Thomas Deepak, Giugliano Robert P
Brigham and Women's Hospital, Boston, MA, USA.
Am Heart J. 2009 Nov;158(5):695-705. doi: 10.1016/j.ahj.2009.08.023.
The American College of Cardiology/American Heart Association and the European Society of Cardiology each recently published updated guidelines for management of patients with acute ST elevation myocardial infarction. In this article, we highlight the most important new recommendations, review their supporting data, and describe differences between the guidelines. Key aspects of these updates include detailed guidance regarding the selection of a reperfusion strategy and the incorporation of newer adjunctive antithrombotic agents. Both new guidelines suggest caution in the administration of intravenous beta-blockers, avoidance of nonsteroidal anti-inflammatory agents, and support a more aggressive approach to secondary risk factor management. The 2 guidelines have some nuanced differences as well as some recommendations that are unique to each guideline. They present different levels of support for the 4 available adjunctive parenteral anticoagulants, vary in their endorsement of routine elective coronary angiography after fibrinolysis, and cite different targets for low density lipoprotein long-term. Major unique recommendations include the American College of Cardiology/American Heart Assocaition's emphasis of a stepped approach to analgesia in patients with musculoskeletal pain beginning with acetaminophen or aspirin and a lower target international normalized ratio in patients receiving warfarin, aspirin, and clopidogrel. Meanwhile, unique recommendations in the European Society of Cardiology guidelines include measures to prevent/treat microvascular obstruction and reperfusion injury associated with percutaneous coronary intervention and greater emphasis on maintaining eugylcemia. As these guidelines represent an evidence based approach, health care providers should become familiar with the new data and the resultant updated recommendations to ensure optimal treatment of their patients with ST-elevation myocardial infarction.
美国心脏病学会/美国心脏协会以及欧洲心脏病学会最近各自发布了急性ST段抬高型心肌梗死患者管理的更新指南。在本文中，我们重点介绍最重要的新建议，回顾其支持数据，并描述指南之间的差异。这些更新的关键方面包括关于再灌注策略选择的详细指导以及纳入更新的辅助抗栓药物。两项新指南均建议谨慎使用静脉β受体阻滞剂，避免使用非甾体抗炎药，并支持对二级危险因素管理采取更积极的方法。这两项指南存在一些细微差别以及各自独有的一些建议。它们对4种可用的辅助肠外抗凝剂的支持程度不同，对溶栓后常规选择性冠状动脉造影的认可程度不同，并且长期低密度脂蛋白的目标引用也不同。主要的独特建议包括美国心脏病学会/美国心脏协会强调对肌肉骨骼疼痛患者采取逐步镇痛方法，从对乙酰氨基酚或阿司匹林开始，以及对华法林、阿司匹林和氯吡格雷联合使用患者采用较低的国际标准化比值目标。同时，欧洲心脏病学会指南中的独特建议包括预防/治疗与经皮冠状动脉介入相关的微血管阻塞和再灌注损伤的措施，以及更加强调维持血糖正常。由于这些指南代表了基于证据的方法，医疗保健提供者应熟悉新数据和由此产生的更新建议，以确保对其ST段抬高型心肌梗死患者进行最佳治疗。
