MI management, basic question

[Fungi121]

Hey all, intern here trying to get all this jazz straight. I know there's a bazillion mnemonics out there, but I'm just trying to make sure my management of STEMI and NSTEMI is correct for what we do in the emergency department. In addition to oxygen, monitor, and IV access:

STEMI --> Aspirin, clopidogrel, nitro (if no contraindications), heparin (ufh vs lmwh depending on institution, I guess), beta blocker (f no contraindications), PCI (and if going to PCI, give IIb/IIIa drug like abciximab)

NSTEMI --> aspirin, clopidogrel, nitro, bblockers....maybe IIb/IIIa inhibitor?

I know this is basic stuff, but I'm getting a lot of different information from different sources, just wanted to clarify..

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[migm]

STEMI -> Aspirin, likely heparin if going to cath, NTG if not inferior, O2 only if hypoxic, Plavix, defer GP2/3b to cards since no better if doing in ER and you may screw them over --> PCI vs lysis depending on institution. Morphine - rather not. B-blocker, only if no e/o heart failure and I think HR/BP is driving ischemia in the ED.

NSTEMI -> as above, change heparin for lovenox if able, may add IIB/IIIB and B-blocker for persistent ischemia but after talking to cards and pushing for cath

the gp inhibitors are great if you are gonna go stick a catheter in them.. if not, i'm not really sure if there's still a concrete benefit for routine use but I do go therefore persistent ischemia.. not sure how others practice.

 

[goodoldalky]

There is no easy answer to your question. The only thing cardiologists agree on across the board for STEMIs is aspirin. There are numerous heparin/heparin analogs/GP 2B3As/thienopyridines, etc. Even the AHA guidelines give nothing more than a menu of all of the options for STEMI.
Briefly,
1. ASA
2. One of the following: Heparin, Lovenox, Angiomax, Arixtra
3. One of the following: Plavix, Brilinta, Effient, Integrilin
PCI
Lyse if time to first medical contact to PCI >120 min.

Beta blockers in the ACUTE phase of a STEMI are really only necessary if there is tachycardia exacerbating ischemia, nitro is a pretty fair drug as long as there is not a concern for an RV infarct in which case you will tank their pressure, use zofran if you give morphine to avoid the "Thew up all the important meds problem". Finally, there was one trial where lipitor given pre PCI for STEMI decreased the 30 day MACE (major adverse cardiac event) rate, so I have worked in hospital systems where that was right behind the aspirin in standard therapy.

NSTEMI's are treated with dual anti platelet therapy and early PCI is really only indicated for ongoing ischemic pain, electrical instability, cardiogenic shock, etc, otherwise there is zero benefit to early PCI and typically this is deferred for a couple days. Usually for me this means that I will administer lovenox and aspirin and on the inpatient side this will become aspirin and then an appropriate GP2B3a or clopidogrel if they end up with a stent.

I will promise you this, it's done differently everywhere because there is no one "standard" correct cocktail.

 

[RustedFox]

Damn good and thought provoking question. Its threads like this that make this forum great.

Hate to be the "simple guy" but the way I approach this is... I'll give it as long as I think it won't hurt them.
I don't B-block often in STEMI, but they're not staying in the ER for 10-15 mins anyways.

Here's generally how the conversation goes with 90%+ of my interventional cards guys:

Me: "Hey, big STEMI. Starting ASA, NTG gtt, heparin bolus... you want plavix or brilinta?
Cards: "Don't care. I'll be there in 10 mins."

 

[alpinism]

Basic but very important point lost on many EM residents:

AVOID oxygen in any MI unless the patient is hypoxemic.

If hypoxemic carefully titrate oxygen to an SpO2 between 94-98%.

http://www.scancrit.com/2012/04/11/oxygen-enough-already/

http://www.scancrit.com/2014/11/26/avoid-oxygen/

 

[medicsb]

There's no longer a good role for beta-blockers in the early management of STEMI, even if tachycardic. COMMIT (https://www.ncbi.nlm.nih.gov/pubmed/16271643) demonstrated this pretty well. Basically, it can wait and be started on the inpatient side after the patient has stabilized, as the benefit of beta-blockade was found after the first 24 hours.

 

[deleted547339]

Must easier than it seems:

1) Anyone with CP gets aspirin
2) Call cards with STEMI, give what they want you to (or don't) and send to the cath lab ASAP; heparin and a second anti-platelet can be given in the ED or in the cath lab, depending on interventional cards preference and availability. 5 minutes to cath lab? Probably just send them. 30 minutes in ED? Probably give brillianta and start a heparin drip
3) NSTEMI nothing you do matters except aspirin. Do whatever cards says because there is no science and it's all just voodoo. Everything else is window dressing. Heparin is universally given, but has no real benefit. Morphine doesn't help and may actually hurt by slowing onset of anti-platelet activity. Data doesn't support beta-blockers in the acute setting, let the docs upstairs do that.

