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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2804_Библиотеки_им_академика_М_И_Перельмана
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Figure 4-4 The benefit of coronary reperfusion is inversely related to ischemia time.Top. Graphic representation of
mortality benefit of coronary reperfusion as a function of ischemia time.77 Bottom. Recommended timeline of events
followingchestpainonsetaccordingtoAHA/ACCguidelines.78AHA/ACC,AmericanHeartAssociation/AmericanCollege
of Cardiology; ECG, electrocardiogram; EMS, emergency medical service; ER, emergency room; PCI, percutaneous
coronaryintervention;STEMI,ST-segmentelevationmyocardialinfarction.
All medical centers should have in place and use an AHA/ACC guideline–based STEMI protocol.
Centers that are not primary PCIcapable should have protocols in place tomeet accepted time-totherapy guidelines, with either rapid transfer to a PCI-capable facility or administration of
thrombolyticswithsubsequenttransfertoaPCIcenter.
In the emergency department, an acute MI protocol should be activated that includes a targeted
clinicalexaminationanda12-leadECGcompletedwithin10minutesofarrival.
The goal ofimmediate management inpatients withSTEMIis to identify candidatesforreperfusion
therapyandto immediatelyinitiatethatprocess. Other priorities include reliefofischemic pain,as
wellasrecognitionandtreatmentofhypotension,pulmonaryedema,andarrhythmia.
Supplemental oxygen should be administered if saturations are <90%. If necessary, institution of
mechanicalventilationdecreasestheworkofbreathingandreducesmyocardialoxygendemand.
Serial ECGsshould be obtained for patientswhodo nothaveST-segment elevationontheinitial
ECG but experience ongoing chest discomfort as they may have an evolving STEMI. Telemetry
shouldbeplacedtomonitorforarrhythmias.
Medications
UpstreammedicaltherapyshouldincludeadministrationofASA,asecondantiplateletagent,an
anticoagulant,andagentsthatreducemyocardialischemia(Table4-17).
TABLE4-17
UPSTREAMMEDICALTHERAPY
Medication Dosage Comments
Aspirin(ASA) 162–325mg Non–enteric-coatedformulations(chewedorcrushed)given
orallyorrectallyfacilitaterapiddrugabsorptionandplatelet
inhibition.
Clopidogrel 600mg
loadingdose,
75–150mg/d
600mgloadingdosefollowedby150mgmaintenancedose
for7dmayreducetheincidenceofstentthrombosisandMI
comparedtothestandard300mgloadingdoseand75mg
maintenancedose.
Cautionshouldbeusedintheelderlybecauseclinicaltrials
validatingclopidogreluseinSTEMIeitherdidnotinclude
elderlypatientsordidnotusealoadingdose.
Prasugrel 60mgloading
dose,10
mg/d
Comparedtoclopidogrel,prasugrelisaquickeractingand
morepotentantiplateletagentwithimprovedefficacybutdid
significantlyincreaseCABGbleedingrates.
Prasugrelshouldnotbeusedinpatients>75yold,<60kg,or
withahistoryofstroke/TIA.
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Ticagrelor 180mg
loading,then
90mgbid
ASAdoseshouldnotexceed100mg.Ticagrelorhasshown
mortalitybenefitoverclopidogrelattheexpenseofhigher
bleedingrates.
Cangrelor 30µg/kgIV
bolus,then4
µg/kg/min
CurrentlyFDA-approvedonlyforpatientsundergoingPCI.
Expenseandmodestevidenceofbenefitcomparedtoother
P2Y12inhibitorslimituse.
Unfractionated
heparin(UFH)
60units/kgIV
bolus,then12
units/kg/h
UFHshouldbegiventoallpatientsundergoingPCIandthose
receivingthrombolyticswiththeexceptionofstreptokinase.
ThemaximumIVbolusis4000units.
Enoxaparin
(LMWH)
30mgIV
bolus,then1
mg/kgSub-Q
bid
Patients>75yoldshouldnotbegivenaloadingdoseand
receive0.75mg/kgSCbid.
Anadditionalloadingdoseof0.3mg/kgshouldbegivenifthe
lastdoseofLMWHwas>8hpriortoPCI.TheuseofLMWH
isonlyvalidatedinthrombolysisandrescuePCI.
