Op-ehea170412 online 119
particularly when administered in the first 2 h of symp-
tải về 4.91 Mb. Chế độ xem pdf
|
1336-2923-1-PB
particularly when administered in the first 2 h of symp- tom onset. 138 These and more recent data support pre-hospital initiation of fibrinolytic treatment when a reperfusion strategy is indi- cated. 97 , 99 , 100 , 237 The STREAM trial showed that pre-hospital fibrinol- ysis followed by an early PCI strategy was associated with a similar outcome as transfer for primary PCI in STEMI patients presenting within 3 h after symptom onset who could not undergo primary PCI within 1 h after FMC. 121 , 238 If trained medical or paramedical staff are able to analyse the ECG on- site or to transmit the ECG to the hospital for interpretation, it is Fibrinolytic therapy Recommendations Class a Level b When fibrinolysis is the reperfusion strategy, it is recommended to initiate this treatment as soon as possible after STEMI diagnosis, preferably in the pre-hospital setting. 96 , 98 , 123 , 222 I A A fibrin-specific agent (i.e. tenecteplase, alteplase, or reteplase) is recommended. 223 , 224 I B A half-dose of tenecteplase should be considered in patients 75 years of age. 121 IIa B Antiplatelet co-therapy with fibrinolysis Oral or i.v. aspirin is indicated. 213 I B Clopidogrel is indicated in addition to aspirin. 225 , 226 I A DAPT (in the form of aspirin plus a P2Y 12 inhibitor c ) is indicated for up to 1 year in patients undergoing fibrinolysis and subsequent PCI. I C Anticoagulation co-therapy with fibrinolysis Anticoagulation is recommended in patients treated with lytics until revascularization (if performed) or for the duration of hospital stay up to 8 days. 199 , 224 , 227 – 233 The anticoagulant can be: • Enoxaparin i.v. followed by s.c. (preferred over UFH). 227 – 232 • UFH given as a weight-adjusted i.v. bolus followed by infusion. 224 • In patients treated with streptokinase: fondaparinux i.v. bolus followed by an s.c. dose 24 h later. 199 , 233 I A I A I B IIa B Transfer after fibrinolysis Transfer to a PCI-capable centre following fibrinolysis is indicated in all patients immediately after fibrinolysis. 121 , 124 , 126 – 130 , 234 I A Interventions following fibrinolysis Emergency angiography and PCI if indicated is recommended in patients with heart failure/shock. 124 , 235 I A Rescue PCI is indicated immediately when fibrinolysis has failed (<50% ST-segment resolution at 60–90 min) or at any time in the presence of haemodynamic or electrical instability, or worsening ischaemia. 121 , 124 , 236 I A Angiography and PCI of the IRA, if indicated, is recommended between 2 and 24 h after successful fibrinolysis. 125 – 128 , 234 I A Emergency angiography and PCI if needed is indicated in the case of recurrent ischaemia or evidence of reocclusion after initial successful fibrinolysis. 124 I B DAPT = dual antiplatelet therapy; IRA = infarct-related artery; i.v. = intravenous; PCI = percutaneous coronary intervention; SBP = systolic blood pressure; s.c. = subcutaneous; STEMI = ST-segment elevation myocardial infarction; UFH = unfractionated heparin. a Class of recommendation. b Level of evidence. c Clopidogrel is the P2Y 12 inhibitor of choice as co-adjuvant and after fibrinolysis, but 48 h after fibrinolysis, switch to prasugrel/ticagrelor may be considered in patients who underwent PCI. ESC Guidelines 139 Downloaded from https://academic.oup.com/eurheartj/article-abstract/39/2/119/4095042 by E-Library Insel user on 07 February 2018 .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. recommended to initiate fibrinolytic therapy in the pre-hospital setting. The aim is to start fibrinolytic therapy within 10 min from STEMI diagnosis. 5.3.3 Angiography and percutaneous coronary intervention after fibrinolysis (pharmacoinvasive strategy) Following initiation of lytic therapy, it is recommended to transfer the patients to a PCI centre (Figure 3 ). In cases of failed fibrinolysis, or if there is evidence of reocclusion or reinfarction with recurrence of ST-segment elevation, immediate angiography and rescue PCI is indi- cated. 124 In this setting, re-administration of fibrinolysis has not been shown to be beneficial and should be discouraged. 124 Even if it is likely that fibrinolysis will be successful (ST-segment resolution > 50% at 60–90 min; typical reperfusion arrhythmia; and disappear- ance of chest pain), a strategy of routine early angiography is recom- mended if there are no contraindications. Several randomized trials 126 – 128 , 234 , 239 , 240 and meta-analyses 129 , 130 have shown that early routine angiography with subsequent PCI (if needed) after fibrinolysis reduced the rates of reinfarction and recurrent ischaemia compared with a ‘watchful waiting’ strategy, in which angiography and revascularization were indicated only in patients with spontane- ous or induced severe ischaemia or LV dysfunction, or in those with a positive outpatient ischaemia test. The benefits of early routine PCI after fibrinolysis were seen in the absence of an increased risk of adverse events (stroke or major bleeding), and across patient sub- groups. 