 

[Zebra Hunter]

Must easier than it seems:

1) Anyone with CP gets aspirin
2) Call cards with STEMI, give what they want you to (or don't) and send to the cath lab ASAP; heparin and a second anti-platelet can be given in the ED or in the cath lab, depending on interventional cards preference and availability. 5 minutes to cath lab? Probably just send them. 30 minutes in ED? Probably give brillianta and start a heparin drip
3) NSTEMI nothing you do matters except aspirin. Do whatever cards says because there is no science and it's all just voodoo. Everything else is window dressing. Heparin is universally given, but has no real benefit. Morphine doesn't help and may actually hurt by slowing onset of anti-platelet activity. Data doesn't support beta-blockers in the acute setting, let the docs upstairs do that.

This is my approach, as well. There is so much variability in cardiologist's preferences with little data to support going one way or the other, that I just give aspirin and call cards to see what else they want. For STEMIs, most of our cardiologists just ask that we bring them up to Cath lab and they'll take care of the meds themselves.

 

[K31]

Basic but very important point lost on many EM residents:

AVOID oxygen in any MI unless the patient is hypoxemic.

This, so much. It's my constant struggle to keep the nurses from putting oxygen on every chest pain patient.

 

[Zebra Hunter]

This, so much. It's my constant struggle to keep the nurses from putting oxygen on every chest pain patient.

Or any non-hypoxic patient, for that matter

http://jamanetwork.com/journals/jama/article-abstract/2565306

 

[coachB]

Must easier than it seems:

1) Anyone with CP gets aspirin
2) Call cards with STEMI, give what they want you to (or don't) and send to the cath lab ASAP; heparin and a second anti-platelet can be given in the ED or in the cath lab, depending on interventional cards preference and availability. 5 minutes to cath lab? Probably just send them. 30 minutes in ED? Probably give brillianta and start a heparin drip
3) NSTEMI nothing you do matters except aspirin. Do whatever cards says because there is no science and it's all just voodoo. Everything else is window dressing. Heparin is universally given, but has no real benefit. Morphine doesn't help and may actually hurt by slowing onset of anti-platelet activity. Data doesn't support beta-blockers in the acute setting, let the docs upstairs do that.

Exactly. Keep it simple.

 

[migm]

There's no longer a good role for beta-blockers in the early management of STEMI, even if tachycardic. COMMIT (https://www.ncbi.nlm.nih.gov/pubmed/16271643) demonstrated this pretty well. Basically, it can wait and be started on the inpatient side after the patient has stabilized, as the benefit of beta-blockade was found after the first 24 hours.

If you think the tachy/htn is driving the persistent ischemia, there is a role.

 

[WilcoWorld]

If you think the tachy/htn is driving the persistent ischemia, there is a role.

Hey all, intern here trying to get all this jazz straight. I know there's a bazillion mnemonics out there, but I'm just trying to make sure my management of STEMI and NSTEMI is correct for what we do in the emergency department. In addition to oxygen, monitor, and IV access:

STEMI --> Aspirin, clopidogrel, nitro (if no contraindications), heparin (ufh vs lmwh depending on institution, I guess), beta blocker (f no contraindications), PCI (and if going to PCI, give IIb/IIIa drug like abciximab)

NSTEMI --> aspirin, clopidogrel, nitro, bblockers....maybe IIb/IIIa inhibitor?

I know this is basic stuff, but I'm getting a lot of different information from different sources, just wanted to clarify..

Beta blockers in the ACUTE phase of a STEMI are really only necessary if there is tachycardia exacerbating ischemia.

It makes intuitive sense that the tachycardic patients should be the ones who benefit from beta blockers. The problem is that we observed the opposite in the COMMIT trial. It was the tachycardic patients who were MOST likely to be harmed after getting beta blocked (higher rates of cardiogenic shock).

My approach: Give 'em aspirin, treat ongoing pain with nitro, hold the O2 unless hypoxic, and monitor for arrhythmias.

Beyond that, I only do what it takes to get a Cardiologist to get the patient out of my ED and to keep me out of my Medical Director's office on Monday morning.

 

[Rendar5]

STEMI: asa, pain reliever, call Cath lab/cardiologist
NSTEMI: asa, pain reliever, call cardiologist and admitting physician

If cards wants other meds then they ask for them. Plavix,, heparin, etc can be given in cath lab. BB's can be given next day. Why would I even give oxygen to someone if their oxygen level is normal...if there's no blood getting past the clot then extra oxygen isn't getting there either

Above doesn't apply to rate related ischemia or other alternate causes of cardiac ischemia.

Pain reliever of choice is nitro. By doesn't have to be. No mortality benefit. Neither is heparin overall (just in subgroup analysis)

 

[pkwraith]

My Department has switched to using ticagrelor preferentially over clopidogrel based on PLATO. Although, it seems the Cardiologist don't really care what antiplatelet is . I've never used a IIb/IIIa, and Cardiologists have never asked for one. When I was on Cards, the only time they avoided using antiplatelets (outside of aspirin) is if the patient is a terrible diabetic or likely triple vessel disease, when a CABG is likely.

