European Resuscitation Council Guidelines for Resuscitation ... - CPR

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18 de 0ctubre de 2010 www.elsuapdetodos.com1358 H.-R. Arntz et al. / Resuscitation 81 (2010) 1353–1363the increased bleeding risk with Gp IIB/IIIA inhibitors when usedwith heparins.AntithrombinsUnfractionated heparin (UFH) is an indirect inhibitor of thrombin,which in combination with ASA is used as an adjunct withfibrinolytic therapy or primary PCI (PPCI) and is an important partof treatment of unstable angina and STEMI. Limitations of unfractionatedheparin include its unpredictable anticoagulant effect inindividual patients, the need to give it intravenously and the needto monitor aPTT. Moreover, heparin can induce thrombocytopenia.Since publication of the 2005 ERC guidelines on ACS, largerandomised trials have been performed testing several alternativeantithrombins for the treatment of patients with ACS. In comparisonwith UFH, these alternatives have a more specific factor Xaactivity (low molecular weight heparins [LMWH], fondaparinux)or are direct thrombin inhibitors (bivalirudin). With these newerantithrombins, in general, there is no need to monitor the coagulationsystem and there is a reduced risk of thrombocytopenia.Antithrombins in non-STEMI-ACSIn comparison with UFH, enoxaparin reduces the combined endpointof mortality, myocardial infarction and the need for urgentrevascularisation, if given within the first 24–36 h of onset of symptomsof non-STEMI-ACS [53,54]. Although enoxaparin causes moreminor bleeding than UFH, the incidence of serious bleeding is notincreased.Bleeding worsens the prognosis of patients with ACS [55]. Fondaparinuxand bivalirudin cause less bleeding than UFH [56–59].Inmost of the trials on patients presenting with non-STEMI-ACS, theUFH alternatives were given only after hospital admission; it maybe invalid to extrapolate the results of these studies to the prehospitalor ED setting. For patients with a planned initial conservativeapproach, fondaparinux and enoxaparin are reasonable alternativesto UFH. There are insufficient data to recommend any LMWHother than enoxaparin. For patients with an increased bleedingrisk consider giving fondaparinux or bivalirudin. For patients witha planned invasive approach, enoxaparin or bivalirudin are reasonablealternatives to UFH. In one study, catheter thrombi wereobserved in patients undergoing PCI who had received fondaparinux– additional UFH was required [56]. Since enoxaparin andfondaparinux may accumulate in patients with renal impairment,dose adjustment is necessary; bivalirudin or UFH are alternatives inthis situation. Bleeding risk may be increased by switching the anticoagulant;therefore, the initial agent should be maintained withthe exception of fondaparinux where additional UFH is necessaryfor patients undergoing PCI [60].Antithrombins in STEMIAntithrombins for patients to be treated with fibrinolysisEnoxaparin. Several randomised studies of patients with STEMIundergoing fibrinolysis have shown that additional treatment withenoxaparin instead of UFH produced better clinical outcomes (irrespectiveof the fibrinolytic used) but a slightly increased bleedingrate in elderly (≥75 years) and low weight patients (BW < 60 kg)[61–63]. Reduced doses of enoxaparin in elderly and low weightpatients maintained the improved outcome while reducing thebleeding rate [64]. It is also reasonable to give enoxaparin insteadof UFH for prehospital treatment.Dosing of enoxaparin: In patients
18 de 0ctubre de 2010 www.elsuapdetodos.comH.-R. Arntz et al. / Resuscitation 81 (2010) 1353–1363 1359with non-STEMI-ACS for transport to tertiary care centres offering24/7 PCI services. In this context, several specific decisions have tobe made during initial care beyond the basic diagnostic steps necessaryfor clinical evaluation of the patient and interpretation of a12-lead ECG. These decisions relate to:(1) Reperfusion strategy in patients with STEMI i.e. PPCI vs (pre-)hospital fibrinolysis.(2) Bypassing a closer but non-PCI capable hospital and taking measuresto shorten the delay to intervention if PPCI is the chosenstrategy.(3) Procedures in special situations e.g. for patients successfullyresuscitated from non-traumatic cardiac arrest, patients withshock or patients with non-STEMI ACS who are unstable or havesigns of very high risk.Reperfusion strategy in patients presenting with STEMITable 5.1Contraindications for fibrinolysis. aAbsolute contraindicationsHaemorrhagic stroke or stroke of unknown origin at any timeIschaemic stroke in the preceding 6 monthsCentral nervous system damage or neoplasmsRecent major trauma/surgery/head injury (within the preceding 3 weeks)Gastro-intestinal bleeding within the last monthKnown bleeding disorderAortic dissectionRelative contraindicationsTransient ischaemic attack in preceding 6 monthsOral anticoagulant therapyPregnancy within 1-week post-partumNon-compressible puncturesTraumatic resuscitationRefractory hypertension (systole. blood pressure >180 mm HgAdvanced liver diseaseInfective endocarditisActive peptic ulcerReperfusion therapy in patients with STEMI is the most importantadvance in the treatment of myocardial