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Reperfusion
I IIa IIb III STEMI patients presenting to a hospital with PCI
capability should be treated with primary PCI
within 90 minutes of first medical contact.

I IIa IIb III STEMI patients presenting to a hospital without


PCI capability and who cannot be transferred to a
PCI center for intervention within 90 minutes of
first medical contact should be treated with
fibrinolytic therapy within 30 minutes of hospital
presentation, unless contraindicated.
( ( 1 ! 

Lives Saved per Thousand Treated
 †9

 37 35
 25
19 18

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_acilitated PCI
I IIa IIb III A planned reperfusion strategy using full-
full-dose
fibrinolytic therapy followed by immediate PCI may be
harmful.
Immediate or Emergency
Invasive Strategy and Rescue PCI
Coronary angiography with intent to perform PCI (or
emergency CABG) is recommended for patients who
have received fibrinolytic therapy and have any of the
following:
I IIa IIb III

Cardiogenic shock in patients less than 75 years who


are suitable candidates for revascularization.
I IIa IIb III
Severe congestive heart failure and/or pulmonary edema
(Killip class III).
I IIa IIb III

Hemodynamically compromising ventricular arrhythmias.


Immediate or Emergency
Invasive Strategy and Rescue PCI

I IIa
II IIb III Coronary angiography with intent to perform rescue PCI is
a reasonable for patients in who fibrinolytic therapy has failed
ST--segment elevation <50% resolved after 90 minutes
ST
following initiation of fibrinolytic therapy
Moderate or large area of myocardium at risk
Anticoagulants as Ancillary Therapy
I IIa IIb III
Patients undergoing reperfusion with
fibrinolytics should receive anticoagulant
therapy for a minimum of †8 hours, and
preferably for the duration of the index
hospitalization, up to 8 days.

I IIa IIb III


Regimens other than U_H are recommended
if therapy is given for more than †8 hours
because of risk of heparin-
heparin-induced
thrombocytopenia.

Regimens with established efficacy include:


U_H, enoxaparin, fondaparinux
 

þ Recommended in:
Ä Patients receiving fibrinolytics (not
SK/APSAC)
Ä All patients undergoing PCI.

þ Dosing:
Ä 60 unit/kg bolus then 12 units/kg/hr (max
†000/1000)
Beta--Blockers
Beta
Oral beta-
beta-blocker therapy should be initiated in
the first 2† hours for patients who do not have
the following:
Signs of heart failure
Evidence of low output state
I IIa IIb III
Increased risk for cardiogenic shock
Age >70 years
Systolic blood pressure <120 mm Hg
Sinus tachycardia (heart rate >110 or < 60 bpm)
Increased time since onset of symptoms of STEMI
Relative contraindications to beta-
beta-blockade
PR interval >0.2† seconds
second-- or third-
second third-degree heart block
active asthma or reactive airway disease
Beta--Blockers
Beta
It is reasonable to administer an IV beta-
beta-
blocker at the time of STEMI presentation to
I IIa IIb III patients who are hypertensive and who do not
have any of the following:
Signs of heart failure
Evidence of low output state
Increased risk for cardiogenic shock
Other relative contraindications to beta-
beta-blockade

I IIa IIb III IV beta blockers should not be administered to patients


who have any of the following:
Signs of heart failure
Evidence of low output state
Increased risk of cardiogenic shock
Other relative contraindications to beta-
beta-blockade

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&     "(& 

2007 Goals: Secondary Prevention
Smoking: Complete cessation, no exposure
to environmental tobacco smoke.

Blood Pressure Control: <1†0/90 mmHg or


<130/80 mmHg if patient have diabetes or
chronic kidney disease.

Physical Activity: 30 minutes, 7 days per


week (minimum 5 days per week).
2007 Goals: Secondary Prevention
Weight Management:
Goals: BMI 18.5 - 2†.9 kg/m2 and
Waist circumference in men <†0 in;
women <35 in

Diabetes Management:
HbA1c less than 7%.

Influenza Vaccination:
Patients with cardiovascular disease should have
an annual influenza vaccination.