Bivalirudin 0.75mg/kgIV
bolus,then
1.75mg/kg/h
BivalirudinhasbeenvalidatedinpatientsundergoingPCIand
hasnotbeenstudiedinconjunctionwiththrombolysis.
Patientswhoreceivedaheparinboluspriortobivalirudinhada
lowerincidenceofstentthrombosisthanthosewhoonly
receivedbivalirudin.
Fondaparinux 2.5mgIV
bolus,2.5mg
Sub-Qdaily
ShowntobesuperiortoUFHwhenusedduringthrombolysis
withdecreasedbleedingrates.
Fondaparinuxincreasestheriskofcatheterthrombosiswhen
usedduringPCI.
79
Nitroglycerin 0.4mgSLor
aerosol
infusion;10–
200μg/minIV
Sublingualoraerosolnitroglycerincanbegivenevery5minfor
atotalofthreedosesintheabsenceofhypotension.IV
nitroglycerincanbeusedforuncontrolledchestdiscomfort.
Metoprolol 25mgPO
qid,uptitrate
asneeded
β-Blockersshouldbeavoidedinpatientswithevidenceof
heartfailure,hemodynamicinstability,markedfirst-degreeAV
block,advancedheartblock,andbronchospasm.
AV,atrioventricular;CABG,coronaryarterybypassgraft;LMWH,low–molecular-weightheparin;MI,myocardialinfarction;PCI,
percutaneouscoronaryintervention;SL,sublingual;STEMI,ST-segmentelevationmyocardialinfarction;TIA,transientischemic
attack.
ASA 162–325 mg should be given orally (chewed) or rectally immediately to all patients with
suspectedacuteMI;325mgispreferredforthosewhoareASAnaïve.AfterPCI,thesubsequentdose
ofASAis81mg/dindefinitely.
80
P2Y12 inhibitor loading dose should be given to all STEMI patients, as part of DAPT, as soon as
possibleafterpresentation.Costandbleedingriskshouldbetakenintoconsiderationwhenchoosingan
agent. (Please also refer to the antiplatelet sectionon UA/NSTEMIfor background information and
dosingonagentslistedinthefollowingtext.)
IfthepatientisgoingforPCI,oneofthefollowingshouldbeaddedtoASAandanticoagulant:
Ticagrelor180mgloadingdose,then90mgbid(Note:maintenanceASAmustbe<100mgdaily)
for a minimum of 12 months. It is the preferred P2Y12 inhibitor for ACS due to its mortality
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advantageoverothersinthisclass.
Clopidogrel600mgloadingdose,then75mgdailyfor12months.
Prasugrel60mgloadingdose, then10 mgdailyforminimumof12 months(contraindicated in
patientswithpriorCVA/TIAoractivepathologicalbleedingandavoidedinthose>75yearsand
withweight<60kg).Prasugrelshouldonlybegivenafterdiagnosticangiography (orwithin
anhourofPCI)givenahigherincidenceofbleedingcomparedtoclopidogrel.
81
Ifthepatientistoreceivefibrinolytictherapy,alongwithASAandananticoagulant,patientsshould
receive:
Clopidogrel300mgloadingdoseifgivenduringthefirst24hoursoftherapy;ifstarted24hours
afteradministrationoffibrinolytics,a600-mgloadingdoseispreferred.Maintenanceis75mg/d.
Patientsolderthan75yearsshouldnotbegiventheloadingdose.
GPIIb/IIIainhibitorsdonothavearoutineroleintheinitialpresentationofSTEMIpatientsoraspart
ofadjunctivetherapywiththrombolytics.
AnticoagulanttherapyshouldbeinitiatedonpresentationinallpatientswithSTEMIregardlessofthe
choiceofPCIorthrombolytictherapy.PleasealsorefertotheMedicationssectionforUA/NSTEMI
forbackgroundinformationonagentslistedinthefollowingtext.
AnticoagulantchoiceforpatientswhowillreceiveprimaryPCI:
UFH is often preferred during PCI by many operators due to the availability and real-time
therapeutic monitoring with activating clotting times (ACTs) in the catheterization laboratory.
Additional bolus doses of UFH are given at PCI, with the dose and ACT goal dependent on
whetheraGPIIb/IIIaantagonisthasbeengiven.
