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Myocardial Infarction (MI) - PPCI/Thrombolysis

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August 11, 2020

PPCI (Leeds PPCI Pathway)

  • Target: Door to balloon 90min
  • Criteria:
    • Time: Chest pain within 12hrs (or worsened within 12hrs)
    • ECG:  ST elevation MI (1mm Limb or 2mm Chest leads) OR New LBBB. (Posterior MI do posterior leads and discuss with LGI)
  • Actions:
    • Resuscitate
    • Contact PPCI team @ LGI (Mobile No. up in Resus)
    • Arrange blue light (P1) ambulance to LGI
    • Prasagrel 60mg if no previous CVA or Ticagrelor 180mg if previous CVA and Aspirin 300mg (if anti-coagulated Discuss with PCI team)
  • Problems: 
    • Intubated patient: Often LGI would accept but need to arrange Cardiac ICU. If no bed patient could go for PCI to return locally immediately after PCI to our ICU’S?
    • LGI Full: Occasionally the cath lab is full and can’t accept your patient
      • Calling Manchester and Sheffield: It’s worth a go but they don’t have agreements with us  so having your patient accepted can be difficult
      • Don’t Forget Thrombolyisis: We need to open up the patients artery, if there is no quick decision to go for PPCI – Consider Thrombolysis

Thrombolysis

This may not have all the advantages of PPCI but if unavailable within the 90min we should be thinking of thrombolysis.

*** Streptokinase is less affective then Tenectoplase***

if Ambulance >90min despite escalation discuss with on-call cardiology

  • Target: Door to needle 20min
  • Criteria:
    • Time: Chest pain within 12hrs (or worsened within 12hrs)
    • ECG:  ST elevation MI (1mm Limb or 2mm Chest leads) OR New LBBB
  • Actions:
    • Resuscitate
    • Consider Contraindications
    • Consent
    • Drug: Tenecteplase + Fondaparinux (see below)
    • ECG monitoring
    • Repeat ECG 60min – If ST elevation remains Re-Refer for PPCI
    • Transfer to CCU

Contrindications (EMA)

  • Bleeding
    • Significant bleeding disorder:Current or within the past 6 months
    • Effective oral anticoagulant treatment: e.g. warfarin sodium (INR > 1.3)
    • Known haemorrhagic diathesis
    • Major surgery, biopsy of a parenchymal organ, or significant trauma: within 2 months
    • Neoplasm: with increased bleeding risk
  • Central nervous system
    • Damage: (i.e. neoplasm, aneurysm, intracranial or spinal surgery)
    • Head trauma: recent
    • Stroke: ANY Haemorrhagic stroke OR an Ischaemic stroke or Transient Ischaemic Attack in the preceding 6 months
    • Dementia
  • Cardiovascular
    • Severe uncontrolled hypertension: SBP >180mmHg OR DBP >100mmHg
    • Prolonged/Traumatic cardiopulmonary resuscitation: in last 2 weeks
    • Acute pericarditis and/or subacute bacterial endocarditis
    • Arterial aneurysm/dissection OR arterial/venous malformation
  • Gastrointestinal
    • Acute pancreatitis
    • Severe hepatic dysfunction, including hepatic failure, cirrhosis, portal hypertension (oesophageal varices) and active hepatitis
    • Active peptic ulceration

Pregnancy/Post-Partum

There is limited amount of data from the use of Tenectaplase in pregnant women. The benefit of treatment must be evaluated against the potential risks in case of myocardial infarction during pregnancy.

Consent

Improves the chances of surviving by approximately 25%,

Risks include;

  • Significant bleeding, which is not normally life threatening and can occur in about 4 in 100 patients
  • Life-threatening stroke, which can affect up to 2 in every 100 patients
  • Allergic reactions: and other side effects that do not usually cause any major problems.

Drugs

Tenectaplase  – National Shortage

***Fondaparinux 2.5mg IV STAT – should also be given with Tenectaplase***

Streptokinase – Preferred agent if alive

  • 1’500’000 units over 60 minutes, to be initiated within 12 hours of symptom onset. – BNF

Alteplase – small stock for cardiac arrest only

  • 50mg  over 1-2 min (consider second dose after 15min if no ROSC)