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Akshay Khandelwal MD @KhandelwalMD
, 19 tweets, 41 min read Read on Twitter
1/10 #STEMI from ruptured plaque, less plaque erosion. @BraunwaldEugene pic demonstrates LDL oxidized, glycated➡️cytokines release express adhesion molecules➡️monocytes roll, diapedesis➡️ingest LDL, become foam cell➡️SMC migrate, proliferate➡️some apoptosis➡️plaque
2/10 Why #STEMI on #ECG
1. Diastolic current of injury: current away from relatively depolarized injury➡️TQ depression➡️normalized on ECG➡️ST elevation
2. Systolic current of injury: current towards injury due to early repol➡️ST elevation
3/10 Gotta hurry, #TimeIsMuscle. Myocardial salvage best early, but we usually get patient on point C or B on #GerschCurve. Hey #millenials: #lytics do work esp in 1st hour, but #PPCI decreases NFMI/CVA/death. @bnallamo showed if delay to PPCI < 60 minutes, #lytics better
4/10 use #lytics when no #PPCI on site if early presentation, non #AMICGS, low risk of bleeding. For mod-high risk #STEMI transfer early even if reperf successful, esp if not: pharmacoinvasive strategy with early angiography best: REACT, TRANSFER AMI, CARESS in AMI, NORDISTEMI
5/10 @ACCinTouch @American_Heart guidelines published in @JACCJournals and @CircAHA for #STEMI reperfusion clear: board-relevant, important for patient care
6/10 Antiplatelet therapy for #STEMI: aspirin as good as #lytics! #OldIsGold. Have patients chew, because buccal absorption leads to peak plasma levels in 10 minutes.
7/10 DAPT and anticoag RX imp for #STEMI. While 2b/3a and cangrelor options, many (including @HenryFordNews) load with P2Y12 inhibitors. Our preference is ticagrelor/heparin because of PLATO, pharmacokinetics, & we are 90% #radialfirst for #STEMI; what's yours?
8/10 Nonculprit #PCI for #STEMI. Growing evidence (outside of #AMICGS) that complete revasc (index procedure, index hospitalization, or #FFR guided) may improve composite endpoints for patients. Rationale may be mult plaque ruptures due to global inflammatory state
9/10 Don't forget med rx! #reperfusion therapy may be your passion, but #OMT must be your bedrock. Beta blockers, ACE-I/ARBs, statins, and cardiac rehab. Risk assess to reduce reinfarction, readmission, death.
10/10. How far we've come. More achieve #D2B <90 minutes but survival worsening in those who don't. #STEMI systems of care critical. Need to manage #AMICGS. Advocate! #MissionLifeline @ACCCVQuality #ACCAccreditation #DetroitCSI #NationalCSI @Cardiology @AmHeartAdvocacy
conclusion/10. That concludes my #STEMI #FITSurvivalGuide for #ACCFIT. Lots to cover in a 10-tweet #tweetorial, feel free to fill in the gaps!
Oops! That should be if delay to #PPCI > 60 minutes, #lytics better.
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