STEMI - I Gde Rurus Suryawan, MD, FIHA.pdf

CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015

CURRENT MANAGEMENT OF STEMI

I GDE RURUS SURYAWANGILANG M. RAHMAN

Acute thrombosis induced bya ruptured or eroded

atherosclerotic coronaryplaque, with or without

concomitantvasoconstriction, causing a

sudden and critical reductionin blood flow

2Hamm CW et al. Eur Heart J 2011;32:2999 – 3054


DEFINITION

“ STEMI is a clinical syndrome characterized byischemic symptom which related to persistent ST

segment elevation in ECG ”

O’Gara et al: J Am Coll Cardiol. 2013 ; 29;:61(4)


Non-Traditional• Homocysteine• Lipoprotein (a)• C-Reactive Protein (CRP)

TraditionalModifiable• Dyslipidemia• Smoking• Hypertension• Diabetes Mellitus• Lack of physical ActivityNon Modifiable• Advanced age• Male Gender• Hereditary

CARDIOVASCULAR RISK FACTOR

PATHOGENESIS


PATHOGENESIS

Total Occlusion of Coronary Artery

Vulnerable Plaque Rupture

Thrombus Formation

Endothelial Dysfunction

CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 20152015 ESC Guidelines NSTEMI


PATHOGENESIS

Myocardial Infarction

Biomarker Release


DIAGNOSIS

Typical chest pain persist >20min:• Pain, burning or weight sensation• Radiate to the neck, back or arm• Not relieved by rest or nitrate

Other Symptom:• Shortness of breath• Nausea• Diaphoresis• Palpitation

Usually normal,Sign of Complication;• Tachypnea,• Hypotension• Tachycardia-Bradycardia• Jugular veins distention• Gallop S3• Pulmonary Rales• Systolic Murmur

SYMPTOM SIGN


J-point + 0,04 Sec

Baseline

- ST-Elevation in minimaltwo contagious lead≥0,1mV

- In lead V2-V3 :≥0,2 mV in male ≥40 y.o≥0,25 mV in male<40 y.o≥0,15 mV in female

Target:≤10 minutes fromFirst Medical Contact

ESC Guidelines, 2012

DIAGNOSIS

ECG


DIAGNOSIS

Biomarker Specificity Onset Peak Duration

CK-MB Less 3-4 hrs 12-24 hrs 48-72 hrs

Troponin T Specific 3-12 hrs 12-24 hrs 8-21 days

Troponin I Specific 3-12 hrs 12-24 hrs 7-11 days

Biomarker

ACLS, 2012

CK-MB or Troponin


MANAGEMENT



Onset ofsymptomsof STEMI

9-1-1EMS

Dispatch

EMS on-scene• Encourage 12-lead ECGs• Consider prehospital fibrinolytic ifcapable and EMS-to-needle within 30 min

EMSTriagePlan

Hospital fibrinolysis :Door-to-Needle within 30 min

Not PCIcapable

PCIcapableGoals†

Total ischemic time: Within 120 min*

EMS transportEMS onscene

P :Patient Dispatch

5 min aftersymptom onset

1 min Within8 min

Pre hospital Fibrinolytic EMS-to-Handle within 30 min

*Golden Hour = First 60 minutes

EMS transport:EMS-to-Balloon within 90 min

Patient self-transport:Hospital Door-to-Balloonwithin 90 min

Emergency Medical System


EMERGENCY ROOM

Indicated in patient with hypoxia (Sa02 <95%), dyspnea, and heart failure

• Morphine 4-8 mg i.v• Relieve pain and anxiety• Adverse reaction: Hypotension, respiratory depression, and vomiting

OXYGENATION

INTRAVENOUS OPIOID

ASPIRIN• Aspirin oral (chewable) or i.v should be given in STEMI• Loading dose 300-325 mg , maintenance dose 75-100 mg od


EMERGENCY ROOMP2Y12 RECEPTOR BLOCKER

• Ticagrelor & Prasugrel are preferable and recommended in patientswho planned for Primary PCI

• Loading dose Ticagrelor 180 mg or Prasugrel 60 mg• Loading dose Clopidogrel 600 mg (Primary PCI) or 300 mg (Fibrinolysis)