EnoxaparinuseinSTEMIpatientsasananticoagulantforPCIisunclear,andwegenerallydonot
recommendit.
BivalirudincanbegiventopatientsalreadytreatedwithASAandclopidogrelonpresentation.
□ BivalirudinisanacceptablealternativetotheuseofcombinedheparinandGPIIb/IIIainhibitor
duringPCIwithlowerbleedingratesbuthigherrateofstentthrombosis.
82,83
□ ItistheagentofchoiceinpatientswithknownHIT.
□ ItcanbegivenwithorwithoutpriortreatmentwithUFH.IfpatientisbeingtreatedwithUFH,
discontinueUFHfor30minutespriortostartingbivalirudin.
□ Doseis0.75mg/kgbolus,then1.75mg/kg/hinfusion.
Patientswhowillreceivefibrinolytictherapyshouldbestartedoneither:
UFHwithmonitoringtoensuretheactivatedPTTistwicetheupperlimitofnormal.UFHshould
becontinuedforatleast48hoursafterfibrinolysis.IfangiographywithintenttoperformPCIis
anticipatedtooccurearlyafterfibrinolysis,thenUFHmaybepreferable.
Enoxaparin,iftheserumcreatinineis<2.5mg/dLinmenor2mg/dLinwomen,aninitial30-mg
IVbolusisgivenfollowed15minuteslaterwith1mg/kgSub-Qbid.Givefortheentiretyofthe
indexhospitalizationbutnottoexceed8days.
BivalirudincanbeusedforHIT-positivepatientsbuthasnotbeenstudiedextensivelyinSTEMI
patientsorpatientswithfibrinolysis.
Anti-ischemic therapy (also refer to the Medications section for UA/NSTEMI for background
informationonagentslistedhere).
Nitroglycerin should be administered to patients with ischemic chest pain, to aid in control of
hypertension,or as part ofthe managementofHF.Nitroglycerinshouldeither be avoided or used
withcautioninpatientswith:
Hypotension(systolicBP[SBP]<90mmHg)
RVinfarct
Heartrate>100bpmor<50bpm
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Documenteduseofphosphodiesteraseinhibitors(e.g.,sildenafil)inprevious48hours
Morphine(2–4mgIV)canbeusedforrefractorychestpainthatisnotresponsivetonitroglycerin.
Adequateanalgesiadecreaseslevelsofcirculatingcatecholaminesandreducesmyocardial oxygen
consumption.
BBs improve myocardial ischemia, limit infarct size, and reduce major adverse cardiac events
includingmortality,recurrentischemia,andmalignantarrhythmias.
OralBBsshouldbestartedinallpatientswithSTEMIwithinthefirst24hourswhodonothave
signs of new HF, evidence ofcardiogenic shock (Killip class IIor greater), ageolder than 70
years,SBP<120mmHg,pulse>110or<60bpm,oradvancedheartblock.
84
IVBBscanincreasemortalityinpatientswithSTEMIandshouldbereservedformanagementof
arrhythmias or acute treatment of accelerated hypertension in patients without the earlier
mentionedfeatures.SinustachycardiainthesettingofaSTEMImaybeacompensatoryresponse
tomaintaincardiacoutputandshouldnotpromptIVBBuse.
AcuteCoronaryReperfusion
Themajority ofpatientswhosufferanacuteSTEMIhavethromboticocclusionofa coronary artery.
Earlyrestorationofcoronaryperfusionlimitsinfarctsize,preservesLVfunction,andreducesmortality.
All other therapies are secondary and should not delay the timely goal of achieving coronary
reperfusion.
Unlessspontaneousresolutionofischemiaoccurs(asdeterminedbyresolutionofchestdiscomfortand
normalizationofSTelevation),thechoiceofreperfusionstrategyincludesthrombolysis,primaryPCI,
oremergentCABG(Figure4-5).
Normalization oftheECGandsymptoms should notprecludethepatientbeingreferred forurgent
diagnosticangiography.Morphinemaymaskongoingischemicsymptoms.
