Chapter 37. Special Considerations: ST-Segment Elevation Myocardial Infarction
Which of the following is the most appropriate management strategy for a patient presenting 180 minutes following the onset of symptoms to a non–percutaneous coronary intervention (PCI)–capable hospital located 60 minutes away from a PCI-capable hospital?
A. Immediate transfer to a PCI-capable hospital
D. Fibrinolysis with rescue PCI as indicated
The results from randomized trials indicate that outcomes are better when patients with ST-segment elevation myocardial infarction (STEMI) who present to non-PCI hospitals are transferred to a PCI facility for primary PCI compared with being given fibrinolytic therapy at the local hospital. Current guidelines recommend the door-to-balloon (D2B) time be ≤90 minutes for patients presenting to a PCI facility and ≤120 minutes for patients transferred from a non-PCI facility. Currently, guidelines recommend that patients with cardiogenic shock, patients who are ineligible for fibrinolytic therapy, and patients who can be treated within 120 minutes be transferred for primary PCI.
Which of the following has not been demonstrated to be an advantage of a radial compared to a femoral approach in STEMI?
A. Reduced rate of stroke
C. Reduced rate of major adverse cardiac events (MACE)
D. Reduced rate of bleeding
Evidence supporting better outcomes with radial catheterization comes from a 2015 meta-analysis of 4 large, contemporary, multicenter trials and trials of patients. Comparing radial with femoral access, the risk was lower in terms of major bleeding (relative risk [RR], 0.57; 95% confidence interval [CI], 0.37-0.88), death (RR, 0.73; 95% CI, 0.59-0.90), and MACE (RR, 0.86; 95% CI, 0.75-0.98).
Which of the following drugs has not been shown to be effective for treatment of no-reflow phenomenon?
No reflow is generally due to microvascular dysfunction from spasm, distal embolization, or endothelial injury. No reflow usually can be reestablished with the use of intracoronary verapamil, adenosine, nicardipine, or nitroprusside given through the guiding catheter or an infusion catheter or the distal lumen of the balloon catheter.