241 Thus, early angiography with subsequent PCI if indicated is also the recommended standard of care after successful fibrinolysis (see Figure 3 ). A crucial issue is the optimal time delay between successful lysis and PCI; there was a wide variation in delay in trials, from a median of 1.3 h in the Combined Angioplasty and Pharmacological Intervention versus Thrombolytics ALone in Acute Myocardial Infarction (CAPITAL AMI) trial 240 to 17 h in the Grupo de An alisis de la Cardiopatıa Isque´mica Aguda (GRACIA)-1 234 and STREAM trials. 121 In a pooled patient-level analysis of six randomized trials, very early angiography (<2 h) after fibrinolysis was not associated with an increased risk of 30 day death/ reinfarction or in-hospital major bleeding, and a shorter time from symptom onset to angiography (<4 h) was associated with reduced 30 day and 1 year death/reinfarction and 30 day recurrent ischaemia. 125 Table 7 Doses of fibrinolytic agents and antithrombotic co-therapies a PTT = activated partial thromboplastin time; eGFR = estimated glomerular filtration rate; i.v. = intravenous; IU = international units; rPA = recombinant plasminogen activator; s.c. = subcutaneous; tPA = tissue plasminogen activator; UFH = unfractionated heparin. 140 ESC Guidelines Downloaded from https://academic.oup.com/eurheartj/article-abstract/39/2/119/4095042 by E-Library Insel user on 07 February 2018 .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. . Based on this analysis, as well as on trials having a median delay between start of lysis and angiography of 2–17 h, 121 , 126 – 128 a time- window of 2–24 h after successful lysis is recommended. 5.3.4 Comparison of fibrinolytic agents A fibrin-specific agent should be preferred. 224 Single-bolus weight- adjusted tenecteplase tissue plasminogen activator (TNK-tPA) is equivalent to accelerated tPA in reducing 30 day mortality, but is safer in preventing non-cerebral bleeds and blood transfusion, and is easier to use in the pre-hospital setting. 223 5.3.5 Adjunctive antiplatelet and anticoagulant therapies An early study showed that the benefits of aspirin and fibrinolytics (i.e. streptokinase) were additive. 213 The first dose of aspirin should be chewed or given i.v. and a low dose (75–100 mg) given orally daily thereafter. Clopidogrel added to aspirin reduces the risk of cardio- vascular events and overall mortality in patients treated with fibrinol- ysis 225 , 226 and should be added to aspirin as an adjunct to lytic therapy. Prasugrel and ticagrelor have not been studied as adjuncts to fibrinolysis. There is no evidence that administration of GP IIb/IIIa inhibitors improves myocardial perfusion or outcomes in patients treated with fibrinolysis, and bleeding may increase. 242 Parenteral anticoagulation should preferably be given until revascula- rization (if performed). Otherwise, it should be given for at least 48 h or for the duration of hospital stay, up to 8 days. In spite of an increased risk of major bleeding, the net clinical benefit favoured enoxaparin over UFH in the ASsessment of the Safety and Efficacy of a New Thrombolytic 3 (ASSENT 3) trial (n = 6095). 227 In the large Enoxaparin and Thrombolysis Reperfusion for Acute myocardial infarction Treatment–Thrombolysis In Myocardial Infarction 25 (ExTRACT–TIMI 25) trial (n = 20 506), a lower dose of enoxaparin was given to patients 75 years of age and to those with impaired renal function (estimated creatinine clearance <30 mL/min). Enoxaparin was associated with a reduction in the risk of death and reinfarction at 30 days when compared with a weight-adjusted UFH dose, but at the cost of a significant increase in non-cerebral bleeding complications. The net clinical benefit (i.e. absence of death, non-fatal infarction, and intracra- nial haemorrhage) favoured enoxaparin. 229 , 230 Finally, fondaparinux was shown in the large OASIS-6 trial to be superior in this setting to placebo or UFH in preventing death and reinfarction, 199 , 233 especially in patients who received streptokinase. In a large trial with streptokinase, 243 significantly fewer reinfarc- tions were seen with bivalirudin given for 48 h compared with UFH, though at the cost of a modest and non-significant increase in non- cerebral bleeding complications. Bivalirudin has not been studied with fibrin-specific agents. Thus, there is no evidence in support of direct thrombin inhibitors as an adjunct to fibrinolysis. Weight-adjusted i.v. tenecteplase, aspirin, and clopidogrel given orally, and enoxaparin i.v. followed by s.c. administration until the time of PCI (revascularisation), comprise the antithrombotic cocktail most extensively studied as tải về 4.91 Mb. Chia sẻ với bạn bè của bạn:
|