Reperfusion Therapy, Cardiac

Basics

Description

  • Cardiac reperfusion therapy is 1st-line therapy for patients that present with ST-segment elevation myocardial infarction (STEMI)
  • Early percutaneous coronary intervention (PCI), but not fibrinolytics may be considered in those with unstable angina (UA)/non–ST-segment elevation MI (NSTEMI)
  • Fibrinolytic therapy:
    • Reduces morbidity and mortality in STEMI in cases where PCI is not available in <120 min
    • Early intervention is associated with smaller infarct and reduced risk of decreased ejection fraction
    • Most beneficial within 1st 4 hr, particularly 1st 70 min
    • Goal of fibrinolytic therapy is a door-to-needle time of 30 min if PCI is not planned or delayed >120 min
  • PCI:
    • Balloon inflation, stent placement, and thrombus removal are possible options
    • CABG of complex vessel disease may be considered after primary PCI. PCI of low complexity noninfarct vessels at the time of primary PCI is not currently recommended, but an area of ongoing investigation
    • Goal of primary PCI is a door-to-balloon time of 90 min from 1st medical contact for STEMI or <120 min if at a non-PCI center
    • PCI provides greater coronary patency and thrombolysis in MI flow than do fibrinolytics and decreased mortality and morbidity
    • Lower risk of bleeding than with fibrinolytics
    • PCI can be both diagnostic as well as therapeutic
    • PCI should be strongly considered within 1st 48 hr after NSTEMI in discussion with a cardiologist
  • Glycoprotein IIb/IIIa inhibitors:
    • Antiplatelet agents that bind to platelet receptor glycoprotein IIb/IIIa and inhibit platelet aggregation
    • Reduce mortality and reinfarction rate in patients in whom PCI is planned; reasonable to administer at time of primary PCI
    • Not indicated for patients with STEMI, unless also undergoing PCI
  • Unfractionated heparin (UFH) and low–molecular-weight heparin (LMWH):
  • Bivalirudin, in lieu of heparin and GP IIb/IIIa inhibitor, has been associated with a lower risk of periprocedural bleeding:
    • Adjuncts in treatment with aspirin, ticagrelor, fibrinolytics, glycoprotein IIb/IIIa
    • Ticagrelor should be added to standard therapy regardless of whether PCI or reperfusion therapy is planned
  • Statin therapy reduces clinical events in patients with stable coronary artery disease. This may also extend to patients experiencing an acute ischemic coronary event

Etiology

  • STEMI is caused by occlusion of an epicardial coronary artery, usually as a result of plaque rupture and subsequent thrombotic event
  • UA/NSTEMI is caused by a partial occlusion of coronary artery, also due to thrombus

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