STEMI - I Gde Rurus Suryawan, MD, FIHA PDF

CURRENT MANAGEMENT OF STEMI
I GDE RURUS SURYAWAN

GILANG M. RAHMAN
CARDIOVASCULAR EMERGENCIES COURSE
Bumi Surabaya Hotel, November 7-8th, 2015
Acute thrombosis induced by

a ruptured or eroded
atherosclerotic coronary
plaque, with or without
concomitant
vasoconstriction, causing a
sudden and critical reduction
in blood flow
Hamm CW et al. Eur Heart J 2011;32:2999 3054
DEFINITION
STEMI is a clinical syndrome characterized by
ischemic symptom which related to persistent ST
segment elevation in ECG
OGara et al: J Am Coll Cardiol. 2013 ; 29;:61(4)
PATHOGENESIS
CARDIOVASCULAR RISK FACTOR
Traditional
Non-Traditional
Modifiable
Homocysteine
Dyslipidemia
Lipoprotein (a)
Smoking
C-Reactive Protein (CRP)
Hypertension
Diabetes Mellitus
Lack of physical Activity

Non Modifiable
Advanced age
Male Gender
Hereditary
PATHOGENESIS
Total Occlusion of Coronary Artery
Vulnerable Plaque Rupture
Thrombus Formation
Endothelial Dysfunction
2015 ESC Guidelines NSTEMI
PATHOGENESIS
Myocardial Infarction
Biomarker Release
DIAGNOSIS
SYMPTOM
Typical chest pain persist >20
min:
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
SIGN
Usually normal,
Sign of Complication;
Tachypnea,
Hypotension
Tachycardia-Bradycardia
Jugular veins distention
Gallop S3
Pulmonary Rales
Systolic Murmur
DIAGNOSIS
ECG
J-point + 0,04 Sec
Baseline
Target:
10 minutes from
First Medical Contact
- ST-Elevation in minimal
two 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
ESC Guidelines, 2012

DIAGNOSIS
Biomarker
Biomarker
Specificity
Peak
CK-MB orOnset
Troponin
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
ACLS, 2012
MANAGEMENT
Emergency Medical System

Hospital fibrinolysis :
Door-to-Needle within 30 min
Not PCI
capable
Onset of
symptoms
of STEMI
9-1-1
EMS
Dispatch
EMS on-scene
Encourage 12-lead ECGs

Consider prehospital fibrinolytic if
capable and EMS-to-needle within 30 min
Goals
Patient
Dispatch
5 min after
symptom onset
1 min
EMS on
scene
P:
Within
8 min
EMS
Triage
Plan
PCI
capable
EMS transport
Pre hospital Fibrinolytic EMS-toHandle within 30 min
EMS transport:EMS-to-Balloon within 90 min
Patient self-transport:Hospital Door-to-Balloon

within 90 min
Total ischemic time: Within 120 min*

*Golden Hour = First 60 minutes
EMERGENCY ROOM
OXYGENATION
Indicated in patient with hypoxia (Sa02 <95%), dyspnea, and heart failure
INTRAVENOUS OPIOID
Morphine 4-8 mg i.v

Relieve pain and anxiety
Adverse reaction: Hypotension, respiratory depression, and vomiting
ASPIRIN
Aspirin oral (chewable) or i.v should be given in STEMI
Loading dose 300-325 mg , maintenance dose 75-100 mg od
EMERGENCY ROOM
P2Y12 RECEPTOR BLOCKER
Ticagrelor & Prasugrel are preferable and recommended in patients

who 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, & HOCM
BETA 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 THERAPY
STRATEGY
Primary PCI
Fibrinolysis
VS
ESC GUIDELINES,2012
Primary-PCI Capable Centre

PCI is indicated for all STEMI patient in onset less
than 12 hours
Door to baloon time target is <90 minutes or <60
minutes in new onset STEMI with large area at risk
PCI procedure with balloon angioplasty+stent is
more recommended than balloon angioplasty alone
Periprocedural antithrombotic therapy should be
given in Primary PCI
ESC Guidelines 2012; ACC/AHA Guidelines 2013
Non Primary-PCI Capable Centre
Fibrinolysis is recommended for all patient with onset 12 hours if estimating

time transfer to PCI capable centre >120 minutes, unless contraindicated
In new onset STEMI (<2 hours) with large infarcted area and low bleeding
risk, Fibrinolysis is recommended if estimating time transfer to PCI capable
centre >90 minutes
Fibrin specific agent (Alteplase, Reteplase, atau Tenecleptase) is more

recommended than nonspecific agent (Streptokinase)
Periprocedural antithrombotic therapy should be given as well
ESC Guidelines 2012; ACC/AHA Guidelines 2013
Coronary Artery Bypass Graft

The number of patients who require CABG
In acute phase of STEMI is relatively small
Urgent CABG is indicated in patients
with STEMI and coronary anatomy
not amenable to PCI who have
ongoing or recurrent ischemia,
cardiogenic shock, severe HF, or
other high-risk features
CABG is recommended in patients
with STEMI at time of operative repair
of mechanical defects.[
ACC/AHA Guidelines 2013
NON REPERFUSED STEMI

