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Myocardial Infarction: Difference between revisions
→Treatment
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== Treatment == | == Treatment == | ||
[[File:Figure_2_-_Reperfusion_strategies.png| | [[File:Figure_2_-_Reperfusion_strategies.png|thumb|400px|Reperfusion strategies. The thick arrow indicates the preferred strategy.]] | ||
As the formation of an intracoronary thrombus is the most common cause of the ACS and (recurrent) subsequent outcomes, the cornerstone in the treatment of ACS is antithrombotic treatment. All patients diagnosed with ACS should start with aspirin and a P2Y12 receptor blocker (clopidogrel, prasugrel or ticagrelor). <Cite>REFNAME15</Cite> Aspirin and the P2Y12 receptor blocker are both platelet aggregation inhibitors. The treatment of ACS also focuses on medication to keep the workload of the heart as low as possible. β blockers lower heart rate and blood pressure, to decrease the oxygen demand of the heart. <Cite>REFNAME16</Cite> Nitrates dilatate the coronary arteries so the heart receives more oxygenated blood. <Cite>REFNAME17</Cite> | As the formation of an intracoronary thrombus is the most common cause of the ACS and (recurrent) subsequent outcomes, the cornerstone in the treatment of ACS is antithrombotic treatment. All patients diagnosed with ACS should start with aspirin and a P2Y12 receptor blocker (clopidogrel, prasugrel or ticagrelor). <Cite>REFNAME15</Cite> Aspirin and the P2Y12 receptor blocker are both platelet aggregation inhibitors. The treatment of ACS also focuses on medication to keep the workload of the heart as low as possible. β blockers lower heart rate and blood pressure, to decrease the oxygen demand of the heart. <Cite>REFNAME16</Cite> Nitrates dilatate the coronary arteries so the heart receives more oxygenated blood. <Cite>REFNAME17</Cite> | ||
Depending on the (working) diagnosis STEMI or NSTE-ACS, the reperfusion strategy differs. | Depending on the (working) diagnosis STEMI or NSTE-ACS, the reperfusion strategy differs. | ||
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=== ''ST-Segment Elevation Myocardial Infarction'' === | === ''ST-Segment Elevation Myocardial Infarction'' === | ||
Initial treatment of STEMI is relief of ischemic pain, stabilization of the hemodynamic status, restoration of coronary flow, and myocardial tissue perfusion. Reperfusion therapy should be initiated as quickly as possible within 12 hours after symptom onset by preferably primary percutaneous coronary intervention (PCI) or otherwise fibrinolysis. Meanwhile other measures as continuous cardiac monitoring, oxygen and intravenous access are necessary to guarantee the safety of the patient. <Cite>REFNAME18</Cite> | Initial treatment of STEMI is relief of ischemic pain, stabilization of the hemodynamic status, restoration of coronary flow, and myocardial tissue perfusion. Reperfusion therapy should be initiated as quickly as possible within 12 hours after symptom onset by preferably primary percutaneous coronary intervention (PCI) or otherwise fibrinolysis. Meanwhile other measures as continuous cardiac monitoring, oxygen and intravenous access are necessary to guarantee the safety of the patient. <Cite>REFNAME18</Cite> | ||
Rapid revascularisation is essential to minimize the size of the myocardial infarction and thereby reduce mortality. In the first hours after symptom onset the amount of salvageable myocardium by reperfusion is greatest. <Cite>REFNAME19</Cite>, <Cite>REFNAME20</Cite> There is no consensus whether reperfusion after 12 hours from the onset of symptoms is still beneficial. | Rapid revascularisation is essential to minimize the size of the myocardial infarction and thereby reduce mortality. In the first hours after symptom onset the amount of salvageable myocardium by reperfusion is greatest. <Cite>REFNAME19</Cite>, <Cite>REFNAME20</Cite> There is no consensus whether reperfusion after 12 hours from the onset of symptoms is still beneficial. | ||