infarction in the last 25years. For patients presenting with STEMI within 12 h of symptomonset, reperfusion should be initiated as soon as possible independentof the method chosen [7,70–72]. Reperfusion may be achievedwith fibrinolysis, with PPCI, or a combination of both. Efficacy ofreperfusion therapy is profoundly dependent on the duration ofsymptoms. Fibrinolysis is effective specifically in the first 2–3 hafter symptom onset; PPCI is less time sensitive [73].FibrinolysisA meta-analysis of six trials involving 6434 patients documenteda 17% decrease in mortality among patients treated without-of-hospital fibrinolysis compared with in-hospital fibrinolysis[74]. An effective and safe system for out-of-hospital fibrinolytictherapy requires adequate facilities for the diagnosis and treatmentof STEMI and its complications. Ideally, there should be a capabilityof communicating with experienced hospital doctors (e.g. emergencyphysicians or cardiologists). The average time gained without-of-hospital fibrinolysis was 60 min, and the results were independentof the experience of the provider. Thus, giving fibrinolyticsout-of-hospital to patients with STEMI or signs and symptoms of anACS with presumed new LBBB is beneficial. Fibrinolytic therapy canbe given safely by trained paramedics, nurses or physicians usingan established protocol [75–80]. The efficacy is greatest within thefirst 3 h of the onset of symptoms [74]. Patients with symptoms ofACS and ECG evidence of STEMI (or presumably new LBBB or trueposterior infarction) presenting directly to the ED should be givenfibrinolytic therapy as soon as possible unless there is timely accessto PPCI.Risks of fibrinolytic therapyHealthcare professionals who give fibrinolytic therapy must beaware of its contraindications (Table 5.1) and risks. Patients withlarge AMIs (e.g. indicated by extensive ECG changes) are likely togain most from fibrinolytic therapy. Benefits of fibrinolytic therapyare less impressive in inferior wall infarctions than in anteriorinfarctions. Older patients have an absolute higher risk of death,but the absolute benefit of fibrinolytic therapy is similar to thatof younger patients. Patients over 75 years have an increasedrisk of intracranial bleeding from fibrinolysis; thus, the absolutebenefit of fibrinolysis is reduced by this complication. The riskof intracranial bleeding is increased in patients with a systolicblood pressure of over 180 mm Hg; this degree of hypertensionis a relative contraindication to fibrinolytic therapy. The risk ofintracranial bleeding is also depending on the use of antithrombinand antiplatelet therapy.a According to the guidelines of the European Society of Cardiology.Primary percutaneous interventionCoronary angioplasty with or without stent placement hasbecome the first-line treatment for patients with STEMI, becauseit has been shown to be superior to fibrinolysis in the combinedendpoints of death, stroke and reinfarction in several studies andmeta-analyses [81,82]. This improvement was found when PPCIwas undertaken by a skilled person in a high-volume centre with alimited delay to first balloon inflation after first medical contact[83]. Therefore PPCI performed at a high-volume centre shortlyafter first medical contact (FMC), by an experienced operator whomaintains an appropriate expert status, is the preferred treatmentas it improves morbidity and mortality as compared with immediatefibrinolysis.Fibrinolysis vs primary PCIPrimary PCI has been limited by access to catheter laboratoryfacilities, appropriately skilled clinicians and delay to first ballooninflation. Fibrinolysis therapy is a widely available reperfusionstrategy. Both treatment strategies are well established and havebeen the subject of large randomised multicentre trials over the lastdecades. Over this time both therapies have evolved significantlyand the body of evidence is heterogeneous. In the randomised studiescomparing PPCI with fibrinolytic therapy, the typical delay fromdecision to the beginning of treatment with either PPCI or fibrinolytictherapy was less than 60 min. Several reports and registriescomparing fibrinolytic (including prehospital administration) therapywith PPCI showed a trend of improved survival if fibrinolytictherapy was initiated within 2 h of onset of symptoms and was combinedwith rescue or delayed PCI [84–86]. In registries that reflectstandard practice more realistically the acceptable PPCI relateddelay (i.e. the diagnosis to balloon interval minus the diagnosisto needle interval) to maintain the superiority of PPCI over fibrinolysisvaried considerably between 45 and >180 min dependingon the patients’ conditions (i.e. age, localisation of infarction, andduration of symptoms) [87]. Moreover there are few data for benefitof PPCI over fibrinolysis in specific subgroups such as patientspost-CABG, with renal failure or with diabetes [88,89]. Time delayto PCI may be significantly shortened by improving the systems ofcare [13,90–93], e.g.www.elsuapdetodos.com• Prehospital ECG registration• ECG transmission to the receiving hospital• Arranging single call activation of the catheterization laboratory
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