Present 12 hours onset
Present >12 hours onset
Common Cause:
Spontaneus Reperfusion
Contraindicated to any reperfusion
therapy
Common Cause:
Late presenters
Resource limitation
Hemodinamically and/or Electrically unstable

Ongoing Ischemia in onset 12-24 hours
Cohen, et al 2012
NO
Viability & Functional
Assestment
Adjuvant Therapy
No Reperfusion
Therapy
YES
Urgent PCI
Elective
PCI
CASE ILUSTRATION
A 63 Years old gentleman with history of hypertension
and diabetic came to ER of primary hospital with
prolonged typical chest pain with 2 hours onset
Vital sign: BP 150/90 mmHg, HR 95 bpm, RR 24, axillar

temp 370C, with no abnormality in other physical
examination
ECG Shows ST-segment elevation (V1-V6) at anterior

leads
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
SUMMARY
Acute emergency care is very important, the key point of
STEMI management is reperfusion therapy
Determining the appropriate reperfusion therapy strategy is

highly depend on the clinical setting and resource availability
in each medical center
Time to perform reperfusion is the most important variable

to get a better outcomes
Guidelines of STEMI management can guide the
practitioners to perform a good acute emergency care and

to choose the most appropriate reperfusion therapy
strategy
LONGTERM MANAGEMENT
To improve long term outcome and as a secondary
prevention of reccurent MI, hospitalization, and chronic
heart 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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CURRENT MANAGEMENT OF STEMI

I GDE RURUS SURYAWAN

CARDIOVASCULAR EMERGENCIES COURSE

Bumi Surabaya Hotel, November 7-8th, 2015

Acute thrombosis induced by

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

OGara et al: J Am Coll Cardiol. 2013 ; 29;:61(4)

CARDIOVASCULAR EMERGENCIES COURSE

Bumi Surabaya Hotel, November 7-8th, 2015

C-Reactive Protein (CRP)

Lack of physical Activity

Bumi Surabaya Hotel, November 7-8th, 2015

Vulnerable Plaque Rupture

Bumi Surabaya Hotel, November 7-8th, 2015

2015 ESC Guidelines NSTEMI

CARDIOVASCULAR EMERGENCIES COURSE

Bumi Surabaya Hotel, November 7-8th, 2015

CARDIOVASCULAR EMERGENCIES COURSE

Bumi Surabaya Hotel, November 7-8th, 2015

CARDIOVASCULAR EMERGENCIES COURSE

Bumi Surabaya Hotel, November 7-8th, 2015

J-point + 0,04 Sec

ESC Guidelines, 2012

Bumi Surabaya Hotel, November 7-8th, 2015

CARDIOVASCULAR EMERGENCIES COURSE

Bumi Surabaya Hotel, November 7-8th, 2015

CARDIOVASCULAR EMERGENCIES COURSE

Bumi Surabaya Hotel, November 7-8th, 2015

CARDIOVASCULAR EMERGENCIES COURSE

Bumi Surabaya Hotel, November 7-8th, 2015

Emergency Medical System

Encourage 12-lead ECGs

EMS transport:EMS-to-Balloon within 90 min

Patient self-transport:Hospital Door-to-Balloon

Total ischemic time: Within 120 min*

CARDIOVASCULAR EMERGENCIES COURSE

Bumi Surabaya Hotel, November 7-8th, 2015

Morphine 4-8 mg i.v

CARDIOVASCULAR EMERGENCIES COURSE

Bumi Surabaya Hotel, November 7-8th, 2015

Ticagrelor & Prasugrel are preferable and recommended in patients

Short acting nitrates (Nitroglyserin 0,4 mg or ISDN 5 mg S.L) is recommended

Reduce myocardial oxygen demand and incident of lethal arrhythmia

Bumi Surabaya Hotel, November 7-8th, 2015

CARDIOVASCULAR EMERGENCIES COURSE

Bumi Surabaya Hotel, November 7-8th, 2015

CARDIOVASCULAR EMERGENCIES COURSE

Bumi Surabaya Hotel, November 7-8th, 2015

Primary-PCI Capable Centre

CARDIOVASCULAR EMERGENCIES COURSE

Bumi Surabaya Hotel, November 7-8th, 2015

Non Primary-PCI Capable Centre

Fibrinolysis is recommended for all patient with onset 12 hours if estimating

Fibrin specific agent (Alteplase, Reteplase, atau Tenecleptase) is more

Periprocedural antithrombotic therapy should be given as well

ESC Guidelines 2012; ACC/AHA Guidelines 2013

CARDIOVASCULAR EMERGENCIES COURSE

Bumi Surabaya Hotel, November 7-8th, 2015

CARDIOVASCULAR EMERGENCIES COURSE

Bumi Surabaya Hotel, November 7-8th, 2015

CARDIOVASCULAR EMERGENCIES COURSE

Bumi Surabaya Hotel, November 7-8th, 2015