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Figure4-5 Strategies for coronary reperfusion andrisk assessment.1If fibrinolytics are to be given, use clopidogrel
only. If primary PCI is planned, give ticagrelor, prasugrel, or clopidogrel.2UFH may be used with either PCI or
thrombolytic therapy, whereas bivalirudin has only been studied with PCI and LMWH has only been validated for
fibrinolytictherapyandrescuePCI.Inpatientswhoaretoreceivefibrinolysis,LMWHandfondaparinuxarepreferredto
UFH.3Patientswhodonotexperiencechest pain relief,haverecurrentchest pain, have unstable arrhythmias,develop
heart failure,or have ST-segment elevations that donotnormalize 60–90 minutes following fibrinolysis shouldundergo
rescue PCI.4Signs of successful reperfusion include chest pain relief, 50% reduction in ST-segment elevation, and
idioventricular rhythm. P2Y12 inhibitors include antiplatelet agents: clopidogrel, prasugrel, and ticagrelor. ASA, aspirin;
CABG, coronary artery bypass graft; LMWH, low–molecular-weight heparin; NTG, nitroglycerin; PCI, percutaneous
coronaryintervention;STEMI,ST-segmentelevationmyocardialinfarction;UFH,unfractionatedheparin.
Note: Ongoing symptoms are notrequiredcriteria for treatmentof STEMI inthe first 12 hours of
symptomonset.Patientswhoarrivewithin12hoursoftheirsymptoms,despitesymptomresolution,
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butwith continued ECGchanges of STEMI are still candidatesfor immediate reperfusion (either
primary PCI or fibrinolytics). We recommend angiography with intent for PCI/CABG in such a
circumstance.
Thechoiceofreperfusiontherapyshouldbeconsideredofsecondaryimportancetotheoverallgoalof
achievingreperfusioninatimelymanner.
PrimaryPCI
Primary PCI is the preferred reperfusion strategy when available within 90 minutes of first
medical contact. Compared to fibrinolytic therapy, PCI offers superior vessel patency and
perfusion(TIMI3flow)withlessreinfarction,lessriskofintracranialhemorrhage,andimproved
survival regardless of lesion locationor patient age. STEMIpatients with symptom onset<12
hourspriorhaveabetterprognosisandoutcomeafterPCI.PCIshouldstillberoutinelyofferedto
patientswithSTEMIwhohaveongoingsymptomsthatbegan12–24hourspriortopresentation.
PCI may also be considered, although evidence of benefit is limited,in patients who are now
asymptomaticbuthadsymptomsintheprevious12-to24-hourperiod.
Asymptomatic patients who are hemodynamically and electrically stable without evidence of
ischemia and whose symptoms began morethan 24 hours prior should not be offered PCI of a
totallyoccludedinfarctartery.
85
PCIisalwayspreferredoverfibrinolysisinthefollowingsituations:
□ PatientswhopresentwithsevereHForcardiogenicshockshouldreceiveprimaryPCI(evenif
transfertoa PCIcentermaycausedelaysbeyond currenttimegoalsforreperfusion).Patients
withKillipclassIII/IVorTIMIriskscore≥5representhigh-riskgroupswherePCIispreferred
despiteapotentialtimedelay.
86,87
□ Haveacontraindicationtofibrinolytictherapy.
□ HavehadrecentPCIorpriorCABG.
□ PCIisgenerallypreferredtofibrinolysisinpatientswithsymptomonset>12hoursprior.
88,89
Coronarystentingis superior toballoonangioplasty aloneandreducestheratesoftargetvessel
revascularization.
Iftheinfarct-relatedarteryissuccessfullytreatedandpatientshavelesionsinnon–infarct-related
arteries that are amenable to PCI, complete revascularization results in a decrease in the
composite of cardiovascular death and MI, as well as a decrease in future need for
revascularization.90Timing,priortodischargeorreturnintheoutpatientsetting,shoulddependon
the clinical stability of the patient and comorbid illnesses (i.e., renal function). Both are
acceptablestrategiesforrevascularizationofnonculpritpathology.
Previously,itwasthought tobeadvantageousforpatientsinshocktohavesignificantlesionsin
non–infarct-related arteries intervened on if feasible. However,in theCULPRIT-SHOCKtrial,
culprit-lesion only PCI resulted in a reduction in all-cause mortality and need for renal
replacementtherapy.
