【medical-news】【资讯翻译】2013版AHA STEMI治疗指南系列6——延时的侵入性治疗
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翻译时请参照版规 【版务】科技动态版版规及加分细则（ 2014-02-21 更新）
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5. Delayed Invasive Management: Recommendations
5.1 Coronary Angiography in Patients Who Initially Were Managed With Fibrinolytic Therapy or Who Did Not Receive Reperfusion
Class I
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5. Delayed Invasive Management: Recommendations
5.1 Coronary Angiography in Patients Who Initially Were Managed With Fibrinolytic Therapy or Who Did Not Receive Reperfusion
Class I
Cardiac catheterization and coronary angiography with intent to perform revascularization should be performed after STEMI in patients with any of the following:
Cardiogenic shock or acute severe HF that develops after initial presentation(Level of Evidence: B);
Intermediate- or high-risk findings on predischarge noninvasive ischemia testing(Level of Evidence: B); or
Myocardial ischemia that is spontaneous or provoked by minimal exertion during hospitalization. (Level of Evidence: C)
Coronary angiography with intent to perform revascularization is reasonable for patients with evidence of failed reperfusion or reocclusion after fibrinolytic therapy. Angiography can be performed as soon as logistically feasible. (Level of Evidence: B)
Coronary angiography is reasonable before hospital discharge in stable§ patients with STEMI after successful fibrinolytic therapy. Angiography can be performed as soon as logistically feasible, and ideally within 24 hours, but should not be performed within the first 2 to 3 hours after administration of fibrinolytic therapy. (Level of Evidence: B)
PCI of an anatomically significant stenosis in the infarct artery should be performed in patients with suitable anatomy and any of the following:
Cardiogenic shock or acute severe HF (Level of Evidence: B);
Intermediate- or high-risk findings on predischarge noninvasive ischemia testing(Level of Evidence: C); or
Myocardial ischemia that is spontaneous or provoked by minimal exertion during hospitalization. (Level of Evidence: C)
Delayed PCI is reasonable in patients with STEMI and evidence of failed reperfusion or reocclusion after fibrinolytic therapy. PCI can be performed as soon as logistically feasible at the receiving hospital (Level of Evidence: B)
Delayed PCI of a significant stenosis in a patent infarct artery is reasonable in stable§ patients with STEMI after fibrinolytic therapy. PCI can be performed as soon as logistically feasible at the receiving hospital, and ideally within 24 hours, but should not be performed within the first 2 to 3 hours after administration of fibrinolytic therapy. (Level of Evidence: B)
Delayed PCI of a significant stenosis in a patent infarct artery greater than 24 hours after STEMI may be considered as part of an invasive strategy in stable§ patients. (Level of Evidence: B)
Delayed PCI of a totally occluded infarct artery greater than 24 hours after STEMI should not be performed in asymptomatic patients with 1- or 2-vessel disease if they are hemodynamically and electrically stable and do not have evidence of severe ischemia. (Level of Evidence: B)
PCI is indicated in a noninfarct artery at a time separate from primary PCI in patients who have spontaneous symptoms of myocardial ischemia. (Level of Evidence: C)
PCI is reasonable in a noninfarct artery at a time separate from primary PCI in patients with intermediate- or high-risk findings on noninvasive testing。(Level of Evidence: B)
After PCI, aspirin should be continued indefinitely。 (Level of Evidence: A)
Clopidogrel should be provided as follows:
A 300-mg loading dose should be given before or at the time of PCI to patients who did not receive a previous loading dose and who are undergoing PCI within 24 hours of receiving fibrinolytic therapy (Level of Evidence: C);
A 600-mg loading dose should be given before or at the time of PCI to patients who did not receive a previous loading dose and who are undergoing PCI more than 24 hours after receiving fibrinolytic therapy (Level of Evidence: C); and
A dose of 75 mg daily should be given after PCI.(Level of Evidence: C)
After PCI, it is reasonable to use 81 mg of aspirin per day in preference to higher maintenance doses. (Level of Evidence: B)
Prasugrel, in a 60-mg loading dose, is reasonable once the coronary anatomy is known in patients who did not receive a previous loading dose of clopidogrel at the time of administration of a fibrinolytic agent, but prasugrel should not be given sooner than 24 hours after administration of a fibrin-specific agent or 48 hours after administration of a non–fibrin-specific agent.(Level of Evidence: B)
Prasugrel, in a 10-mg daily maintenance dose, is reasonable after PCI. (Level of Evidence: B)
Prasugrel should not be administered to patients with a history of prior stroke or transient ischemic attack。 (Level of Evidence: B)
For patients with STEMI undergoing PCI after receiving fibrinolytic therapy with intravenous UFH, additional boluses of intravenous UFH should be administered as needed to support the procedure, taking into account whether GP IIb/IIIa receptor antagonists have been administered. (Level of Evidence: C)
For patients with STEMI undergoing PCI after receiving fibrinolytic therapy with enoxaparin, if the last subcutaneous dose was administered within the prior 8 hours, no additional enoxaparin should be given; if the last subcutaneous dose was administered between 8 and 12 hours earlier, enoxaparin 0.3 mg/kg IV should be given.(Level of Evidence: B)
Fondaparinux should not be used as the sole anticoagulant to support PCI. An additional anticoagulant with anti-IIa activity should be administered because of the risk of catheter thrombosis. (Level of Evidence: C)
Class IIa
5.2 PCI of an Infarct Artery in Patients Who Initially Were Managed With Fibrinolysis or Who Did Not Receive Reperfusion Therapy
Class I
Class IIa
Class IIb
Class III: No Benefit
5.3 PCI of a Noninfarct Artery Before Hospital Discharge
Class I
Class IIa
5.4 Adjunctive Antithrombotic Therapy to Support Delayed PCI After Fibrinolytic Therapy
5.4.1 Antiplatelet Therapy to Support PCI After Fibrinolytic Therapy
Class I
Class IIa
Class III: Harm
5.4.2 Anticoagulant Therapy to Support PCI After Fibrinolytic Therapy
Class I
Class III: Harm
§Although individual circumstances will vary, clinical stability is defined by the absence of low output, hypotension, persistent tachycardia, apparent shock, high-grade ventricular or symptomatic supraventricular tachyarrhythmias, and spontaneous recurrent ischemia.
