Coronary Revascularisation in

STEMI

Dr. Ilham Uddin, Sp JP, FIHA

SMF Jantung - RSI Sultan Agung

Hospitalizations in the U.S. Due to Acute
Coronary Syndromes (ACS)

Acute Coronary
Syndromes*

1.57 Million Hospital Admissions - ACS

UA/NSTEMI STEMI

1.24 million .33 million

Admissions per year Admissions per year

Heart Disease and Stroke Statistics 2007 Update. Circulation 2007; 115:69-171.
*Primary and secondary diagnoses. About 0.57 million NSTEMI and 0.67 million UA.
ACC/AHA 2009 Joint STEMI/PCI Guidelines Focused Update

2
 Acute Coronary Syndrome (ACS)

Definition: The spectrum of acute ischemia

related syndromes ranging from UA to MI
with or without ST elevation that are
secondary to acute plaque rupture or plaque
erosion.

[----UA---------NSTEMI----------STEMI----]
Pathophysiology of Stable Angina and ACS

Pathophysiology ACS

Decreased O2 Supply

Asymptomatic
Flow- limiting stenosis
Anemia
Plaque rupture/clot

Angina
Increased O2 Demand

O2 supply/demand mismatchIschemia

Myocardial ischemianecrosis
 Pathophysiology of ACS
Evolution of Coronary Thrombosis
Unstable
NSTEMI STEMI
Angina
Non-occlusive
thrombus Complete thrombus
Non occlusive sufficient to cause occlusion
thrombus tissue damage & mild
myocardial necrosis ST elevations on
Non specific ECG or new LBBB
ECG ST depression +/-
T wave inversion on Elevated cardiac
Normal cardiac ECG enzymes
enzymes
Elevated cardiac More severe
enzymes symptoms
 STEMI
Name 3 situations in which you cannot
diagnose STEMI
 STEMI
Name 3 situations in which you cannot
diagnose STEMI

Left Ventricular Hypertrophy

Chronic or Rate Dependent LBBB

Paced Rhythm
 Cardiac Catheterization
Name the only 3 situations that demand
emergent cardiac catheterization.
 Cardiac Catheterization
Name the only 3 situations that demand
emergent cardiac catheterization.

STEMI or new LBBB

ACS with hemodynamic or electrical instability
despite optimal medical management
Uncontrolled CP despite optimal medical
management
 Diagnosis of ACS

At least 2 of the following

History ( angina or angina
equivalent)
Acute ischemic ECG changes
Typical rise and fall of cardiac
markers
Absence of another identifiable
etiology
 Timing of Release of Various Biomarkers After
Acute Myocardial Infarction

Shapiro BP, Jaffe AS. Cardiac biomarkers. In: Murphy JG, Lloyd MA, editors. Mayo Clinic Cardiology: Concise Textbook. 3 rd ed. Rochester, MN:
Mayo Clinic Scientific Press and New York: Informa Healthcare USA, 2007:77380.
Anderson JL, et al. J Am Coll Cardiol 2007;50:e1e157, Figure 5.
Early Invasive

Conservative
Tcheng J Am Coll Cardiol 48:1336, 2006 23
STEMI - Reperfusion Strategies
Minimize all time delays (specially within
2h symptom onset)
Transportation to PCI centre (high volume
operators)
If admission to hosp without PCI:
.transportation to PCI centre if time delay <
2h (1st med contact and ballon inflation)
.if > 2h: thrombolysis and transfer to PCI
center (3h-24h)
System
delay
Patient
Delay

www.escardio.org/guidelines
 STEMI - Revascularization
recommendations
By-pass the emergency room and ICU!!!
PCI for ONLY the Culprit Lesion
Recommendation I A for chest pain < 12h
& persistent ST elevation
Recommendation IIa C for chest pain
>12h &<24h + persistent ST elevation (or
previously undocumented LBBB)
 STEMI - PCI after fibrinolysis
Routine PCI after successful fibrinolysis
within 24h :I A
Rescue PCI in patients with failed
fibrinolysis (persistent ST segment
elevation (>50% of the max elevation) &/or persistent
pain): PCI as soon as possible
IIa A
 Cardiogenic Shock
Early repefusion & haemodynamic support
Echography mandatory: LV assessment, MR
(papillary muscle rupture), VSD, free wall rupture,
cardiac tamponnade
Circulatory assistance: IABP (if
haemodynamic impairment) : I C; benefits
balanced against complications (Shock II trial)
Extracorporeal membrane oxygenator
(ECMO): AHF with potential for fct recovery after revasc
STEMI Interventional Techniques
and Antithrombotic Therapy in the
Cathetterization Laboratory
Do whatever it takes to reduce time from symptom onset
to ER arrival and time from ER arrival to PCI!