91
TransradialapproachinSTEMIreducesbleeding andmayhaveamortalitybenefitcomparedto
transfemoralaccess.
□ Dorsalradialarteryaccessisanotheralternative.
FacilitatedPCI,astrategyofreduceddoseofGPIIb/IIIainhibitors and/orfibrinolyticagentjust
priortoPCI,shouldnotberoutinelyusedbecauseitdoesnotimproveefficacyandsignificantly
increasesbleedingrates.
Fibrinolytictherapy
Fibrinolytictherapyhasthemainadvantagesofwidespreadavailabilityandeaseofdelivery.The
primary disadvantagesoffibrinolytictherapy aretheriskofintracranialhemorrhage,uncertainty
ofwhethernormalcoronaryflowhasbeenrestored,andriskofre-occlusionoftheinfarct-related
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artery.
FibrinolysisisindicatedwhenprimaryPCIisnotavailableinatimelyfashion(i.e.,delay>120
minutes or time-to-transfer > 120 minutes). Transfer to a PCI-capable facility should occur
regardlessofwhetherfibrinolyticsaregivenornot.
Fibrinolytic therapy is indicated for use if given within 12 hours of the symptom onset with
qualifyingECGchangesofSTelevation,newLBBB,ortrueposteriorMI.Whengiven,itshould
be administered within 30 minutes of initial patient contact. Fibrinolytic therapy is most
successfulwhengiveninthefirst3hoursofsymptomonset,afterwhichthebenefittapers.
Patients presenting to a hospital without PCI capability should be transferred for primaryPCI,
rather than being given fibrinolytics, iftime from firstmedical contacttoPCIwill notbe >120
minutes.Thisseemsparticularlyrelevanttopatientsarriving3–12hoursfromsymptomonset.
InpatientstransferredforPCI,primary PCIsignificantlylowered theincidenceofdeath,MI,or
strokecomparedtoon-sitethrombolysis.
91-94
All patients should be transferred to a PCI-capable facility after fibrinolysis (early routine
angiography);thisshouldoccururgentlyifpatientsareinshockorhavefailedreperfusion.
Availablethrombolyticagentsincludethefibrin-selectiveagentssuchasalteplase(recombinant
tissue plasminogen activator [rt-PA]), reteplase (r-PA), and tenecteplase (TNK-tPA).
Streptokinaseistheonlynonselectiveagentinuse.Furtherdetailsanddosinginformationcanbe
foundinTable4-18.
□ TNK-tPA is the current agent of choice due to similar efficacy, lower risk of bleeding,and
convenientsinglebolusadministrationascomparedtort-PA.Streptokinaseisthecheapestand
stillwidelyusedworldwide.
TABLE4-18
FIBRINOLYTICAGENTS
Medication Dosage Comments
Streptokinase
(SK)
1.5million
unitsIVover
60min
Produces a generalized fibrinolytic state (not clot
specific).
SKreducesmortalityfollowingSTEMI:18%relative
riskreductionand2%absoluteriskreduction.
95
Allergic reactions including skin rashes, fever, and
anaphylaxis may be seen in 1%–2% of patients.
Isolatedhypotensionoccursin10%ofpatientsand
usuallyrespondstovolumeexpansion.
Becauseofthedevelopmentofantibodies,patients
who were previously treated with SK should be
givenanalternatethrombolyticagent.
Recombinant
tissue
plasminogen
activator(rtPA)
15mgIV
bolus
0.75mg/kg
over30min
(maximum50
mg)
Fibrin-selective agent with improved clot specificity
comparedtoSK.
Doesnotcauseallergicreactionsorhypotension.
MortalitybenefitcomparedtoSKattheexpenseof
anincreasedriskofintracranialhemorrhage.
96,97
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0.5mg/kg
over60min
(maximum35
mg)
Reteplase(rPA)
Two10-unit
IVboluses
administered
30minapart
Fibrin selective agent with a longer half-life but
reducedclotspecificitycomparedtort-PA.
Mortalitybenefitequivalenttothatofrt-PA.
97
Tenecteplase
(TNK-tPA)
0.5mg/kgIV
bolus(total
dose30–50
mg)
Geneticallyengineeredvariant of rt-PA withslower
plasma clearance, improved fibrin specificity, and
higherresistancetoPAI-1.
