2009 ACC/AHA STEMI Update

2205.pdf (page 2 of 39)

Document available here.

Recommendations relevant to emergency medicine:

1. GP IIb/IIIa receptor antagonists (abciximab/reopro or eptifibatide/integrilin) can wait for the cath lab.

2. 300 to 600 mg oral clopidogrel as soon as possible is a class I recommendation. Prasugrel is the new, more expensive clopidogrel.

3. Unfractionated heparin, LMWH, fondaparinux, and bivalirudin are all acceptable anticoagulants. If patients are waiting around and PTT is subtherapeutic, rebolus unfractionated heparin.

4. Transfer thrombolysis patients to a PCI center after giving the lytic and “considering” a “preparatory” anticoagulant and antiplatelet.

5. Keep serum glucose below 180.

6. NSTEMI/UA patients going to the cath lab should get aspirin and clopidogrel (or prasugrel).

DDx positive troponin

1. ACS

2. Pulmonary embolism

3. ESRD

4. Myopericarditis

5. Stanford A dissection

6. Acute heart failure

7. Strenuous exercise

8. Cardiac toxins

9. Ablation therapy / cardioversion / defibrillation

10. Cardiac infiltrative disorders (sarcoid, amyloid)

11. Heart transplant (+trop can last 3 months)

12. Cardiac contusion after blunt chest trauma

13. Sepsis / critical illness

14. Rhabdomyolysis

Korff S, Katus HA, Giannitsis E. Differential diagnosis of elevated
troponins. Heart 2006;92:987-993.

369. Plavix mechanism and indication in ACS / Heparin mechanism and indication in ACS

We need to dose UFH based on the patient’s weight. In addition,
we all should be aware of the most recent ACC/AHA guidelines for NSTE
ACS, which now recommend dosing of UFH at 60 U/kg (maximum, 4000
U) as an intravenous bolus and 12 U/kg per hour (maximum, 1000 U/h) as
a maintenance infusion [2]. Second, be especially meticulous about dosing
with women and with elderly patients.

Melloni C, Alexander KP, Chen AY, et al. Unfractionated heparin dosing
and risk of major bleeding in non-ST-segment elevation acute coronary
syndromes. Am Heart J 2008;156:209-215.

General UFH unfractionated heparin protocol dosing

ICUPocketGuide.pdf (page 48 of 63)