Hi all! Just to clarify, since I realized it may be confusing listening to this. While TNK could treat both a STEMI or an ischemic CVA, giving it for stroke is going to preclude the patient from receiving antiplatelet agents/asa/clopidogrel (and, therefore, can not do PCI). Cardiology typically waits for a period of time before taking to the Cath lab. Hope that helps and thanks for listening.
Susy.... please tell me if I'm wrong.. giving aspirin and (sometimes plavix, heparin) is helpful in lytic-treated STEMI's (we use TNK for some STEMI's, don't always have PCI in house, and for stroke) ....
Addition of Clopidogrel to Aspirin and Fibrinolytic Therapy for Myocardial Infarction with ST-Segment Elevation List of authors. Marc S. Sabatine, M.D., M.P.H., Christopher P. Cannon, M.D., C. Michael Gibson, M.D., Jose L. López-Sendón, M.D., Gilles Montalescot, M.D., Pierre Theroux, M.D., Marc J. Claeys, M.D., Ph.D., Frank Cools, M.D., Karen A. Hill, B.A., Allan M. Skene, Ph.D., Carolyn H. McCabe, B.S., and Eugene Braunwald, M.D. for the CLARITY–TIMI 28 Investigators* March 24, 2005 N Engl J Med 2005; 352:1179-1189 DOI: 10.1056/NEJMoa050522
all very cool... great teaching case... tragic, in this young runner.
I think it's more that with patients with CVA receiving TNK, it's usually recommended that all anticoagulant and anti platelet agents are held for 24 hours. That being said, it's a complicated conversation between Neurology and Cardiology and there are probably some cases where Cardiology will elect to proceed with emergent PCI. I am sure it is practice locale dependent as well. In this case, I am guessing that given the echo and thought that this was probably Takostubo and less likely an occlusion AMI, the decision was not to move to emergent PCI. Thanks for listening and investigating!
I am concerned with administration of lytics in someone with an abnormal head CT (min time 6 hours for that to happen from what I can find) and SUB-acute infarcts on MRI. This patient had absolute contraindications to lytics IMO.
Thanks for listening Brian. This was a case presentation used to review non ACS related causes of STE. The patient was evaluated by an EM physician, cardiologist, and neurologist while in the ED. I can only assume these three physicians and the rest of the medical team provided the best care possible. Per their evaluation and history, the patient did not have an absolute contraindication to TNK. Contemporary troponin would not necessarily be elevated after an ultra marathon and, in the setting of concerning ECG, would not be my leading diagnosis.
I don't see how a read of "subacute infarct" on MRI would qualify a patient for lytics. Clearly the patient did not bleed, but I and my neurology colleagues I consulted about this case would not have given them based on the head CT and MRI findings. Clearly the patient did okay, but I don't see how we can recommend lytics in the face of a "subacute infarct" on the MRI.
Hello EM:RAP team! I'm an ED doc in Joplin MO and in my shop the cardiologists don't want to hear about NSTEMIs. It's the practice of our group to start all NSTEMIs on Heparin and admit them to the floor. But, this is contrary to my understanding of the use of heparin. I've always thought that it's okay to use heparin as a temporizing method prior to taking them to the cath lab. This NNT article (https://www.thennt.com/nnt/heparin-for-acute-coronary-syndromes/) backs this way of thinking up, but whenever I mention this cochrane review the cardiologists look at me like I've got 2 heads. What is the right use of heparin for ACS?
Nathaniel - great question. We discussed much of this here in cards corner: https://www.emrap.org/episode/emrapdecember/cardiology Basically, segment agrees with your persepective - no real benefit Shownotes: What is the actual benefit of heparin in STEMI patients? The heparin maintains patency after the use of thrombolytics. tPA is relatively short-acting and the heparin is necessary to maintain patency. Patients receiving PCI need heparin on board to maintain the safety of the PCI. The catheter can cause endothelial damage which can lead to thrombus formation and myocardial infarction. How quickly do you need to give the heparin? It needs to be given at some point before they insert the catheter and the balloon. It may be given in the emergency department or the cath lab. A 2008 Cochrane review found that administration of heparin to unstable angina patients had a small short term decrease in progression to full infarction with no improvement in mortality or risk of revascularization. The benefit was gone after a month and there was a slight increase in the risk of bleeds. If the patient is not going to the cath lab, there doesn’t appear to be a significant benefit to heparin based on the current evidence. Andrade-Castellanos, CA et al. Heparin versus placebo for non-ST elevation acute coronary syndromes. Cochrane Database Syst Rev. 2014 Jun 27;(6):CD003462. PMID: 24972265
To join the conversation, you need to subscribe.
Sign up today for full access to all episodes and to join the conversation.
To earn CME for this chapter, you need to subscribe.
Sign up today for full access to all episodes and earn CME.