Mortality benefit equivalent to that of rt-PA with
reducedbleedingrates.
98
Monitoringisrequiredwitha goalaPTTof 1.5–2.5
timescontrol.
aPTT, activated partial thromboplastin time; PAI-1, plasminogen activator inhibitor-1; STEMI, ST-segment elevation
myocardialinfarction.
□ Fibrin-selective agents should be used incombination with anticoagulant therapy, ASA, and
clopidogrel(seeearlier).GPIIb/IIIainhibitorsshouldnotbeusedinconjunction.Prasugreland
ticagrelorhavenotbeenstudiedforusewithfibrinolytics.
Fibrinolytictherapyiscontraindicated:
□ InpatientswithECGevidenceofST-segmentdepressions(unlessposteriorMIsuspected).
□ In those who are asymptomatic with initial symptoms occurring >24 hours prior (this is in
contrasttopatientswhoareasymptomaticwithsymptomonset<12hoursprior;seeearlier).
□ Inpatientswithothercontraindicationstofibrinolysis(Table4-19).
TABLE4-19
CONTRAINDICATIONSTOTHROMBOLYTICTHERAPY
AbsoluteContraindications RelativeContraindications
History of intracranial hemorrhage or
hemorrhagicstroke
Ischemicstrokewithin3mo
Known structural cerebrovascular lesion
(AVMs,aneurysms,tumor)
Closedheadinjurywithin3mo
Aorticdissection
Severe uncontrolled hypertension (SBP >
180mmHg,DBP>110mmHg)
Activebleedingorbleedingdiathesis
Acutepericarditis
Prior ischemic stroke > 3 mo
ago
Allergy or previous use of
streptokinase(>5dago)
a
Recent internal bleeding (2–4
wk)
Prolonged/traumatic CPR
morethan10min
Majorsurgerywithin3weeks
Activepepticulcerdisease
Noncompressible vascular
punctures
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Historyofintraocularbleeding
Pregnancy
Uncontrolledhypertension
Useoforalanticoagulants
AVM, arteriovenous malformation;CPR, cardiopulmonary resuscitation; DBP, diastolic blood pressure;SBP, systolic
bloodpressure.
a
Thrombolyticsotherthanstreptokinasemaybeused.
□ Inpatientswithpresenceoffiveormoreriskfactorsforintracranialhemorrhage.
AnypatientwhoexperiencesasuddenchangeinneurologicstatusshouldundergourgentheadCT,
and all anticoagulant and thrombolytic therapies should be discontinued. Neurologic and
neurosurgicalconsultationshouldbeobtainedimmediately.
Major bleeding complications that require blood transfusion occur in approximately 10% of
patients.
Postfibrinolysiscare
□ All patients should receive appropriate DAPT and at least 48 hours ofanticoagulationafter
fibrinolysis.
□ Routine coronary angiography within 24 hours of thrombolysis has reduced adverse cardiac
eventscomparedtorescuePCI.
99
□ Immediatetransferforangiography(3–24 hoursafterfibrinolysis)ataPCI-capable facilityis
alsoproventobebeneficial.
100
□ Evidenceforsuccessfulfibrinolysisincludes:
Reliefofchestpainoranginasymptoms
>50%reductioninST-segmentelevationsat90minutes
Reperfusion arrhythmia (i.e., accelerated idioventricular rhythm) up to 2 hours after
completionofinfusion
EmergencyCABGisahigh-riskprocedurethatshouldbeconsideredonlyifthepatienthassevere
leftmaindiseaseorrefractoryischemiainthesettingoffailedPCIorcoronaryanatomythatisnot
amenabletoPCI.Emergencysurgeryshouldalso beconsideredforpatientswithacutemechanical
complications of MI including papillary muscle rupture, severe ischemic MR, VSD, ventricular
aneurysm formation in the setting of intractable ventricular arrhythmias, or ventricular free wall
rupture.
Peri-InfarctManagement
Thecoronarycareunit(CCU)wasthefirstmajoradvanceinthemoderneraoftreatmentofacuteMI.
AllpatientswithSTEMIshouldbeobservedinaspecializedCCUorintensivecareunitsettingforat
least24hoursafterSTEMI.
