ACLS review: Acute Coronary Syndromes Part 9

Reperfusion

·         Restores flow in the infarct-related artery

·         Limits infarct size

·         Reduces mortality rates

·         Optimal fibrinolysis restores normal coronary flow in 50% to 60% of subjects

·         PPCI is able to achieve restored flow in >90% of subjects.

Note:  The patency rates achieved with PPCI translates into reduced mortality and reinfarction rates as compared to fibrinolytic therapy.
This benefit is even greater in patients presenting with cardiogenic shock.
PPCI also results in a decreased risk of intracranial hemorrhage and stroke, making it the reperfusion strategy of choice
Circulation. 2010; 122: S787-S817 doi: 10.1161/​CIRCULATIONAHA.110.971028

Key to Reperfusion Therapy

·         The key to reperfusion therapy is that the earlier therapy begins, the better the outcome

·         Time = muscle

·         Better outcomes have been reported if reperfusion therapy is initiated less than 12 hours since the onset of the symptoms

Note:  In patients presenting within 2 hours of symptom onset or when delays to PCI are anticipated, fibrinolytic therapy is recommended. In these circumstances fibrinolytic therapy has equivalent or improved outcomes compared to PCI, especially when the benefit to bleeding risk is favorable (eg, young age, anterior location of MI) (Class 1, LOE B).
Circulation. 2010; 122: S787-S817 doi: 10.1161/​CIRCULATIONAHA.110.971028

Fibrinolytics

·         Treatment for STEMI who present within 12 hours of symptoms and who lack contraindications

·         The goal is a door-to-needle time of less than 30 minutes. The shorter the time to reperfusion, the greater the benefit.

·         A 47% reduction in mortality with fibrinolytic therapy was provided within the first hour after onset of symptoms

Note:  Fibrinolytic therapy is recommended for STEMI if symptom onset has been within 12 hours of presentation and PCI is not available within 90 minutes of first medical contact

Patients are evaluated for risk and benefit; for absolute and relative contraindications to therapy

Fibrinolytic therapy is generally not recommended for patients presenting between 12 and 24 hours after onset of symptoms unless continuing ischemic pain is present with continuing ST-segment elevation

Fibrinolytics

·         Patients who have symptoms highly suggestive of ACS and ECG findings consistent with LBBB

·         Inferior wall STEMI

·         Patient subgroups with comorbidities

Note: Patients who have symptoms highly suggestive of ACS and ECG findings consistent with LBBB are also appropriate candidates for fibrinolysis because they have the highest mortality rate when LBBB is due to extensive

Inferior wall STEMI also benefits from fibrinolysis, yet the magnitude of this outcome improvement is markedly less robust

Fibrinolytics have been shown to be beneficial across a spectrum of patient subgroups with comorbidities such as previous MI, diabetes, tachycardia, and hypotension.

Older patients (>75 years) have a higher risk of death, their absolute benefit appears to be similar to that of younger patients