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Management of ST elevation myocardial infarction: update 2009

Acute Coronary Syndromes (ACS)

This update session was launched by Prof. Clemmensen who reviewed the organizational challenges of pre hospital reperfusion. About a third of AMI patients do not make it alive to hospital, which emphasizes the great importance of pre hospital management. Public awareness, CPR and AEDs are critically important. Proper triage is greatly facilitated by ECG telemetry for expert consultation. This facilitates direct triage of patients to PCI-capable centers, which is a better approach than transfer to the nearest hospital and secondary transfer for primary PCI. Unfortunately, not all ambulances in Europe have ECG capability and only a third can transmit an ECG. Ambulances should have telemetry capability and a single phone number that they can use for expert consultation. Extensive training of ambulance personnel is also important.

Prof. Nicolas Danchin then discussed reperfusion strategies. While primary PCI is clearly the preferred method of reperfusion, its universal application is a major challenge in real life and timely thrombolysis remains important. The point of equipoise between primary PCI and thrombolysis varies with the patient’s risk and time since symptom onset, and care must be taken not to delay reperfusion unnecessarily in preparation for primary PCI. The main two strategies that combine thrombolysis and primary PCI are facilitated PCI and the pharmaco-invasive approach. Facilitated PCI, i.e. systematic administration of thrombolysis in patients scheduled for primary PCI, has proven to be not better, or even worse than primary PCI.

Conversely, in patients who have received thrombolysis, routine early angiography with PCI as needed, performed 6-24 hours after admission, has been shown to be beneficial in a number of studies (most recently the CARESS in AMI and the TRANSFER AMI studies) and should be adopted. Finally, real world experience, such as reported by the Vienna and the French FAST AMI registries, indicates that effective networks, incorporating primary PCI to as often as possible and pre hospital thrombolysis when delays to PCI are expected, yield excellent results.

Prof. Lars Wallentin reviewed the available evidence for pharmacological support during STEMI. As outlined by the recent ESC guidelines, all patients should receive aspirin and clopidogrel. Prasugrel  and Ticagrelor are new attractive alternatives. There is then a choice between unfractionated heparin, enoxaparin, fondaparinux (with streptokinase) and bivalirudin. GP IIb/IIIa inhibitors, most notably abciximab, have an important role as well. Numerous combinations of these agents are possible and further study is needed to define the optimal one.

Dr. Abbate discussed management of patients presenting beyond the 12 hour window of reperfusion. The approach to these patients should be individualized. In patients presenting between 12-72 hours, there are data to suggest that if they are hemodynamically compromised or when there is evidence of ongoing ischemia, revascularization is beneficial. The OAT trial showed no benefit of revascularization in this subset of patients if the infarct related artery was totally occluded. In patients presenting beyond 72 hours, there was again no benefit for revascularization in OAT but other studies, where some patients had a patent vessel and/or evidence of ischemia did show benefit such that most of these patients should still have diagnostic angiography to determine coronary anatomy, following which individualized decisions can be made regarding the potential benefit of revascularization. In general, PCI should be performed if the infarct related artery shows a significant lesion but is not totally occluded.




Management of ST elevation myocardial infarction: update 2009

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.