Susy D, MD - August 1, 2022 1:34 PM
Hi all! Just to clarify, since I realized it may be confusing listening to this. While TNK could treat both a STEMI or an ischemic CVA, giving it for stroke is going to preclude the patient from receiving antiplatelet agents/asa/clopidogrel (and, therefore, can not do PCI). Cardiology typically waits for a period of time before taking to the Cath lab. Hope that helps and thanks for listening.
tom f. - August 5, 2022 1:39 AM
excellent, Susy and Swami. even "STEMI's" are not always simple.
tom
tom f. - August 5, 2022 1:53 AM
Susy.... please tell me if I'm wrong.. giving aspirin and (sometimes plavix, heparin) is helpful in lytic-treated STEMI's (we use TNK for some STEMI's, don't always have PCI in house, and for stroke) ....
Addition of Clopidogrel to Aspirin and Fibrinolytic Therapy for Myocardial Infarction with ST-Segment Elevation
List of authors.
Marc S. Sabatine, M.D., M.P.H., Christopher P. Cannon, M.D., C. Michael Gibson, M.D., Jose L. López-Sendón, M.D., Gilles Montalescot, M.D., Pierre Theroux, M.D., Marc J. Claeys, M.D., Ph.D., Frank Cools, M.D., Karen A. Hill, B.A., Allan M. Skene, Ph.D., Carolyn H. McCabe, B.S., and Eugene Braunwald, M.D. for the CLARITY–TIMI 28 Investigators*
March 24, 2005
N Engl J Med 2005; 352:1179-1189
DOI: 10.1056/NEJMoa050522
all very cool... great teaching case... tragic, in this young runner.
tom fiero
ed doc
merced
Susy D, MD - August 5, 2022 11:44 AM
I think it's more that with patients with CVA receiving TNK, it's usually recommended that all anticoagulant and anti platelet agents are held for 24 hours. That being said, it's a complicated conversation between Neurology and Cardiology and there are probably some cases where Cardiology will elect to proceed with emergent PCI. I am sure it is practice locale dependent as well. In this case, I am guessing that given the echo and thought that this was probably Takostubo and less likely an occlusion AMI, the decision was not to move to emergent PCI. Thanks for listening and investigating!
brian h. - August 29, 2022 12:31 PM
I am concerned with administration of lytics in someone with an abnormal head CT (min time 6 hours for that to happen from what I can find) and SUB-acute infarcts on MRI. This patient had absolute contraindications to lytics IMO.
brian h. - August 29, 2022 12:37 PM
also, the trop elevation should be expected simply from running an ultra-marathon
Susy D, MD - August 30, 2022 12:07 PM
Thanks for listening Brian. This was a case presentation used to review non ACS related causes of STE. The patient was evaluated by an EM physician, cardiologist, and neurologist while in the ED. I can only assume these three physicians and the rest of the medical team provided the best care possible. Per their evaluation and history, the patient did not have an absolute contraindication to TNK. Contemporary troponin would not necessarily be elevated after an ultra marathon and, in the setting of concerning ECG, would not be my leading diagnosis.
brian h. - August 30, 2022 12:53 PM
I don't see how a read of "subacute infarct" on MRI would qualify a patient for lytics. Clearly the patient did not bleed, but I and my neurology colleagues I consulted about this case would not have given them based on the head CT and MRI findings. Clearly the patient did okay, but I don't see how we can recommend lytics in the face of a "subacute infarct" on the MRI.
brian h. - August 30, 2022 12:54 PM
https://radiopaedia.org/articles/ischaemic-stroke
Nathaniel R. - January 24, 2023 1:50 PM
Hello EM:RAP team!
I'm an ED doc in Joplin MO and in my shop the cardiologists don't want to hear about NSTEMIs. It's the practice of our group to start all NSTEMIs on Heparin and admit them to the floor. But, this is contrary to my understanding of the use of heparin. I've always thought that it's okay to use heparin as a temporizing method prior to taking them to the cath lab. This NNT article (https://www.thennt.com/nnt/heparin-for-acute-coronary-syndromes/) backs this way of thinking up, but whenever I mention this cochrane review the cardiologists look at me like I've got 2 heads.
What is the right use of heparin for ACS?
Nathaniel Rider, MD
Anand S. - January 24, 2023 3:05 PM
Nathaniel - great question. We discussed much of this here in cards corner: https://www.emrap.org/episode/emrapdecember/cardiology
Basically, segment agrees with your persepective - no real benefit
Shownotes:
What is the actual benefit of heparin in STEMI patients? The heparin maintains patency after the use of thrombolytics. tPA is relatively short-acting and the heparin is necessary to maintain patency. Patients receiving PCI need heparin on board to maintain the safety of the PCI. The catheter can cause endothelial damage which can lead to thrombus formation and myocardial infarction.
How quickly do you need to give the heparin? It needs to be given at some point before they insert the catheter and the balloon. It may be given in the emergency department or the cath lab.
A 2008 Cochrane review found that administration of heparin to unstable angina patients had a small short term decrease in progression to full infarction with no improvement in mortality or risk of revascularization.
The benefit was gone after a month and there was a slight increase in the risk of bleeds.
If the patient is not going to the cath lab, there doesn’t appear to be a significant benefit to heparin based on the current evidence.
Andrade-Castellanos, CA et al. Heparin versus placebo for non-ST elevation acute coronary syndromes. Cochrane Database Syst Rev. 2014 Jun 27;(6):CD003462. PMID: 24972265