Читать книгу Practical Cardiovascular Medicine - Elias B. Hanna - Страница 110

1 If there is a pre-established transfer system with a predicted DTB <120 minutes, a transfer for primary PCI is the best strategy and is superior to fibrinolysis (DANAMI-2 and PRAGUE trials).²⁷ This usually implies a distance <60 miles, often with a helicopter transfer, a door-in door-out time <30 minutes, direct activation of the outside PCI team through a central pager, and direct transfer to the outside cath lab.⁴⁸

2 When DTB is expected to be >120 minutes, administer primary fibrinolytic therapy and immediately transfer the patient to allow the performance of routine early PCI 2–24 hours later, or to allow immediate rescue PCI if no response to fibrinolysis. Several registries suggest that timely fibrinolysis followed by semiurgent transfer for PCI offers a benefit similar to that seen in patients presenting to a PCI hospital and undergoing a timely primary PCI.48,49Beside fibrinolytics, the patient should receive aspirin, heparin bolus and infusion, and 300 mg of clopidogrel. Prasugrel, ticagrelor, or 600 mg of clopidogrel have not been studied in the first 24 hours of fibrinolytic therapy and may only be used if PCI is performed >24 hours later. Subcutaneous enoxaparin is not appropriate in patients undergoing early PCI. Glycoprotein IIb/IIa inhibitors may be used during PCI (rather than upstream of PCI).⁴⁴

3 When DTB is expected to be >120 minutes but the patient is presenting >3–4 hours after symptom onset and has a non-anterior MI with low-risk clinical features (Killip class I, heart rate <100 bpm, SBP >100 mmHg), a transfer for primary PCI without preceding fibrinolytic therapy may be reasonable in individual cases, although not clearly expressed in the guidelines.

4 If fibrinolytic therapy is contraindicated, immediately transfer for primary PCI regardless of the expected DTB.

5 For cardiogenic shock or acute severe HF (Killip class III or IV), administer fibrinolytic therapy if DTB is expected to be >120 minutes, and immediately transfer for PCI.

6 In patients presenting early, prehospital fibrinolytic therapy delivered by paramedics and followed by early transfer to a PCI facility has been associated with further reduction in mortality compared with in-hospital fibrinolytic therapy according to a meta-analysis of randomized trials, and a mortality comparable to that of primary PCI (STREAM, CAPTIM trial).30,50 This is the preferred strategy in patients unable to undergo timely PCI, in regions where such a system can be implemented, as per ESC guidelines.⁴⁹

To prevent the dilemma of non-PCI hospitals, emergency medical systems are encouraged to triage STEMI patients to a PCI center and to bypass non-PCI hospitals, even if a non-PCI hospital is closer (class I ACC and ESC guidelines). In a statewide registry, bypassing a closer non-PCI hospital in favor of a PCI hospital led to an additional 16 min drive, yet was associated with significant reduction of time to reperfusion (31 min) and lower mortality. In fact, only 35% of patients brought to non-PCI hospitals received fibrinolytics; the majority were transferred for primary PCI, resulting in much longer time to reperfusion.⁵¹ Nonetheless, to meet the DTB guidelines, the drive to the PCI hospital should not exceed 45-60 min.

Also, consider bypassing the emergency department and taking the patient directly to the catheterization laboratory when the diagnosis is certain, as this results in a 20-min or a third reduction of DTB.⁵²