ACLS review: Acute Coronary Syndromes Part 10

Absolute Contraindications for Fibrinolytic Therapy*

·         Any prior intracranial hemorrhage

·         Known structural cerebral vascular lesion (eg, AVM)

·         Known malignant intracranial neoplasm (primary or metastatic)

·         Ischemic stroke within 3 months EXCEPT acute ischemic stroke within 3 hours

Absolute Contraindications for Fibrinolytic Therapy*
·         Suspected aortic dissection

·         Active bleeding or bleeding diathesis (excluding menses)

·         Significant closed head trauma or facial trauma within 3 months

Note:  Contraindications and cautions for fibrinolytic use in STEMI from ACC/AHA 2004 Guideline Update*

Relative Contraindications for Fibrinolytic Therapy*

·         History of chronic, severe, poorly controlled hypertension

·         Severe uncontrolled hypertension on presentation (SBP >180 mm Hg or DBP >110 mm Hg)

·         History of prior ischemic stroke >3 months, dementia, or known

Relative Contraindications for Fibrinolytic Therapy*

·         Recent (within 2 to 4 weeks) internal bleeding

·         Intracranial pathology not covered in contraindications

·         Traumatic or prolonged (>10 minutes) CPR or major surgery (<3 weeks)

·         Noncompressible vascular punctures

Relative Contraindications for Fibrinolytic Therapy*

·         For streptokinase/anistreplase: prior exposure (<5 days ago) or prior allergic reaction to these agents

·         Pregnancy

·         Active peptic ulcer

·         Current use of anticoagulants: the higher the INR, the higher the risk of bleeding

Note:  Contraindications and cautions for fibrinolytic use in STEMI from ACC/AHA 2004 Guideline Update*

Risk Factors for Intracranial Hemorrhage with Fibrinolytics

·         Age (>65 years),

·         Low body weight (<70 kg),

·         Hypertension on presentation (>180/110 mm Hg)

·         Use of rtPA (alteplase)

Percutaneous Coronary Intervention (PCI)

·         Coronary angioplasty by a skilled provider with or without stent placement is the treatment of choice for STEMI

·         For patients at non-PCI centers where transfer can result in an effective balloon time of <90 minutes from first medical contact

·         PPCI also applicable in for NSTEMI when emergent revascularization may result in hemodynamic and electric stability

Note:  Skilled provider:  (performing >75 PCIs per year) at a skilled PCI facility (performing > 200 PCIs annually, of which at least 36 are primary PCI for STEMI) (Class I, LOE A)

PCI versus Fibrinolytic Therapy

·         PCI has greater benefits than fibrinolytics

·         Treatment of choice for patients presenting within 90 minutes of onset of symptoms

·         Fewer contraindications than fibrinolytics

Note:  PPCI confers has clinical benefit as compared to fibrinolysis (both in terms of death and reinfarction or stroke) for the majority of patients.
PCI is the preferred reperfusion strategy in the STEMI patient who can arrive in the catheterization laboratory with balloon inflation within 90 minutes of initial hospital arrival

PCI versus Fibrinolytic Therapy

·         Treatment option for patients with  NSTEMI

·         Treatment option for patients who present to the with late symptoms of AMI

·         STEMI patients presenting in shock

Note:  High-risk STEMI patients, “late presenters” (ie, >3 hours since the onset of STEMI symptoms), and individuals with contraindication to fibrinolysis are all candidates for PCI as well.

And, of course, if the diagnosis of STEMI is in doubt, regardless of the reason, initial coronary angiography followed by PCI is the most appropriate diagnostic and therapeutic strategy.

For those STEMI patients presenting in shock, PCI (or CABG) is the preferred reperfusion treatment

Sources: O'Connor RE, Brady W, Brooks SC, Diercks D, Egan J, Ghaemmaghami C, Menon V, O'Neil BJ, Travers AH, Yannopoulos D. Part 10: acute coronary syndromes: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122(suppl 3):S787–S817