New US guideline on coronary artery revascularization recommends a shorter 1- to 3-month duration of dual antiplatelet therapy after percutaneous coronary intervention in select patients
A new guideline on coronary artery revascularization has been published by the American Heart Association and American College of Cardiology in partnership with the Society for Cardiovascular Angiography. Key recommendations include:
A shorter 1- to 3-month duration of dual antiplatelet therapy (DAPT) following percutaneous coronary intervention (PCI) for selected patients, with subsequent transition to P2Y12 inhibitor monotherapy, to reduce the risk of bleeding events. Previously, DAPT was recommended for 6 to 12 months following PCI.
For hospitals without catheterization laboratories, consider routine transfer to a PCI facility for all hemodynamically stable patients if transfer times are reasonable and total ischemic time after presentation is less than 120 minutes.
Coronary artery bypass graft (CABG) should not be undertaken after failed primary PCI in the absence of ischemia or a large area of myocardium at risk, or if surgical revascularization is not feasible due to a no-reflow state or poor distal targets.
Use a patient-centered shared decision-making process for patients with ST-elevation myocardial infarction for whom the optimal coronary revascularization strategy is not clear (e.g., if there is complex coronary disease and/or comorbid conditions). This should utilize a multidisciplinary team that includes representatives from interventional cardiology, cardiac surgery, and clinical cardiology.
ST-elevation myocardial infarction (STEMI) presents with central chest pain that is classically heavy in nature, like a sensation of pressure or squeezing. Examination is variable, and findings range from normal to a critically ill patient in cardiogenic shock.
STEMI is suspected when a patient presents with persistent ST-segment elevation in two or more anatomically contiguous ECG leads in the context of a consistent clinical history.
Creatine kinase-MB and cardiac-specific troponins confirm diagnosis. Treatment should, however, be started immediately in patients with a typical history and ECG changes, without waiting for laboratory results.
Immediate and prompt revascularization can prevent or decrease myocardial damage and decrease morbidity and mortality.
About 15% of patients in the US who have an acute myocardial infarction (MI) will die of it.
Survivors of acute MI should be closely followed up for adequate modification of risk factors and development of complications.
Myocardial infarction is myocardial cell death that occurs because of a prolonged mismatch between perfusion and demand. This is usually caused by occlusion in the coronary arteries. ST-elevation myocardial infarction (STEMI) is suspected when a patient presents with persistent ST-segment elevation in two or more anatomically contiguous ECG leads in the context of a consistent clinical history.
History and exam
Key diagnostic factors
- chest pain
- cardiogenic shock
Other diagnostic factors
- nausea and/or vomiting
- dizziness or lightheadedness
- additional heart sounds
- nonclassic location or nature of pain
- reduced consciousness
- abnormal breath sounds
- metabolic syndrome
- physical inactivity
- renal insufficiency
- established coronary artery disease
- family history of premature coronary artery disease
- cocaine use
- male sex
- advanced age
1st investigations to order
- cardiac biomarkers
- blood glucose
- electrolytes, BUN, and creatinine
- serum lipids
- chest x-ray
- coronary angiogram
Investigations to consider
suspected myocardial infarction
- Unstable angina
- Aortic dissection
- Guideline for the evaluation and diagnosis of chest pain
- ACC/AHA/SCAI guideline for coronary artery revascularization
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