Patientsshouldhavecontinuoustelemetrymonitoringtodetectforrecurrentischemiaandarrhythmias.
Daily evaluation should include assessment for recurrent chest discomfort, new HF symptoms, and
routineECGs.PhysicalexamshouldfocusonnewmurmursandanyevidenceofHF.
A baselineechocardiogram should beobtainedtodocumentEF, wall motion abnormalities, valvular
lesions,andpresenceofventricularthrombus.
CardiacpacingmayberequiredinthesettingofanacuteMI.Rhythmdisturbancemaybetransientin
nature, inwhichcase temporary pacing is sufficientuntil a stable rhythm returns (see the following
text).AscomparedtoinferiorwallMIswhereAVblockistransientandstable,AVblockwithanterior
wall MIs canbe unstable with wide QRS escape rhythms with 80% mortality and usually requires
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temporaryandthenpermanentpacemakers.
Post-STEMIMedicalTherapy
SeealsoMedicationssectionforUA/NSTEMI.
ASA should be continued indefinitely. Dose of 81 mg/d has been shown to be effective after PCI;
however,therangeof75–162mg/dhasalsobeenendorsed.
Clopidogrel(75mg/d),prasugrel(10mg/d),orticagrelor(90mgbid)shouldbegivenforaminimum
of12 months regardless ofwhether a bare metal stent(BMS) or drug-elutingstent (DES) was used
(thisisincontrasttonon-ACSpatientswhoreceiveaBMSandtheminimumdurationoftherapyis
1month).
BBs confer a mortality benefit following acute MI. Treatment should begin as soon as possible
(preferablywithinthefirst24hours)andcontinuedindefinitelyunlesscontraindicated.
ACEinhibitorsprovide areductioninshort-termmortality,incidenceofHF, andrecurrentMI when
initiatedwithinthefirst24hoursofanacuteMI.
101,102
PatientswithEF<40%,largeanteriorMI,andpriorMIderivethemostbenefitfromACEinhibitor
therapy.
Contraindications include hypotension, history of angioedema with use, pregnancy, acute renal
failure,andhyperkalemia.
ARBscanbeusedinpatientswhoareintolerantofACEinhibitors.
HMG-CoAreductaseinhibitorsshouldbestartedinall patientsinthe absenceofcontraindications.
Severaltrialshaveshownthebenefitofearlyandaggressiveuseofhigh-dosestatinsfollowingacute
MI.Thegoalisatleast50%reductioninLDLorLDL<70mg/dL.PatientsunabletoachieveLDL<70
mg/dLdespite a highintensity should be evaluatedfor adjunctive therapywithaPCSK9inhibitoror
ezetimibe.
Aldosteronereceptor antagonists(spironolactoneandeplerenone)haveshownbenefitinpost-MI
patientswithLVEF<40%andindiabetics.
103,104
Cautionshouldbeusedinpatientswithhyperkalemia
andrenalinsufficiency.
Warfarin should not be routinelyprescribed topatients withapical hypokinesis inthesetting of an
anterior MI in theabsence of LV thrombusor other indicationsfor anticoagulation. Such therapy is
associated with increased bleeding and death. The actual risk of developing LV thrombus is low
becausemanypatientswillhaverecoveryofhypokinesis.
105
SPECIALCONSIDERATIONS
Specialclinicalsituations
RVMIisseeninpatientswithanacuteinferiorMIsecondarytocompleteocclusionoftheproximal
RCA. RV function is very preload dependent, and frequently, hypotension responds to fluid
resuscitation.
Theclinical triadofhypotension,elevatedjugular venouspressure,andclear lungfields in the
settingofSTEMIshouldpromptanevaluationforRVinfarctormassivepulmonaryembolism.
One-mmSTelevationsintheV1orV4RleadsarethemostsensitivemarkerofRVinvolvement.
InitialtherapyisIVfluids.Ifhypotensionpersists,inotropicsupportwithdobutamineand/orIABP
may be necessary. Right-sided mechanical support devices are available when pharmacologic
supportfails.
Invasive hemodynamic monitoring is critical in the persistently hypotensive patient because it
guidesvolumestatusandtheneedforinotropicandmechanicalsupport.
InpatientswithheartblockandAV dyssynchrony,sequentialAV pacinghasamarkedbeneficial
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