Recent Publications

Sustain the Gain — “The Virginia Heart Attack Coalition”

Dr. Peter O’Brien and Dr. Mike Kontos (6/17/11)

Slides and audio presentation from this webinar provide an overview of VHAC/ML and recent data relevant to Virginia. You can also listen to a thought-provoking Q&A session joined by Dr. David Burt.

2009 UPDATED PRIMARY PCI AND STEMI RECOMMENDATIONS

This is a condensed version of the focused updated recommendations for PCI and for STEMI.

Glycoprotein IIb/IIIa Receptor Antagonists

Class IIa -— (changed from a IIb to a IIa for tirofiban and eptifibatide). Either abciximab, tirofiban or eptifibatide can be used for primary PCI. The infusion should be continued for 12 to 18 hours at the discretion of the physician.

Thienopyridines

Class I

Primary PCI

Clopidogrel, 300 to 600 mg, as early as possible before or at the time of primary or nonprimary PCI.

Or

Prasugrel 60 mg should be given as soon as possible for primary PCI.

STEMI, nonprimary PCI

Received fibrinolytic therapy, already given clopidogrel — clopidogrel should be continued

Received fibrinolytic therapy, no thienopyridine given — clopidogrel, 300 to 600 mg should be given

No fibrinolytic therapy–either clopidogrel or, once anatomy is known and PCI is planned, prasugrel should be given within 1 hour after PCI.

Current thienopyridine treatment, need for CABG, attempt to stop prasugrel for at least 7 days.

Class IIa — Supplementation with GP IIb/IIIa receptor antagonists can be beneficial when added to clopidogrel.

Class IIb — Continuation of clopidogrel or prasugrel >15 months may be considered in patients undergoing DES placement (Change–increased from 1 year to 15 months).

Class III — In STEMI patients undergoing primary PCI with a history of CVA or TIA, prasugrel is not recommended.

Anti-coagulants

Class I

For patients undergoing primary PCI, with prior treatment with UFH, either UFH (ACT should be monitored) or bivalirudin can be given (Change–Bivalirudin was added as acceptable for primary PCI).

Class IIa

In STEMI patients undergoing PCI who are at high risk of bleeding, bivalirudin is reasonable (New recommendation).

Recommendations for Triage and Transfer for PCI

Class I

Each community should develop a STEMI system of care that follows standards at least as stringent as those developed as Mission: Lifeline, to include the following:

ongoing multidisciplinary team meetings that include EMS, non–PCI hospitals and PCI hospitals;

a process for prehospital identification and activation;

destination protocols for STEMI receiving centers;

transfer protocols for patients who arrive at STEMI referral centers who are primary PCI candidates, are ineligible for fibrinolytic drugs, and/or are in cardiogenic shock.

Class IIa

high-risk patients treated with fibrinolytic therapy at a non–PCI-capable facility may be transferred as soon as possible to a PCI-capable facility.

Class IIb

not at high risk treated wtih fibrinolytic therapy at a non–PCI-capable facility may be considered for transfer as soon as possible to a PCI-capable facility

(These are modified from prior recommendations)

Intensive Glucose control

Class I

aggressive control of glucose levels with insulin infusion is no longer recommended.

Instead:

Class IIa

an insulin-based regimen to achieve and maintain glucose levels l < 180 mg/dL while avoiding hypoglycemia is recommended (although ideal target glucose level is unknown).

New recommendations (Not previously addressed in prior PCI and STEMI recommendations)

Thrombus aspiration is considered a Class IIa.

Drug eluting stents instead of BMS are considered a Class IIa.

In patients with renal failure, either an isosmolar contrast or a low-molecular-weight contrast other than ioxaglate or iohexol is indicated (Now Class I, modified from recommending isosmolar contrast agents are indicated and are preferred).

PCI Only Recommendations

Left Main PCI — Follow up angiography in patients who had PCI to unprotected left main disease is no longer recommended.

Class IIb — Stenting of the left main as an alternative to CABG may be considered if the anatomy is associated with a low risk of PCI complications and clinical conditions predict an increased risk of adverse surgical outcomes (New recommendation).

The recommendations for use of glycoprotein IIb/IIIa inhibitors in primary PCI remain unchanged (Class IIa), despite findings from several recent studies suggesting that the benefit of these drugs is reduced in patients who are pretreated with dual antiplatelet therapy. In addition, the small-molecule agents tirofiban and eptifibatide have been elevated to the same class of recommendation as abciximab.

In regard to thienopyridines:

Relying on data from the TRITON–TIMI 38 trial , the guideline authors now recommended prasugrel as an option for antiplatelet treatment before PCI (except in STEMI patients with a history of stroke or transient ischemic attack).

More emphasis is given to the alternative of an increased clopidogrel loading dose (600 mg instead of 300 mg).

Despite a recent FDA advisory , the guideline authors declined to make a specific recommendation about the concurrent use of clopidogrel and proton-pump inhibitors.

Bivalirudin is now considered an acceptable anticoagulant for primary PCI, based on data from the HORIZONS-AMI trial (Class I, level of evidence B).

A new Class I recommendation encourages communities to develop systems of STEMI care to improve recognition, catheterization laboratory activation, and transfer protocols. In addition, a new Class IIa recommendation encourages early transfer of patients at high cardiovascular risk who receive fibrinolytic therapy at a facility without PCI capability to a facility with PCI capability.

Findings from two new — but small — trials support manual thrombus aspiration before primary PCI, prompting a new Class IIa recommendation of this practice as a reasonable strategy.

Similarly, drug-eluting stents are now considered a reasonable alternative to bare-metal stents (Class IIa) in patients with STEMI (they remain a Class IIb recommendation in patients with unstable angina or non-STEMI).

A new recommendation (Class IIb) supports PCI for left main coronary lesions in patients at low risk for procedural complications and high risk for adverse surgical outcomes. The previous recommendation for planned angiographic follow-up 2 to 6 months after such procedures has been removed.

The guideline authors now recommend early administration of dual antiplatelet therapy in patients with unstable angina or NSTEMI and angiography within 12 to 24 hours after admission for such patients at high cardiovascular risk.

 

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