Public awareness of MI Sx
Chest pain centers of
excellence with lower DBTs
and excellent outcomes
Regional coordination
Ambulance ECG telemetry
Ambulance/ER CCL activation
ICs sleep in hospital
Continual QI
ESC STEMI guidelines 2012
 AHA/ACC GL - Primary PCI of the Infarct Artery
I IIa IIb III
Primary PCI should be performed in patients
within 12 hours of onset of STEMI.

I IIa IIb III Primary PCI should be performed in patients

with STEMI presenting to a hospital with PCI
capability within 90 minutes of first medical
contact as a systems goal.
Primary PCI should be performed in patients
I IIa IIb III with STEMI who develop severe CHF or
cardiogenic shock and are suitable candidates for
revascularization as soon as possible, irrespective
of time delay
 ACC/AHA GL - Primary PCI for STEMI
Late Presentations

It is reasonable to perform primary PCI for

patients with onset of symptoms within the
prior 12-24 hours and 1 of the following

a. Severe CHF
I IIaIIbIII
b. Hemodynamic or electrical instability

c. Persistent ischemic symptoms

Mortality and complications are higher in patients presenting late

PCI is more challenging - Higher rate of no reflow, Organized thrombus
 The Goal of Primary PCI in STEMI

Restore flow in the

culprit artery and
optimize myocardial
perfusion (by angio
and EKG criteria)
Preserve LV function.
Reduce MI
complications
Reduce mortality.
 Impact of Macroscopic Distal Emboli
PLCX filling defect at
DE occurred in 27 primary PCI site
of 178 (15%) pts
after primary PTCA

ST res
Infarct size
Mortality

Distal thromboemboli

Henriques JPS et al. EHJ 2002;23:1112-7

Mechanical Approaches to Thrombus
Thrombus aspiration Thrombectomy
(Rinspirator, Pronto, Export,
(AngioJet, X-Sizer)
Rescue, Eliminate, etc.)

Distal protection (GuardWire, FilterWire, AngioGuard, etc.)

GuardWire, FilterWire, AngioGuard, EmboShield, etc.

THROMBUS ASPIRATION
 2011 STEMI Update
Thrombus Aspiration During PCI for STEMI

NEW
Recommendation Aspiration thrombectomy
is reasonable for patients
I IIa IIb III
undergoing primary PCI

Kushner et al. Circulation.

2009;120:22712306
 Guidelines

ESC - STEMI 2012

AHA/ACC - STEMI 2012

I IIa IIb III
It is reasonable to use a drug-
eluting stent as an alternative to a
bare-metal stent for primary PCI in STEMI
 The Coronary Stent System

A stent wrapped with ultra-thin

(20m) polymer mesh sleeve.

The mesh is designed for plaque

sealing during stent expansion in
order to prevent embolization
of athero-thrombotic debris.

The sleeve expands seamlessly

when the stent is deployed,
without affecting the structural
integrity of the stent.
 Summary
Optimizing myocardial perfusion during STEMI is challenging.
Manual thrombus aspiration appeared promising especially from
initial studies (TAPAS), but recent studies (INFUSE-MI, TASTE)
and registries failed to duplicate the favorable effect
Embolic protection devices are of doubtful benefit for STEMI PCI
DES preferred stents; MGuard stent may be beneficial in STEMI
PCI but needs to be tested in further clinically powered trials.
Pharmacotherapy: the new anti-platelet agents clearly have an
advantage over clopidogrel in the setting of STEMI primary PCI,
all should be given ASAP
GP IIb/IIIa inhibitors should mainly be given in bailout
situations, but early administrartion as bridge should be studied
IC GP IIb/IIIa administration appears to have an advantage over IV
Thank you !