Acute Coronary Syndromes:

STEMI

Joshua M. Kosowsky, MD
Brigham & Women’s Hospital
Emergency Medicine Physician
 ACS Lecture Overview
• Definition and pathophysiology
• ACS case
– Reperfusion therapy
– Adjunctive medications
• Shock & CHF
• Right Ventricular Infarct
• AHA ACS Prevention Goals
 Acute Coronary Syndrome:
Definition & Pathophysiology

• ACS = range of myocardial ischemic states:

 Unstable angina→ Non-ST segment MI →STEMI

• Pathophysiology:
 Atherosclerotic plaque disruption
 Intracoronary thrombus formation

BMJ  2003;326:1259-1261 (7 June), doi:10.1136/bmj.326.7401.1259
Yeghiazarians et al., NEJM 2000; 342: 101.
Yeghiazarians et al., NEJM 2000; 342: 101.
• 65 yo male with 1 hour
of left sided chest pain
• Diaphoretic
• H/o diabetes and
hyperlipidemia
• T: 98.2 HR: 74
BP: 128/69 RR: 20
 How to treat ACS:

** iv and cardiac monitor **

MONA:
M- morphine
O- oxygen
N- nitrates
A- aspirin
 Time is Muscle
Door

Data Goals:
Lytic therapy: 30 minutes
PCI: 90 minutes
Decision

Drug/Balloon
 Reperfusion
I IIa IIb III STEMI patients presenting to a hospital with PCI
capability should be treated with primary PCI
within 90 minutes of first medical contact.

I IIa IIb III STEMI patients presenting to a hospital without

PCI capability and who cannot be transferred to a
PCI center for intervention within 90 minutes of
first medical contact should be treated with
fibrinolytic therapy within 30 minutes of hospital
presentation, unless contraindicated.
 Benefit of Thrombolytic Therapy
Lives Saved per Thousand Treated
50 49

40 37 35
30 25
19 18
20
10 8

0
-10
-14
-20
BBB Ant Inf ST Depr 0-1hr 2-3hr 4-6hr 7-12hr
ST ST
ECG Findings Time to Treatment
Lancet 343:311,1994
 Fibrinolytic Therapy: Indications

• ST elevation > 1 mm in 2 contiguous leads

or new or presumed new LBBB.
• Signs and symptoms of MI.
• Symptoms < 12 hours.

• OK even if Q waves have appeared.

 Fibrinolytic Therapy:
Absolute Contraindications

• Active internal bleeding

• Suspected aortic dissection
• Known intracranial neoplasm
• Any hemorrhagic stroke ever of other stroke
within the past year.
 Fibrinolytic Therapy:
Relative Contraindications
• Severe hypertension on presentation (BP>180/110)
• History of chronic severe hypertension
• History of prior CVA or other intracranial pathology
• Recent trauma (<2-4wks) or major surgery (<3wks)
• Prolonged or traumatic CPR (>10 min)
• Noncompressible vascular punctures
• Recent internal bleeding (<2-4 weeks)
• For SK/APSAC, prior exposure or allergy (use t-PA)
• Known bleeding diathesis or current INR > 2-3
Fibrinolytic Therapy: Risk of
Intracerebral Hemorrhage
• Overall risk ~0.5%.

• Higher risk with :

– Age> 65
– Weight <70 kg
– initial BP > 180/110
 Measuring Fibrinolytic Success:
• No perfect indicators, but use:
– Pain resolved?
– Amount of ST elevation improved by >70%?

• Start to worry if you’re not seeing these by 45-60 minutes

after the initiation of the lytic.

• If no reperfusion, move to rescue angioplasty.

 Percutaneous Coronary Intervention
(PCI) in Acute MI
• Benefits relative to lytic therapy:
– Successful in >90% of patients
– More complete restoration of arterial patency
– Less re-occlusion
– Fewer strokes
– Probably better outcomes in shock
• Limitations:
– Time
– Lack of widespread availability
 Facilitated PCI
I IIa IIb III A planned reperfusion strategy using full-dose
fibrinolytic therapy followed by immediate PCI may be
harmful.
 Immediate or Emergency
Invasive Strategy and Rescue PCI
Coronary angiography with intent to perform PCI (or
emergency CABG) is recommended for patients who
have received fibrinolytic therapy and have any of the
following:
I IIa IIb III

