Management of acute heart attack: 2019 Clinical Practice Guidelines from the Canadian Cardiovascular Society/Canadian Association of Interventional Cardiology

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

#AskDrKK:How common is sexual dysfunction after acute heart attack?

#DrKKAnswers
1. Sexual dysfunction is common due to concern about risk; side effects of drugs (diuretics, beta blockers, lipid-lowering drugs) and due to risk factors like high lipis, diabetes, smoking, hypertension and psychologic factors [1].
2. Erectile dysfunction after a heart attack occur in one-half to three-quarters of patients. [2,3].
3. ED is also seen after bypass surgery (though less common)
4. Both men and women have less sexual activity and less satisfaction with sexual act after a heart attack [1].
5. Psychologic causes for sexual dysfunction are due to perceptions of their illness [4].
6. Worries about triggering a heart attack or sudden death and depression and anxiety of the disease especially the occurrence of a heart attack contribute. [5,6].
7. The fear can be in the mind of the patient or the spouse.
8. Most doctors do not discuss this issue of sexual act with post-heart attack patients or their spouses [7,8].
9. Counseling may improve sexual function [9].
10. Exercise stress testing is used to measure exercise tolerance and tolerance for sex..

References
1. Am J Cardiol 2000; 85:1283.
2. Arch Sex Behav 1986; 15:499.
3. Chest 1986; 90:681.
4. BMJ 1996; 312:1191.
5. Am J Cardiol 2000; 86:41F.
6. Am J Cardiol 2000; 86:46F.
7. Am J Cardiol 2000; 86:38F.
8. Arch Intern Med 1980; 140:38.
9. J Behav Med 1984; 7:61.

#AskDrKK:What is the absolute risk of acute heart attack after sex?

DrKKAnswers:


Sexual act is a transient trigger that increases risk of heart attack for only a two hour period. The absolute increase in risk is very small.

A 50 year-old man with no cardiac disease with an annual baseline risk of heart attack of 1 percent would increase his annual risk of heart attack to only 1.01 percent from weekly sexual activity.

A person with a high annual risk for a heart attack of 10 percent would increase the annual risk to only 10.1 percent from weekly sexual activity.

Source: Am J Cardiol 2000; 86:10F.

#AskDrKK:What is the risk of acute heart attack after a sexual act?

#DrKKAnswers:
Sexual act contributes to the onset of acute heart attack in only 0.9 percent of patients.

The relative risk of acute heart attack within two hours after sexual activity is 2.5. There is no increased risk of heart attack beyond this time period.

This risk is reduced in patients who undergo regular exercise. The risk is same irrespective of past history of heart disease.

Source:JAMA 1996; 275:1405.