STEMI

St elevated myocardial infarction

Outline
Introduction Clinical diagnosis Investigation Management Case discussion

Introduction
Myocardial infarction due to acute

total occlusion of the coronary artery

Pathogenesis:

Atherosclerotic plaque rupture, fissuring or ulceration with superimposed thrombosis and coronary vasospasm.

Nonatherosclerotic coronary vasospasm alone coronary embolism Vasculitis rare

Clinical Diagnosis of STEMI

It is diagnosed by:
0.1 mV in 2 contiguous limb leads, or V4 to V6 and/or 0.2 mV in 2 contiguous precordial leads V1 to V3 Clinical history of ischaemic type chest pain

ECG changes - diagnosis of STEMI: New onset ST-segment elevation Presumed new LBBB

Evidence of myocardial injury or necrosis as indicated by elevated serum cardiac biomarkers

Retrosternal, severe, crushing, squeezing

1. Clinical history

or pressing in nature, lasting more than 30 minutes, may radiate to the jaw or down the left upper limb, may occur at rest or with activity Associated with

profuse sweating, nausea, vomiting and SOB

Atypical: burning in nature, nausea and

vomiting, lightheadedness and syncope, dyspnea with/without chest pain-> diabetics, elderly and female
Hx of prev IHD, PCI, CABG, risk factors, hx

of CVA

 Early presentation, ECG maybe

2. ECG changes

normal or equivocal -> Serial ECG Characteristic evolving ECG changes

Tall peaked T wave

ST elevation

Q wave

T inversion

Pathological Q wave

ECG patterns

RCA RA, RV, inferoposterior LV

CX lateral, posterior, and inferior LV

LAD anterior septum/ anterior, lateral, and apical wall of LV.

3. Elevated serum cardiac biomarkers

Troponin and CK-MB most specific Troponin remain elevated for 14

days CK-MB rise early and fall earlyuseful to dx reinfarction

Investigation
Serial ECG Chest x ray Blood ix FBC Cardiac enzyme Renal profile, electroytes PT/INR Arterial blood gas Lipid profile FBS, haemoglobin A1c Urgent echocardiogram

Management of STEMI

Early management of STEMI is directed at: Pain relief Establishing early reperfusion

Thrombolytic therapy PCI

Treatment

of complications arrhythmias, etc

Long term management

TIME LOST IS MYOCARDIUM LOST

Thrombolysis Treatment
If given within 1 hour, abort the infarction and reduce mortality by up to 50% If SBP < 90 mmHg, should receive inotropic support prior to treatment Should be given ONLY for STEMI

Streptokinase most widely used agent not fibrin specific and is less efficacious than fibrin selective agents Antigenic IV Streptokinase 1.5 mega Units in 100ml NS over 1 hour

Alteplase fibrin specific achieves better reperfusion at 90min as compared to streptokinase higher rate of reocclusionneed heparin

Tenecteplase, Reteplase Second generation fibrin specific agents as efficacious as alteplase slightly lower bleeding risk as compared to alteplase easier to administersingle/double bolus Heparin needed

Indicator of successful reperfusion 1) Resolution of chest pain 2) Return of ST elevation to isoline or decrease by 50% (within 6090mins) 3) Early peaking CK/CK-MB levels 4) Restoration of hemodynamic and electrical stability

Failed Fibrinolysis persistent chest pain, ST elevation and hemodynamic instability Mx = rescue PCI

Percutaneous Coronary Intervention (PCI) 16

4 types

Primary Facilitated Rescue Delayed (>72 hr after fibrinolytic therapy)

Previously called Angioplasty,

Percutaneous Transluminal Coronary (PTCA) or Balloon Angioplasty

Increase the size of the opening by compressing the plaque deposits against the wall of the artery Pass a tiny balloon attached to a catheter through the vessel to the obstructed site Balloon is then inflated and deflated pushing the plaque against the wall of the artery create a wider channel for the blood to flow through.

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Factors affecting reperfusion technique

Time from onset of symptoms High risk patient Contraindication to fibrinolytic therapy Door-to-balloon time (time from hospital arrival to balloon

dilatation) Door-to-needle time (time from hospital arrival to administration of fibrinolytic therapy)

1) Time from onset of symptoms

Early (within 3 hrs) Both PCI and thrombolysis are effective PCI preferred in: High risk patient Thrombolysis is C/I DTB time DTN time < 60mins Late (3 -12 hrs) PCI is preferred if DTB time < 90 mins in centre with PCI facility If transferred, DTB should be < 2 hours If more, thrombolysis is preferred

Very late (>12hours) Both PCI and thrombolysis is not suitable for asymptomatic and hemodynamically stable pt If not stable-> primary PCI is preferred

2) High risk patient

PCI is preferred

Large infarcts Anterior infarcts Cardiogenic shock Elderly patients Post revascularization (post CABG and post PCI) Post infarct angina

