Canadian Journal of Cardiology
ReviewAssessment and Management of Acute Coronary Syndromes (ACS): A Canadian Perspective on Current Guideline-Recommended Treatment – Part 2: ST-Segment Elevation Myocardial Infarction
Section snippets
Identification of STEMI
The electrocardiogram (ECG) recorded at the time of first medical contact (Emergency Medical Service [EMS], emergency department, or physician's office) permits rapid triage to the optimal reperfusion strategy. When the ECG is performed in the prehospital phase, it allows initiation of prehospital fibrinolysis or selective transfer to a hospital with primary PCI facilities bypassing the emergency department which accelerates access to treatment. The ECG criteria for initiating reperfusion
Reperfusion Strategies
The patient with ischemic chest pain of onset in the past 12 hours and ECG abnormalities consistent with an acute STEMI should be considered for immediate reperfusion by either primary PCI or fibrinolysis. Rapid reperfusion is the key to improved outcomes. Consequently, it is important that timeliness to reperfusion to recommended targets remains an important goal and measure of quality of care.
A significant number of patients who are eligible are not offered reperfusion by either fibrinolysis
Fibrinolysis
Available fibrinolytic agents in Canada include streptokinase, reteplase (rPA), alteplase (tPA), and tenecteplase (TNK). Doses and administration schedules are shown in Table 5. Alteplase is superior to streptokinase,40 and reteplase (double bolus)41 and tenecteplase (single bolus)42 appear comparable to alteplase in efficacy although tenecteplase is a single bolus, weight-adjusted agent also associated with less major (nonintracerebral) bleeding.
Early invasive strategy
An early invasive strategy for the management of patients with STEMI is the use of angiography and PCI performed within a short time (eg, within 6 to 12 hours) after the administration of fibrinolysis. Initial studies of routine PCI after STEMI, and more recent trials that performed angiography and PCI immediately after fibrinolysis showed either harm or no benefit. In contrast, more recent studies examining the role of an early invasive strategy several hours postfibrinolysis have demonstrated
Treatment Options for Patients Presenting Late or Ineligible for Reperfusion Therapy
A review of therapy for STEMI patients who present late or who are ineligible for reperfusion therapy20 shows that there is good evidence for similar benefits for ASA, clopidogrel, heparin, low molecular weight heparin, fondaparinux, β-blocker, statin, and angiotensin converting enzyme inhibitor use in this population as in patients undergoing reperfusion. The ACC/AHA and ESC Guidelines recommendations for these therapies do not distinguish between patients that have had reperfusion therapy or
Discharge and Long-Term Treatment
Treatment and management strategies to improve long-term outcomes in patients with ACS are similar, whether the patient sustained a STEMI or a non-ST elevation ACS. Details of these strategies are found in Table 13 of Part 1.75 Additional Canadian recommendations for antiplatelet therapy after ACS are to be found in the recently published Canadian Cardiovascular Society Guidelines for antiplatelet therapy.70
Funding Sources
Publication of this article was supported by AstraZeneca Canada Inc. and Bristol-Myers Squibb Canada and sanofi-aventis Canada.
Disclosures
David Fitchett has received speaker honoraria from and served on advisory boards for Astra Zeneca, sanofi-aventis, Bristol-Myers Squibb, Eli Lilly, Merck, Novartis, Pfizer, Servier, Boehringer Ingelheim, Abbott, and Roche.
Pierre Theroux has served as a consultant for AstraZeneca, Bristol-Myers Squibb, Eli Lilly, Merck, and sanofi-aventis. Dr Theroux has also received speaker honoraria from AstraZeneca, Boeringher Ingelheim, Bristol-Myers Squibb, and sanofi-aventis, and he has received a
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