medical Associations in Asia and Oceania
(CMAAO)
Group Editor-in-Chief IJCP Publications
President Heart Care Foundation of
India
Past National President
IMA
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