NITRATE

• Short acting nitrates (Nitroglyserin 0,4 mg or ISDN 5 mg S.L) is recommended• Should not be given in : RV infarction is suspected, hypotension, still in effect of

sildenafil/viagra, aorta stenosis, & HOCMBETA BLOCKERS

• Reduce myocardial oxygen demand and incident of lethal arrhythmia• Should not be given in: acute heart failure (Killip >2), significant AV Block,

hypotension (SBP<90mmHg) and bradycardia (<60bpm)


REPERFUSION THERAPYSTRATEGY

VS

Primary PCI Fibrinolysis


ESC GUIDELINES,2012


• PCI is indicated for all STEMI patient in onset lessthan 12 hours

• Door to baloon time target is <90 minutes or <60minutes in new onset STEMI with large area at risk

• PCI procedure with balloon angioplasty+stent ismore recommended than balloon angioplasty alone

• Periprocedural antithrombotic therapy should begiven in Primary PCI

Primary-PCI Capable Centre

ESC Guidelines 2012; ACC/AHA Guidelines 2013


• Fibrinolysis is recommended for all patient with onset ≤12 hours if estimatingtime transfer to PCI capable centre >120 minutes, unless contraindicated

• In new onset STEMI (<2 hours) with large infarcted area and low bleedingrisk, Fibrinolysis is recommended if estimating time transfer to PCI capablecentre >90 minutes

• Fibrin specific agent (Alteplase, Reteplase, atau Tenecleptase) is morerecommended than nonspecific agent (Streptokinase)

• Periprocedural antithrombotic therapy should be given as well

Non Primary-PCI Capable Centre

ESC Guidelines 2012; ACC/AHA Guidelines 2013




Coronary Artery Bypass Graft

Urgent CABG is indicated in patientswith STEMI and coronary anatomy

not amenable to PCI who haveongoing or recurrent ischemia,

cardiogenic shock, severe HF, orother high-risk features

CABG is recommended in patientswith STEMI at time of operative repair

of mechanical defects.[

“ The number of patients who require CABGIn acute phase of STEMI is relatively small ”

ACC/AHA Guidelines 2013


NON REPERFUSED STEMIPresent ≤12 hours onset Present >12 hours onset

Common Cause:• Spontaneus Reperfusion• Contraindicated to any reperfusion

therapy

Common Cause:• Late presenters• Resource limitation

Adjuvant Therapy Urgent PCIElective PCI

• Hemodinamically and/or Electrically unstable• Ongoing Ischemia in onset 12-24 hours

YES

NO

Viability & FunctionalAssestment

No ReperfusionTherapy

Cohen, et al 2012


CASE ILUSTRATION A 63 Years old gentleman with history of hypertension

and diabetic came to ER of primary hospital withprolonged typical chest pain with 2 hours onset

Vital sign: BP 150/90 mmHg, HR 95 bpm, RR 24, axillartemp 370C, with no abnormality in other physicalexamination

ECG Shows ST-segment elevation (V1-V6) at anteriorleads


Question??

1. We have to confirm the diagnosis with serum marker

to establish the diagnosis.. (T/F)

2. At the moment your diagnosis is ?

a. Unstable Angina

b. Non STEMI

c. STEMI


Management DUAL ANTIPLATELETS: Aspirin 300-325 mg plus ? Clopidogrel 600 mg loading then 75 mg od Ticagrelor 180 mg loading, then 90 bid mg Prasugrel 60 mg loading, then 10 mg od

NITRATE

BETA-BLOCKER

THROMBOLYTIC vs PPCI




b



SUMMARY• Acute emergency care is very important, the key point of

STEMI management is reperfusion therapy

• Determining the appropriate reperfusion therapy strategy ishighly depend on the clinical setting and resource availabilityin each medical center

• Time to perform reperfusion is the most important variableto get a better outcomes

• Guidelines of STEMI management can guide thepractitioners to perform a good acute emergency care andto choose the most appropriate reperfusion therapystrategy


LONGTERM MANAGEMENT

• To improve long term outcome and as a secondaryprevention of reccurent MI, hospitalization, and chronicheart failure

• Should be started at Pre-Hospital Discharge

• Long management including : Lifestyle management,Antiplatelet, Beta Blocker, RAAS Inhibitor, Statin, and Nitrate


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