c_acs_ebm

EBM for interventions in acute coronary syndromes

Evidence for interventions in pts with coronary syndromes:

out-of-hospital 12 lead ECG's:

Class I:
  • Patients with AMI receive an earlier diagnosis and faster treatment with fibrinolytic drugs in the ED when paramedics obtain a 12-lead ECG in the field and transmit the tracing to the receiving emergency physician before the patient arrives at the hospital. Out-of-hospital 12-lead ECG diagnostic programs should be implemented in urban and suburban paramedic systems at mean cost per year of life saved ~$A1200 by 5yrs after implementation.

out-of-hospital thrombolysis:

Class IIb (consider):
  • EMS systems that transport large numbers of eligible AMI patients (>= 1 per month) and that routinely have transport times of 1 hour or longer, otherwise not recommended as long as hospital door-to-needle times are ~30min

out-of-hospital triage:

Class I :
  • AMI patients with overt heart failure with or without shock should be transported to a nearby hospital (if available) with IABP and PCI or CABG revascularization capabilities

primary angioplasty vs thrombolysis (fibrinolysis) in pts with AMI:

primary angioplasty (as long as experienced service with full resources needed) for patients:
  • who develop cardiogenic shock or pump failure and can be treated within 18 hours of onset of shock; 
  • who are considered at high risk & who have a contraindication to fibrinolysis; 
  • who are considered at high risk after unsuccessful fibrinolysis; 
  • and as an alternative to fibrinolysis in patients with ST-segment elevation or new (or presumably new) left bundle branch block ==who can undergo angioplasty of the IRA within 12 hours after the onset of symptoms or after more than 12 hours if ischemic symptoms persist==
  • who are considered at high risk who present to the hospital more than 4 hours after symptom onset;
  • who have a possible “stuttering” infarction with ECG changes but no clear indication for fibrinolytic therapy 
  • who have a history of CABG surgery in whom occlusion of a vein graft may have recently occurred
Class IIb (may be helpful and is probably not harmful):
  • who are not at high risk (regardless of whether they are suitable for fibrinolysis or have a contraindication to it);
  • who are at high risk presenting within the first 2 hours after symptom onset; 
  • who are not at high risk after unsuccessful fibrinolysis.
  • who are treated with elective angioplasty of a non-IRA at the time of AMI
  • who have received fibrinolytic therapy and have no symptoms of myocardial ischemia
  • who are eligible for fibrinolysis who are being treated at a center with a low volume of primary angioplasties and no surgical capability
  • who have spontaneous complete reperfusion at the moment of emergency angiography (ie, relief of chest pain, spontaneous and sustained achievement of TIMI grade 3 coronary flow of the IRA, and a reduction of ST-segment elevation of <50% compared with the initial ECG).
insufficient evidence to recommend primary angioplasty:
  • who have inferior AMI and right ventricular involvement
  • who are at high risk presenting more than 12 hours after symptom onset without evidence of ongoing ischemia or hemodynamic impairment.

thrombolysis:

class I (recommended):
  • pts with no C/I to thrombolysis and no evidence of cardiogenic shock and either:
    • AMI with ST elevation or new LBBB, within 6hrs of onset of pain in pts aged < 75 yrs
    • GP IIb/IIIa inhibitors:
Class IIa:
  • patients with unstable angina or non-ST-segment elevation MI who are at high risk for adverse cardiovascular events, especially in conjunction with PCI
Class IIb:
  • consider in patients with an acute coronary syndrome who are not at high risk for adverse cardiovascular events

Glucose-insulin-potassium (GIK):

Class IIb:
  • consider in patients with AMI

References:

  • Aufderheide TP et al. Acute coronary syndromes. Ann Emerg Med. April 2001;37:S163-S181
c_acs_ebm.txt · Last modified: 2008/10/27 04:44 (external edit)