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Acute STEMI: current approach

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NSTEACS vs. STEACS

• Non occluding culprit lesion in 60-85 %• Autolysis• Recurrent ischemia/MI• No time dependent muscle lose• Grayish-white (platelet-rich) vs. reddish

(fibrin- rich)• No role of fibrinolysis in STEACS (TIMI IIIB:

↑MI,↑trend of bleeding)

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ED Evaluation of ED Evaluation of Patients With STEMIPatients With STEMI

Aortic dissection

Pulmonary embolus

Perforating ulcer

Tension pneumothorax

Boerhaave syndrome

(esophageal rupture with

mediastinitis)

Differential Diagnosis of STEMI: Life-Threatening

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“ACS in the year 2011”

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Management of STEMI

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“Thrombolytic Therapy ”

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FibrinolysisFibrinolysis

In the absence of contraindications, fibrinolytic therapy should be administered to STEMI patients with symptom onset within the prior 12 hours.

In the absence of contraindications, fibrinolytic therapy should be administered to STEMI patients with symptom onset within the prior 12 hours and new or presumably new left bundle branch block (LBBB).

III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII

III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII

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“Antiplatelets”

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AspirinAspirinIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII

Aspirin should be chewed by patients who have

not taken aspirin before presentation with STEMI.

The initial dose should be 162 mg (Level of

Evidence: A) to 325 mg (Level of Evidence: C)

Although some trials have used enteric-coated aspirin for initial dosing, more rapid buccal absorption occurs with non–enteric-coated formulations.

III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII

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Death/non-fatal MI at day 30 for the major subgroups

All interaction testsp = NS

p < 0.0001

0.5 1 2Enoxaparin better UFH better

Sex MaleFemale

Age (years) < 75 75

Infarct location AnteriorOther

Diabetes No diabetesDiabetes

Prior MI No prior MIPrior MI

Fibrinolytic StreptokinaseFibrin specific

Time-to-treatment < Median Median

OVERALL N = 20,479

Reduction in risk (%)1816

206

1123

1721

1720

1318

2312

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Adapted with permission from Antman EM, et al. N Engl J Med. 2006;354:1477-88.NS = not significant.

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Cumulative incidence of individual elements of the primary endpoints, death (left) and non-fatal myocardial infarction (right), in patients randomized to the enoxaparin vs. the

unfractionated heparin strategy.

Morrow D A et al. Eur Heart J 2010;31:2097-2102

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2010. For permissions please email: journals.permissions@oxfordjournals.org

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Relative hazard rates and absolute event rates for the primary endpoint at 1 year in various subgroups.

Morrow D A et al. Eur Heart J 2010;31:2097-2102

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2010. For permissions please email: journals.permissions@oxfordjournals.org

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Patients with ongoing ischemic discomfort should receive sublingual NTG (0.4 mg) every 5 minutes for a total of 3 doses, after which an assessment should be made about the need for intravenous NTG.

Intravenous NTG is indicated for relief of ongoing

ischemic discomfort that responds to nitrate therapy,

control of hypertension, or management of pulmonary

congestion.

NitroglycerinNitroglycerin

III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII

III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII

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Nitrates should not be administered to patients with:

Nitrates should not be administered to patients who have received a phosphodiesterase inhibitor for erectile dysfunction within the last 24 hours (48 hours for tadalafil).

• systolic pressure < 90 mm Hg or ≥ to 30 mm Hg below baseline

• severe bradycardia (< 50 bpm)• tachycardia (> 100 bpm) or• suspected RV infarction.

NitroglycerinNitroglycerin

III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII

III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII

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 Practical demonstration of the ST segment resolution score (STR) in a patient treated by fibrinolysis for an acute anterior myocardial infarction.

Eeckhout E Heart 2007;93:632-638

©2007 by BMJ Publishing Group Ltd and British Cardiovascular Society

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58Copyright ©2007 American College of Cardiology Foundation. Restrictions may apply.

Wijeysundera, H. C. et al. J Am Coll Cardiol 2007;49:422-430

Efficacy End Points for Repeat Fibrinolytic Therapy Versus Conservative Therapy

59Copyright ©2007 American College of Cardiology Foundation. Restrictions may apply.

Wijeysundera, H. C. et al. J Am Coll Cardiol 2007;49:422-430

Safety End Points for Repeat Fibrinolytic Therapy Versus Conservative Therapy

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Non-ST-elevation acute coronary syndromes (NSTEACS)

• Unstable angina (UA)• Non-ST-elevation myocardial infraction

(NSTEMI)

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PPI should be used in patients with history of prior GI who require DAPT.

PPI use is reasonable in patients with increased risk of gastrointestinal bleeding (advanced age, concomitant use of warfarin, steroids, nonsteroidal anti-inflammatory drugs, H pylori infection, etc.) who require DAPT.

Routine use of a PPI is not recommended for patients at low risk of gastrointestinal bleeding, who have much less potential to benefit from prophylactic therapy.

PPIs and Antiplatelet Therapy

IIIaIIbIII

IIIaIIbIII

IIIaIIbIII

No Benefit