 

[migm]

It makes intuitive sense that the tachycardic patients should be the ones who benefit from beta blockers. The problem is that we observed the opposite in the COMMIT trial. It was the tachycardic patients who were MOST likely to be harmed after getting beta blocked (higher rates of cardiogenic shock).

My approach: Give 'em aspirin, treat ongoing pain with nitro, hold the O2 unless hypoxic, and monitor for arrhythmias.

Beyond that, I only do what it takes to get a Cardiologist to get the patient out of my ED and to keep me out of my Medical Director's office on Monday morning.

Respectfully, I think you're missing the point that there was no morbidity difference overall *and* that this study included pts with obvious signs of shock prior to giving them whopping doses of IV metoprolol. This is a different patient than one with ACS with persistent ischemic symptoms in need of maximal medical care or emergent cath.

 

[WilcoWorld]

Respectfully, I think you're missing the point that there was no morbidity difference overall *and* that this study included pts with obvious signs of shock prior to giving them whopping doses of IV metoprolol. This is a different patient than one with ACS with persistent ischemic symptoms in need of maximal medical care or emergent cath.

I appreciate the respect, and please understand that the following is also meant respectfully.

Can you be more clear on what point I am missing? Are you saying that the patients we are discussing (ED patients with STEMI and NSTEMI) are dissimilar to those included in the COMMIT trial, and so it's findings shouldn't apply to them?

 

[Daiphon]

It makes intuitive sense that the tachycardic patients should be the ones who benefit from beta blockers. The problem is that we observed the opposite in the COMMIT trial. It was the tachycardic patients who were MOST likely to be harmed after getting beta blocked (higher rates of cardiogenic shock).

My approach: Give 'em aspirin, treat ongoing pain with nitro, hold the O2 unless hypoxic, and monitor for arrhythmias.

Beyond that, I only do what it takes to get a Cardiologist to get the patient out of my ED and to keep me out of my Medical Director's office on Monday morning.

This is why I use esmolol if I think it's rate related - if they start to tank, I turn it off.

O/w agree that BBlockers aren't needed hyperacutely in the immediate management.

-d

Semper Brunneis Pallium

 

[migm]

You know what, I was under the false understanding that this study included a lot more heart failure patients (ie killip class 2+) to whom IV metropolol were given. I pulled the paper up given our conversation and see now that almost 3/4th of their patients had no signs of heart failure on exam and this subgroup had no safety benefit, so I was incorrect.

That said, and I know I'm swimming upstream, it seems like this is a different question than controlling for and managing ongoing ischemia via b-blockade by way of whether or not the patient is having anginal pain, correlating perhaps pain with myocardium and size of infarct.

 

[Siggy]

...and if you want the studies that show the benefit of heparin + ASA, skip to the 42 minute mark.

 

[deleted547339]

...and if you want the studies that show the benefit of heparin + ASA, skip to the 42 minute mark.

That is garbage literature. You can't extrapolate a 1988 study with different EKG definitions of MI, no troponins, no therapeutic cath and a cohort where no one dies to mean aspirin plus heparin is better in our drastically different patient population.

This is why I hate reading cardiology literature.

 

[DrYoda]

STEMI management in the ED is very institution dependent. One place I work it's simply aspirin +heparin--> cath lab. other's want other anticoagulant and antiplatelets on board. you just need to learn what cardiology want's at your specific site(s).

NSTEMI is simply aspirin, heparin/lovenox--> admit.

 

[joeDO2]

There is some evidence that high dose statin in ACS is helpful. Very little downside to the 1-time dose in the ED prior to PCI.

http://www.acepnow.com/article/stud...patients-suspected-acute-coronary-syndrome/3/

I think the two main thought processes are:

STEMI --> time is important. send to PCI. avoid fancy treatments. drips are labor intensive, have minimal benefit, and delay the definitive care.

NSTEMI --> time isn't that important. ask cards what they want because everyone has a different opinion and you have time to ask.

 

[engineeredout]

Plavix loading in the acute setting in the ED is probably not the best idea. If your patient is taken to the cath lab and they're found to have triple vessel disease, and/or lesions more amenable to CABG, the CT surgeon won't be able to take them to the OR for days. Plavix has a long half life, and it has been shown to increase bleeding complications in CABG, which is one of the reasons there's more use of the shorter acting IV anti platelet agents (integrillin etc...)


Still seems like it's all totally dependent on what cardiologist is on call. Sometimes it'll be "ASA, nitro, heparin, integrillin", sometimes it's "ASA and heparin only if it won't delay him getting up here"

 

[shookwell]

Aspirin for everyone unless you have a really compelling reason not to give it (this is also the only therapy I would delay going to cath to give)

No one gets beta blockers unless you have a really compelling reason to give it (a cardiologist requesting it without a clear explanation is not a compelling reason)

Other anti-platelets agents and/or heparin I will give based on the cardiologist's preference

No morphine, if I need an opioid I use fentanyl but I try to avoid that too

Oxygen only if hypoxic