GPC
AHA 2013 (QM) ESC 2012 (QM) NICE 2013 (QB) AUS (QM)
Transfer of Patients With STEMI to a PCI-Capable Hospital for Coronary Angiography After Fibrinolytic Therapy: Recommendations Class I
1. Immediate transfer to a PCI-capable hospital for coronary angiography is recommended for suitable patients with STEMI who develop cardiogenic shock or acute severe HF, irrespective of the time delay from MI onset. (Level of Evidence: B)
Class IIa
1. Urgent transfer to a PCI-capable hospital for coronary angiography is reasonable for patients with STEMI who demonstrate evidence of failed reperfusion or reocclusion after fibrinolytic therapy. (Level of Evidence: B)
2. Transfer to a PCI-capable hospital for coronary angiography is reasonable for patients with STEMI who have received fibrinolytic therapy even when hemodynamically stable§ and with clinical evidence of successful reperfusion. Angiography can be performed as soon as logistically feasible at the receiving hospital, and ideally within 24 hours, but should not be performed within the first 2 to 3 hours after administration of fibrinolytic therapy. (Level of Evidence: B)
As part of an invasive strategy in stable* patients with PCI between 3 and 24 h after successful fibrinolysis (Class IIa, B)
*§Although individual circumstances will vary, clinical stability is defined by the absence of low output, hypotension, persistent tachycardia, apparent shock, high-grade ventricular or symptomatic
Coronary Angiography in Patients Who Initially Were Managed With Fibrinolytic Therapy or Who Did Not Receive Reperfusion:
Recommendations Class I
1. Cardiac catheterization and coronary angiography with intent to perform revascularization should be performed after STEMI in patients with any of the following:
a. Cardiogenic shock or acute severe HF that develops after initial presentation(Level of Evidence: B);
b. Intermediate- or high-risk findings on predischarge noninvasive ischemia testing (Level of Evidence: B); or
c. Myocardial ischemia that is spontaneous or provoked by minimal exertion during hospitalization. (Level of Evidence: C) Class IIa
1.Coronary angiography with intent to perform revascularization is reasonable for patients with evidence of failed reperfusion or reocclusion after fibrinolytic therapy. Angiography can be performed as soon as logistically feasible. (Level of Evidence: B) 2. Coronary angiography is reasonable before hospital discharge in stable§ patients with STEMI after successful fibrinolytic therapy.
Angiography can be performed as soon as logistically feasible, and ideally within 24 hours, but should not be performed within the first 2 to 3 hours after administration of fibrinolytic therapy. (Level of Evidence: B)
§Although individual circumstances will vary, clinical stability is defined by the absence of low output, hypotension, persistent tachycardia, apparent shock, highgrade ventricular or symptomatic supraventricular tachyarrhythmias, and spontaneous recurrent ischemia.
PCI of an Infarct Artery in Patients Who Initially Were Managed With Fibrinolysis or Who Did Not Receive Reperfusion Therapy:
Recommendations Class I
1. PCI of an anatomically significant stenosis in the infarct artery should be performed in patients with suitable anatomy and any of
Transfer to a PCI-capable centre following fibrinolysis Is indicated in all patients after fibrinolysis.Class I, Level A Rescue PCI is indicated immediately when fibrinolysis has failed (<50% ST-segment resolution at 60 min). I A Emergency PCI is indicated in the case of recurrent ischaemia or evidence of reocclusion after initial successful fibrinolysis. I B Emergency angiography with a view to revascularization is indicated in heart failure/shock patients. I A Angiography with a view to revascularization (of the infarct-related artery) is indicated after successful fibrinolysis. I A Optimal timing of angiography for stable patients after successful lysis: 3–24 h. IIa A
Consider coronary angiography during the same hospital admission for people who are clinically stable after successful fibrinolysis.
Among patients treated with fibrinolytic therapy who are not in a PCI-capable hospital, early or immediate transfer to a PCI-capable hospital for angiography, and PCI if indicated, within 24 hours is recommended. Weak IIA Among patients treated with fibrinolytic therapy, for those with ≤50% ST recovery at 60–90 minutes, and/or with
haemodynamic instability, immediate transfer for angiography with a view to rescue angioplasty is recommended. Strong IB Also ongoing haemodynamic instability, and ongoing ischaemic chest pain are indications for immediate angiography.
GPC
AHA 2013 (QM) ESC 2012 (QM) NICE 2013 (QB) AUS (QM)
can be performed as soon as logistically feasible at the receiving hospital. (Level of Evidence: B)
2. Delayed PCI of a significant stenosis in a patent infarct artery is reasonable in stable§ patients with STEMI after fibrinolytic therapy.
PCI can be performed as soon as logistically feasible at the receiving hospital, and ideally within 24 hours, but should not be performed within the first 2 to 3 hours after administration of fibrinolytic therapy. (Level of Evidence: B)
Class IIb
Delayed PCI of a significant stenosis in a patent infarct artery greater than 24 hours after STEMI may be considered as part of an invasive strategy in stable patients. (Level of Evidence: B)
DOCUMENTS CANADIENS
SCC 2004 ET SCC 2009 RQCT 2009 OHTAC 2010 NORMES 2016
Administering fibrinolytic therapy to STEMI patients carries with it not only a responsibility to evaluate the success of reperfusion but also a need to be vigilant for recurrent ischemia and the potential for reinfarction, especially within the first 36 h to 48 h after therapy when this risk is greatest. Patients qualifying for rescue PCI within 6 h of symptom onset should be provided access to priority emergency transport to a PCI facility.
Que les patients fibrinolysés qui présentent des critères de haut risque (IAMEST antérieur ou IAMEST non antérieur avec instabilité hémodynamique combinée ou non à l’une ou l’autre des conditions suivantes : tachycardie, défaillance, infarctus du cœur droit, sous-décalage ST-T dans plusieurs dérivations précordiales) fassent l’objet d’une discussion avec un hémodynamicien quant à un transfert pour coronarographie avec ou sans angioplastie, dans les 6 à 24 heures suivant la fibrinolyse (stratégie pharmaco-invasive);
Que les patients fibrinolysés mais ne présentant pas de critères de haut risque soient traités dans le centre où ils se sont présentés et qu’ils soient soumis à une stratification;
For patients undergoing thrombolytic reperfusion, attempts should be made to refer them subsequently to a PCI facility with a level of urgency most appropriate for the patient’s condition.
In particular, patients who are eligible for rescue PCI should be transferred in a timely manner. The routine use of thrombolysis followed immediately by PCI (facilitated PCI) should not be encouraged due to increased risk of major bleeding.
Suivant l’administration de la fibrinolyse, les lignes directrices de l’AHA recommandaient que l’ECG soit évalué environ 60 minutes plus tard afin de voir s’il y a lieu de mettre en marche un transfert en vue d’une ICP de sauvetage [Antman et al., 2004; O’Gara et al., 2013]. Cette option serait à considérer notamment en présence d’une persistance de l’élévation initiale du segment ST (moins de 50 % de résolution), suggérant un échec de reperfusion.
La stratégie optimale est moins claire en ce qui concerne le recours à l’ICP si la fibrinolyse semble avoir réussi et le patient demeure cliniquement stable. Une de deux approches peut être envisagée, soit un transfert routinier, généralement dans les 6 à 24 heures («
pharmacoinvasive strategy »), soit une approche plus sélective («
ischemia-guided strategy»), en cas de persistance ou récidive d’ischémie ou d’autres facteurs.