Primary PCI is the preferred revascularisation method for patients with STEMI. It is an effective method of securing and maintaining coronary patency and avoids the higher bleeding risk associated with fibrinolysis. If a patient is referred to a non-PCI-capable hospital, and transfer to a PCI-capable hospital in order to perform PCI within 2 hours after the onset of symptoms is not possible, fibrinolytic therapy is recommended. | Primary PCI is the preferred revascularisation method for patients with STEMI. It is an effective method of securing and maintaining coronary patency and avoids the higher bleeding risk associated with fibrinolysis. If a patient is referred to a non-PCI-capable hospital, and transfer to a PCI-capable hospital in order to perform PCI within 2 hours after the onset of symptoms is not possible, fibrinolytic therapy is recommended. | ||
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* Patients with contraindications for fibrinolysis, such as: active bleedings, recent dental surgery, past history of intracranial bleeding. <Cite>REFNAME21</Cite> | * Patients with contraindications for fibrinolysis, such as: active bleedings, recent dental surgery, past history of intracranial bleeding. <Cite>REFNAME21</Cite> | ||
* Patients with cardiogenic shock, severe heart failure and/or pulmonary oedema complicating the myocardial infarction. <Cite>REFNAME22</Cite>, <Cite>REFNAME23</Cite> | * Patients with cardiogenic shock, severe heart failure and/or pulmonary oedema complicating the myocardial infarction. <Cite>REFNAME22</Cite>, <Cite>REFNAME23</Cite> | ||
Available data support the pre-hospital initiation of fibrinolytics if this reperfusion strategy is indicated. Fibrinolytics like streptokinase stimulate the conversion of plasminogen to plasmin. Plasmin demolishes fibrin which is an important constituent of the thrombus. Fibrinolytics are most effective the first hours after the onset of symptoms, and a benefit is observed in terms of reducing mortality within the first twelve hours. <Cite>REFNAME24</Cite> The hazards of thrombolysis are the increased bleeding risk, including strokes. Because re occlusion after fibrinolysis is possible patients should be transferred to a PCI qualified hospital once fibrinolysis is done. <Cite>REFNAME25</Cite> | Available data support the pre-hospital initiation of fibrinolytics if this reperfusion strategy is indicated. Fibrinolytics like streptokinase stimulate the conversion of plasminogen to plasmin. Plasmin demolishes fibrin which is an important constituent of the thrombus. Fibrinolytics are most effective the first hours after the onset of symptoms, and a benefit is observed in terms of reducing mortality within the first twelve hours. <Cite>REFNAME24</Cite> The hazards of thrombolysis are the increased bleeding risk, including strokes. Because re occlusion after fibrinolysis is possible patients should be transferred to a PCI qualified hospital once fibrinolysis is done. <Cite>REFNAME25</Cite> | ||
There are circumstances in which CABG could be indicated, such as failed fibrinolysis and/or PCI, when the patient develops cardiogenic shock, life threatening ventricular arrhythmias, has three vessel disease, or mechanical complications of the MI. <Cite>REFNAME26</Cite> | There are circumstances in which CABG could be indicated, such as failed fibrinolysis and/or PCI, when the patient develops cardiogenic shock, life threatening ventricular arrhythmias, has three vessel disease, or mechanical complications of the MI. <Cite>REFNAME26</Cite> | ||
=== ''Non-ST-Segment Elevation Acute Coronary Syndrome'' === | === ''Non-ST-Segment Elevation Acute Coronary Syndrome'' === | ||
Comparable to STEMI, revascularization in NSTE-ACS relieves symptoms, shortens hospital | Comparable to STEMI, revascularization in NSTE-ACS relieves symptoms, shortens hospital | ||
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The optimal timing of coronary angiography with an intended routine invasive management is still a topic for debate. | The optimal timing of coronary angiography with an intended routine invasive management is still a topic for debate. | ||
== References == | == References == | ||