Ver el código de «ST-segment elevation myocardial infarction»

==Diagnosis==
#≥ 1-mm (0.1mV) ST-segment elevation in at least 2 anatomically contiguous limb leads (aVL to III, including -aVR)
#≥ 1-mm ST-segment elevation in a precordial lead V4 through V6
#≥ 2-mm (0.2mV) ST-segment elevation in V1 through V3
#a new left bundle branch block
ACC/AHA, ESC

==DDx==
#Myocardial ischemia or infarction 
#Noninfarction, transmural ischemia (Prinzmetal's angina pattern or acute takotsubo cardiomyopathy)
#Acute myocardial infarction (MI)
#Post-MI (ventricular aneurysm pattern)-Previous MI with recurrent ischemia in the same area-Acute pericarditis-Normal "early repolarization variants"
#Left ventricular hypertrophy or left bundle branch block (only V1-V2 or V3)-Myocarditis (may look like myocardial infarction or pericarditis)
#Brugada patterns (V1-V3 with right bundle branch block-appearing morphology) 
#Myocardial tumor 
#Myocardial trauma 
#Hyperkalemia (only leads V1 and V2) 
#Hypothermia (J wave/Osborn wave)

==Treatment==
===Adjunctive===
#O2
##Esp for SpO2 <90%
#ASA 162-325mg chewable or 600mg PR
#Plavix
##Loading dose
###300mg
###600mg if PCI anticipated
###No loading dose if >75yr receiving fibrinolytics
#NTG
#Morphine
#BBlocker:
##PO within 24 hours
##IV beta-blocker is reasonable for patients who are hypertensive in the absence of:
###signs of heart failure
###evidence of a low cardiac output state
###post beta-blocker cardiogenic shock risk factors (age > 70 years, systolic blood pressure < 120 mm Hg, sinus tachycardia > 110 bpm or heart rate < 60 bpm, increased time since onset of symptoms of STEMI)
###other relative contraindications to beta blockade (PR interval > 0.24 s, second- or third-degree heart block, active asthma, or reactive airway disease)

===Anticoagulants===
#Heparin (UFH)
##Bolus 60U/kg (max: 4000U)
##12U/kg/h (max: 1000U/h)
##NB: monitor PTT: 50-70s
#LMWH
##<75yo with serum Cr < 2.5 mg/dL (men) or < 2.0 mg/dL (women):
###30mg IV bolus, followed by 1mg/kg SC q12h
##≥ 75yo: 0.75-mg/kg SC q12h
##CrCl < 30 mL/min: 1mg/kg SC qd
##NB: note renal clearance
#Fondaparinux
##Cr < 3.0 mg/dL: 2.5mg IV bolus, then 2.5-mg SC qd, started 24 hr after bolus
##NB: monitor anti-Xa levels
#Bivalirudin
##0.75-mg/kg IV bolus, followed by 1.75 mg/kg/h
##CrCl < 30 mL/min: 0.75-mg/kg IV bolus, followed by 1.0 mg/kg/h

===Antiplatelet===
#GPIIB/IIIa Inhibitors: Abciximab (ReoPro®), Eptifibatide (Integrilin®), Tirofiban (Aggrastat®)
##Given right before PCI
##Defer to cardiologist
#Clopidogrel (Plavix®)
##300mg po x1 (onset 2h, peak 6-15h)
##600mg po x1 (faster onset)


===Definitive===
#Fibrinolytics within 30mins
#PCI within 90mins

==Fibrinolysis==
===Inclusion===
#<12 hours from the onset of chest pain (lasting 30 minutes) and:
#ST elevation of ≥1mm in 2 contiguous limb or precordial leads
#New left bundle branch block

===Exclusion===
#ABSOLUTE
##Any prior ICH
##Known structural CNS lesion (e.g. AV malformation,  intracranial neoplasm)
##Ischemic stroke <3 months (excluding acute ischemic stroke  within last 3h)
##Suspected aortic dissection
##Active bleeding or bleeding diathesis (excluding menses)
##Significant closed-head/facial trauma < 3months
#RELATIVE
##SBP >180 mmHg
##DBP >110 mmHg
##CPR >10min
##<4wk from major trauma/surgery or GI/GU bleed
##Current use of anticoagulants
##Pregnancy
##Active peptic ulcer (guaiac positive)
##Ischemic  stroke in past 3 months
##Dementia or other known  intracranial pathology not noted above
##Noncompressible  vascular punctures w/in past 3 weeks
##Prior exposure (>  5 days) or prior allergic reaction to streptokinase or anistreplase (if  taking these agents)

==Source ==
ACC/AHA Practice Guidelines 2004/5

EBM 6/09

[[Category:Cards]]