3) Contraindications of thrombolysis
Absolute contraindications
Risk of intracranial hemorrhage History of intracranial hemorrhage History of ischemic stroke <3months Structural cerebral lesion (aneurysm, AVM) Intracranial tumour Risk of bleeding Suspected aortic dissection Significant head trauma < 3/12 Active bleeding (except menses)

Relative contraindication
Risk of intracranial hemorrhage Blood pressure >180/110 mmHg Hx of severe, chronic uncontrolled hypertension History of ischemic stroke >3 months Risk of bleeding Recent major surgery < 3 weeks On anti coagulant treatment (INR > 2) Recent internal bleed within 4 weeks Active peptic ulcer

Others: Pregnancy, Prior exposure (> 5 days and within 12 months

of first usage) to streptokinase (if planning to use same agent)

Secondary prevention
Stop smoking Diet control Regular Exercise Control of Hypertension Good Glycemic control Antiplatelet Agents Aspirin 150 mg od (lifelong) and clopidogrel

75 mg od ( dual antiplt at least 1 month) - blockers lifelong if no contraindication ACE Inhibitors and ARB Lipid-lowering therapy- statin Oral Anticoagulant (warfarin) persistent AF, LV thrombus (give for 3- 6 months) Cardiac rehabilitation

Complications of STEMI
Arrhythmias

Tachy or bradyarrhythmias Asymptomatic to cardiogenic shock Free wall rupture, ventricular septal rupture, papillary muscle rupture Inferior MI triad of hypotension, clear lung fields and elevated jugular venous pressure ST elevation in right precordial leads (V4R) Not for diuretics/nitrates, Mx: iv fluid, inotrope Chest pain post STEMI reinfarction, ischemia, pericarditis, Dresslers syndrome DVT

Left ventricular dysfunction or shock

Mechanical complications

Right ventricular infarction

Others

CASE DISCUSSION

HOPI
Mr K, 40 year old malay male, chronic smoker with

u/l DM - default treatment for 1 year Presented with: Chest pain at 11pm last night occurred at rest initially centrally located but later radiated to bilateral chest and back - pressing in nature - lasted 20 minutes pain score 7/10 a/w: SOB, profuse sweating, palpitations, nausea and vomiting - vomited x 2 at kk

In KK Lanchang
In KK, BP 98/72, HR 76 Dxt 18.2 Pt was given iv ranitidine 25mg s/l gtn 1/1 t aspirin 300mg crushed ECG noted st

elevation at lead 1, avl, v2-v5, reciprocal changes st depression at lead 111, avf

In ED
Pain score 4/10 O/E: conscious, alert, not pale, not tacypneic, not tachycardic,

good pulse volume, crt < 2 sec BP 137/67, HR 100 bpm, Spo2 98%, afebrile Lungs clear, equal a/e, cvs drnm p/a soft, non tender No pedal edema

ECG: Ventricular bigeminy, st elevation at 1, v2, v5 Bedside Echo in ED: hypokinesia at anterior, septal and

lateral wall

ECG in ED

Chest X Ray on admission

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Diagnosis: 1. Acute anterolateral MI killip 1 2. Uncontrolled DM tro DKA and HHS Mx in ED: iv streptokinase 1.5 megaunit in 100 cc NS in 1 hour t clopidogrel 300mg given Nasal prong 3l/min Ivi insulin sliding scale, hourly dxt Iv maxolon 10 mg stat Condom catheter

ECG post streptokinase

Management in CCU
Daily ecg and ce ecg and ce stat upon chest pain cont insulin sliding scale strict dxt and vs monitoring kiv for PCI if increasing in chest pain/ ecg new evolving changes start ACS treatment and other medication: t aspirin 150mg od t plavix 75mg od s/c fondaparinux 2.5mg od t simvastatin 40mg on s/l gtn 1/1 prn t perindopril 4mg od t bisoprolol 1.25mg od t alprazolam 0.5mg on syr lactulose 15mls prn

Progression in ward
Blood ix normal, treat as MI and uncontrolled DM T/O of CCU to general ward on 3rd day Echo done inpatient, EF: 45%, RMWA present Patient remain stable in ward, no chest pain CK reducing in trend: 118 > 6376 > 1327 > 298 > 105 Seen by dietitian, physiotherapist Completed s/c fonda for 5/7, discharged well Memo to kk for dxt monitoring, rpt RP in 2 weeks For stop smoking clinic Tca hosp Serdang for further management

Discharge medication:
Tab pantoprazole 40mg od T metformin 1g bd T plavix 75 mg od Tab aspirin 150mg od S/l gtn 1/1 prn Tab bisoprolol 2.5mg od T.Isordil 10mg tds T.Perindopril 4mg od

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