Management of acute STEMI
“For most patients with ST elevation MI, emergency reperfusion treatment should be with primary PCI rather than with thrombolysis. If for logistical reasons it is not possible to transfer the patient to the RIE for PCI within 90 minutes travel time and there are no contra-indications, the following thrombolysis protocol should be used.”
All patients self presenting to ED or having a STEMI during hospital admission should be discussed with RIE in first instance. Any difficult cases can be discussed with BGH cardiology team within normal hours.
RAPID THROMBOLYSIS SAVES LIVES - "TIME IS MUSCLE"
Patients with ST Elevation Myocardial Infarction (Heart Attack) and a clear indication for thrombolysis (Clot buster) should have the drug started within 30 minutes of arrival in Hospital.
We (doctors, porters and nurses) must all make these patients our priority.
Rapid assessment and initiation of treatment is essential prior to formal clerking.
Ischaemic chest pain > 20 minutes (< 12 hours unless ongoing pain) not relieved by GTN
ECG Changes
> 1mm ST elevation in 2 contiguous limb leads
> 2mm ST elevation in 2 contiguous chest leads
LBBB – If known to be old, discuss with the Consultant
All patients usually receive (unless already given) 300mgs Aspirin and 300mgs Clopidogrel loading dose at presentation
This is not exhaustive, any other co-morbidities that increase the likelihood of side effects – D/W Consultant
ABSOLUTE
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RELATIVE – discuss with Consultant
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PATIENTS ON WARFARIN or NOAC SHOULD BE DISCUSSED WITH RIE FOR PPCI
TENECTEPLASE (TNK) should be used for all appropriate ST elevation Myocardial Infarction patients. If Thrombolysis is contra-indicated Primary Angioplasty should be considered.
TNK dosing is weight adjusted (approximate this, don’t waste time with scales) to a maximum of 10 000 units.
The dose works out to be approx. 100 units/kg – PRESCRIBE THIS AS UNITS AND AS AN IV BOLUS
| Patients’ body weight category (KGS) |
TNK (Units) | TNK (MG) | Volume of reconstituted solution (ML) |
| <60 | 6000 | 30 | 6 |
| ≥60 to <70 | 7000 | 35 | 7 |
| ≥70 to <80 | 8000 | 40 | 8 |
| ≥80 to <90 | 9000 | 45 | 9 |
| ≥90 | 1000 | 50 | 10 |
The required dose should be administered as a single intravenous bolus over approximately 10 seconds.
A pre- existing intravenous line may be used for administration of Tenecteplase in 0.9 % sodium chloride
solution only. Tenecteplase is incompatible with dextrose solution.
Send off bloods for urgent coagulation screen, INR (if on Warfarin), FBC and biochemistry prior to administration of thrombolytic. DO NOT WAIT FOR THE RESULTS.
Tenecteplase should be administered with caution in people aged 75 years or over due to higher bleeding risk.
IF THE PATIENT IS ON WARFARIN OR NOAC THEY SHOULD BE DISCUSSED WITH RIE FOR PPCI
FONDAPARINUX/HEPARIN DOSING – COMPLEX READ CAREFULLY
TNK administration is followed immediately by:
Fondaparinux 2.5mgs IV Bolus unless known Heparin induced Thrombocytopenia (Discuss with Haematologist on-call)
CONTRA-INDICATIONS to Fondaparinux include:
Active clinically significant bleeding
Acute Bacterial Endocarditis
Severe renal impairment - Creatinine clearance < 20ml/min
CAUTIONS
| Abnormal clotting, including INR > 1.5 | Discuss with haematologist on call |
| Platelet count < 50 x 10 9/L |
If no contraindications, continue Fondaparinux 2.5mgs subcutaneously once daily until discharge or up to a
maximum of 8 days treatment.
FONDAPARINUX/HEPARIN DOSING – COMPLEX READ CAREFULLY
If S/C Fondaparinux is contra-indicated commence unfractionated Heparin IV - 20 000 units in 20ml neat at a starting rate of 1200 units/hr (1.2mls/hr) for 48 hours. No further bolus dose should be given.
Check APTT at 6 hours and adjust the infusion rate to achieve an APTT (ratio) of 1.5 - 2.5.
If patients have received TNK/5000 units bolus of unfractionated Heparin in the community, omit the initial IV Fondaparinux and continue with S/C Fondaparinux (administering 6 hours after the community dose) or IV unfractionated Heparin as above . Patients who have received TNK/5000UNITS unfractionated Heparin in the community can receive Fondaparinux if there are no contra-indications.
NHS Borders clinical guidelines