Nonpharmacologic Therapy Primary PCI for Ste Acss

^^ Early reperfusion therapy with primary PCI within 90 minutes from time of hospital presentation is the reperfusion treatment of choice for patients presenting with STE ACS.3,4 (Fig. 8-2) For primary PCI, the patient is taken from the emergency department to the cardiac catheterization laboratory and undergoes coronary angiography with either balloon angioplasty or placement of a bare metal or drug-eluting intracoronary stent. About 62% of patients with STE ACS are treated with primary PCI and 18% are treated with fibrinolytics. Results from a meta-analysis of trials comparing fibrinolysis to primary PCI indicate a lower mortality rate with primary PCI.13 One reason for the superiority of primary PCI compared to fibrinolysis is that more than 90% of occluded infarct-related coronary arteries are opened with primary PCI compared to fewer than 60% of coronary arteries opened with currently available fibrinolytics.9 In addition, intracranial hemorrhage and major bleeding risks from primary PCI are lower than the risks of severe bleeding events following fibrinolysis. An invasive strategy of primary PCI is generally preferred in patients presenting to institutions with skilled interventional cardiologists and a catheterization laboratory immediately available, in patients in cardiogenic shock, those with contraindications to fibrinolytics, and those presenting with symptom onset greater than 3 hours ago. A quality performance measure (quality performance measures are measures of quality health care developed from practice guidelines and intended to permit the quality of patient care to be assessed, compared between institutions and over time, and ultimately, improved) in the care of MI patients with STE is the time from hospital presentation to the time that the occluded artery is opened with PCI. This "door-to-primary PCI" time should be equal to or less than 90 minutes.3,14 Currently, the median time for primary PCI is 87 minutes with only 54% of patients being treated within 90 minutes. Hospitals should have policies in place describing triage and catheterization laboratory personnel mobilization for implementing primary PCI for the patient with STE MI.

FIGURE 8-2. Initial pharmacotherapy for ST-segment elevation MI. aFor at least 48 hours. bFor selected patients, see Table 8-2. cFor the duration of hospitalization, up to 8 days. dExact dose not known. (ACSs, acute coronary syndromes; CABG, coronary artery bypass graft surgery; hrs, hours; IV, intravenous; NTG, nitroglycerin; PCI, percutaneous coronary intervention; SC, subcutaneous; SL, sublingual; UFH, unfractionated heparin.) (Adapted from Spinler SA, de Denus S. Acute Coronary Syndromes. In DiPiro JT, Talbert RL, Yee GC, et al., eds. Pharmacotherapy: A Pathophysiologic Approach. 7th ed. New York: McGraw-Hill; 2008: 256, with permission.) From Refs. 3, 9.

FIGURE 8-2. Initial pharmacotherapy for ST-segment elevation MI. aFor at least 48 hours. bFor selected patients, see Table 8-2. cFor the duration of hospitalization, up to 8 days. dExact dose not known. (ACSs, acute coronary syndromes; CABG, coronary artery bypass graft surgery; hrs, hours; IV, intravenous; NTG, nitroglycerin; PCI, percutaneous coronary intervention; SC, subcutaneous; SL, sublingual; UFH, unfractionated heparin.) (Adapted from Spinler SA, de Denus S. Acute Coronary Syndromes. In DiPiro JT, Talbert RL, Yee GC, et al., eds. Pharmacotherapy: A Pathophysiologic Approach. 7th ed. New York: McGraw-Hill; 2008: 256, with permission.) From Refs. 3, 9.

FIGURE 8-3. Initial pharmacotherapy for non-ST-segment elevation ACS. aFor selected patients, see Table 8-2. bEnoxaparin, UFH, fondaparinux plus UFH, or bivalirudin for early invasive strategy; enoxaparin or fondaprinux if no angiography/PCI planned. cln patients unlikely to undergo coronary artery bypass graft surgery. dMay require an IV supplemental dose of enoxaparin, see Table 8-2.

May require an IV supplemental dose of UFH, see Table 8-2 signs and symptoms of recurrent ischemia. 9SC enoxaparin or UFH can be continued at a lower dose for venous thromboembolism prophylaxis. (ACE, angiotensin-converting enzyme; ACSs, acute coronary syndromes; ARB, angiotensin receptor blocker; hrs, hours; IV, intravenous; NTG, nitroglycerin; PCI, percutaneous coronary intervention; SC, subcutaneous; SL, sublingual; UFH, unfractionated heparin.) (Adapted from Spinler SA, de Denus S. Acute Coronary Syndromes. In DiPiro JT, Talbert RL, Yee GC, et al., (eds.) Pharmacotherapy: A Pathophysiologic Approach. 7th ed. New York: McGraw-Hill; 2008: 264, with permission.)

FIGURE 8-3. Initial pharmacotherapy for non-ST-segment elevation ACS. aFor selected patients, see Table 8-2. bEnoxaparin, UFH, fondaparinux plus UFH, or bivalirudin for early invasive strategy; enoxaparin or fondaprinux if no angiography/PCI planned. cln patients unlikely to undergo coronary artery bypass graft surgery. dMay require an IV supplemental dose of enoxaparin, see Table 8-2.

May require an IV supplemental dose of UFH, see Table 8-2 signs and symptoms of recurrent ischemia. 9SC enoxaparin or UFH can be continued at a lower dose for venous thromboembolism prophylaxis. (ACE, angiotensin-converting enzyme; ACSs, acute coronary syndromes; ARB, angiotensin receptor blocker; hrs, hours; IV, intravenous; NTG, nitroglycerin; PCI, percutaneous coronary intervention; SC, subcutaneous; SL, sublingual; UFH, unfractionated heparin.) (Adapted from Spinler SA, de Denus S. Acute Coronary Syndromes. In DiPiro JT, Talbert RL, Yee GC, et al., (eds.) Pharmacotherapy: A Pathophysiologic Approach. 7th ed. New York: McGraw-Hill; 2008: 264, with permission.)

Patient Encounter 1, Part 2

Identify your acute treatment goals forSD.

Is reperfusion therapy with fibrinolysis indicated at this time?

What adjunctive pharmacotherapy should be administered to SD in the emergency department?

What additional pharmacotherapy should be initiated on the first day of SD's hospitalization following successful reperfusion?

PCI during hospitalization for STE MI may also be appropriate in other patients following STE MI, such as those in whom fibrinolysis is not successful, those presenting later in cardiogenic shock, those with life-threatening ventricular arrhythmias, and those with persistent rest ischemia or signs of ischemia on stress testing following MI.34

Was this article helpful?

0 0
Beating Insomnia

Beating Insomnia

Discover How to Beat Insomnia Naturally & Enjoy a Great Night’s Sleep. The Secrets You Need to Know to Fall Asleep Fast, Sleep Through the Night & Awaken Feeling Rested, Refreshed and Rejuvenated.

Get My Free Ebook


Post a comment