Cardiogenic shock in patients less than 75 years who

are suitable candidates for revascularization.
I IIa IIb III
Severe congestive heart failure and/or pulmonary edema
(Killip class III).
I IIa IIb III

Hemodynamically compromising ventricular

arrhythmias.
 Immediate or Emergency
Invasive Strategy and Rescue PCI

Coronary angiography with intent to perform rescue PCI is

I IIa
II IIb
II III
a b
reasonable for patients in who fibrinolytic therapy has
failed
ST-segment elevation <50% resolved after 90 minutes
following initiation of fibrinolytic therapy
Moderate or large area of myocardium at risk
Anticoagulants as Ancillary Therapy
I IIa IIb III
Patients undergoing reperfusion with
fibrinolytics should receive anticoagulant
therapy for a minimum of 48 hours, and
preferably for the duration of the index
hospitalization, up to 8 days.

I IIa IIb III

Regimens other than UFH are recommended
if therapy is given for more than 48 hours
because of risk of heparin-induced
thrombocytopenia.

Regimens with established efficacy include:

UFH, enoxaparin, fondaparinux
 Heparin

• Recommended in:
– Patients receiving fibrinolytics (not
SK/APSAC)
– All patients undergoing PCI.

• Dosing:
– 60 unit/kg bolus then 12 units/kg/hr (max
4000/1000)
 Beta-Blockers
Oral beta-blocker therapy should be initiated in
the first 24 hours for patients who do not have
the following:
Signs of heart failure
Evidence of low output state
I IIa IIb III
Increased risk for cardiogenic shock
Age >70 years
Systolic blood pressure <120 mm Hg
Sinus tachycardia (heart rate >110 or < 60 bpm)
Increased time since onset of symptoms of STEMI
Relative contraindications to beta-blockade
PR interval >0.24 seconds
second- or third-degree heart block
active asthma or reactive airway disease
 Beta-Blockers
It is reasonable to administer an IV beta-
blocker at the time of STEMI presentation to
I IIa IIb III patients who are hypertensive and who do not
have any of the following:
Signs of heart failure
Evidence of low output state
Increased risk for cardiogenic shock
Other relative contraindications to beta-blockade

I IIa IIb III IV beta blockers should not be administered to patients

who have any of the following:
Signs of heart failure
Evidence of low output state
Increased risk of cardiogenic shock
Other relative contraindications to beta-blockade
 Treatment of Shock and CHF
• For both, PCI is choice for reperfusion therapy.
• CHF:
– iv diuretics
– nitrates for preload and afterload reduction (keep SBP>90)
– consider dobutamine
• Hypotension:
– if SBP <80: norepinephrine
– if SBP 80-90: dopamine
 Right Ventricular Infarction

Presentation:
• ST elevation inferiorly (II, III, AVF)
• Hypotension (worse with preload reducing
agents: nitrates, morphine, diuretics)
• Classic triad:
– Jugular venous distention
– Clear lungs
– Hypotension
 RV Infarct
• 10-50% of inferior wall MIs (II,III, AVF)
have associated right ventricular infarct
• Contractility of the right ventricle depends
on diastolic pressure and output can
decrease dramatically with decreased
preload (volume)
• Also increased loss of AV synchrony
• ST elevation inferiorly in leads II, III, & AVF
•ST elevation anteriorly in V1
 • To do a right sided EKG
place pre-cordial leads
(V1-V6) across the
right side of the chest
in a mirror image of
the standard left-sided
leads (V1R-V6R)
• Lead V4T is placed in the
right 5th intercostal space
at the mid-clavicular line

Standard EKG lead placement

 Key Treatment Points
• Give IVF to increase preload to treat
hypotension
• Increased incidence of AV block requiring
packing support
• Increased in-hospital mortality to
aggressively pursue definitive treatment
2007 Goals: Secondary Prevention
Smoking: Complete cessation, no exposure
to environmental tobacco smoke.

Blood Pressure Control: <140/90 mmHg or

<130/80 mmHg if patient have diabetes or
chronic kidney disease.

Physical Activity: 30 minutes, 7 days per

week (minimum 5 days per week).
2007 Goals: Secondary Prevention
Weight Management:
Goals: BMI 18.5 - 24.9 kg/m2 and
Waist circumference in men <40 in;
women <35 in

Diabetes Management:
HbA1c less than 7%.

Influenza Vaccination:
Patients with cardiovascular disease should have
an annual influenza vaccination.