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STEMI Primer: 101 From Presentation to Cath Lab

STEMI Primer: 101 From Presentation to Cath Lab. Michael S. Blanc, FACC, FSCAI Community Heart & Vascular Center San Angelo Community Medical Center San Angelo, TX. https:// youtu.be /9Wmqq3TfV5w. “Vulnerable” Plaque and “Stable” Plaque. Libby. Circulation . 1995;91:2844-2850.

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STEMI Primer: 101 From Presentation to Cath Lab

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  1. STEMI Primer: 101From Presentation to Cath Lab Michael S. Blanc, FACC, FSCAI Community Heart & Vascular Center San Angelo Community Medical Center San Angelo, TX

  2. https://youtu.be/9Wmqq3TfV5w

  3. “Vulnerable” Plaque and “Stable” Plaque Libby. Circulation. 1995;91:2844-2850.

  4. Severity of Coronary Artery Stenosis before Acute MI Most MIs associated with non-flow limiting lesions Circulation Vol 93, No12 June 15, 1996 Ambrose, Giroud, Little, Nobuyoshi, et al

  5. Symptoms of Heart Attack • Chest discomfort • Jaw or arm discomfort • Shortness of breath • Cold sweat • Upset stomach • Fatigue • Over 25% of patients have no chest discomfort • Heart is not heavily innervated and pain is typically not severe

  6. Age > 70 Prior myocardial infarction Female gender Hypertension History of CHF Hyperlipidemia Diabetes Race Clinical Criteria ECG Criteria Chest x-ray-cardiomegaly Markedly elevated cardiac enzymes Elevated BUN Hemodynamic Criteria Complications VSD/PMD-rupture Myocardial rupture Acute Phase Risk Stratification: Pre-infarction characteristics Continuing Medical Implementation …...bridging the care gap

  7. Acute Phase Risk Stratification:Physical Examination • Clinical assessment of LV dysfunction • No history of CHF • No CHF with index MI • No LBBB, pacemaker or LVH with ST-T’s • Absence of Q waves-site of MI or outside index territory • 91 % predictive value of EF  40% • Killip classification • Hemodynamic classification • Mechanical complications Continuing Medical Implementation …...bridging the care gap

  8. Hypotension Pulsus alternans Reduced volume carotid LV apical enlargement/displacement Sustained apex - to S2 Soft S1 Paradoxically split S2 S3 gallop (not S4 = impaired LV compliance) Mitral regurgitation Pulmonary congestion rales Clinical Signs of LV Dysfunction Continuing Medical Implementation …...bridging the care gap

  9. Acute Phase Risk Stratification:Importance of LV dysfunction Continuing Medical Implementation …...bridging the care gap

  10. Complications of Acute Myocardial Infarction • Arrhythmic Complications • Mechanical Complications • Ischemic Complications • Miscellaneous Complications • [DVT, PE, Pericarditits, TPA complications, Pneumonia]

  11. Mechanical Complications of Acute Myocardial Infarction • Papillary Muscle Rupture – Acute MR • Ventricular Septal Defect • Right Ventricular MI • Free Wall Rupture • Cardiogenic shock • Cardiac Tamponade

  12. Acute Mortality Reduction • Early Recognition of Symptoms • Pre -Hospital Resuscitation of Sudden Death • Fast-Track Protocol for Thrombolytic Therapy • Code STEMI – Direct PCI protocols • Optimal Use of Adjunctive Therapy • Monitoring for Complications • Evidence Based Risk Stratification • Appropriate Revascularization for NSTEMI Continuing Medical Implementation …...bridging the care gap

  13. Prognosis Post MI • Mortality in the first year post MI averages 10% • Subsequently mortality 5% per year • 85% of deaths due to CAD • 50% of these sudden • 50% within first 3 months • 33% within the first three weeks Continuing Medical Implementation …...bridging the care gap

  14. b-Block ASSENT-2 CCU GUSTO GUSTO-3 GISSI-1 Pre-CCU ISIS-2 Early Mortality After AMI Mortality at 25 - 30 Days SK SK+ASA tPA tPA & rPA tPA & TNK Continuing Medical Implementation …...bridging the care gap

  15. Medications • ASA 325 mg po chewed • Ticagrelor (Brilinta) 180 mg • Alternative-Clopidogrel (Plavix) 600 mg • Alternative-Prasugrel (Effient) 60 mg • Heparin 5000 unit IV • Atorvastatin 80 mg

  16. Primary endpoint: CV death, MI or stroke 12 11 10 9 8 7 6 5 4 3 2 1 0 Clopidogrel 11.0 9.3 Ticagrelor K-M estimated rate (% per year) HR: 0.85 (95% CI = 0.74–0.97), p=0.02 0 1 2 3 4 5 6 7 8 9 10 11 12 Months No. at risk Ticagrelor 4,201 3,887 3,834 3,732 3,011 2,297 1,891 Clopidogrel 4,229 3,892 3,823 3,730 3,022 2,333 1,868

  17. Beta-Blockers

  18. COMMIT: Study design INCLUSION: >45,000 patients with suspected acute MI (ST change orLBBB) within 24 h of symptom onset TREATMENT: Metoprolol 15 mg iv over 15 mins, then 200 mg oral daily vs matching placebo EXCLUSION: Shock, systolic BP <100 mmHg, heart rate <50/min or II/III AV block 1 OUTCOMES: Death & death, re-MI or VF/arrest up to 4 weeks in hospital (or prior discharge) Mean treatment and follow-up: 16 days

  19. Effects of Metoprolol COMMIT (N = 45,852) Totality of Evidence (N = 52,411) Death13%P=0.0006 ReMI22%P=0.0002 30% relative increase in *cardiogenic shock VF15%P=0.002 Lancet. 2005;366:1622. *Risk factors for cardiogenic shock :heart failure, age > 70 , systolic blood pressure < 120, sinus tachycardia > 110 or heart rate < 60, increased time since onset of STEMI symptoms

  20. Beta-Blockers • Recommendations - Class Ia (B) • ORAL beta-blocker therapy SHOULD BE initiated in the first 24 hours for patients who DO NOT have any of the following: • signs of heart failure, • evidence of a low output state, • increased risk for cardiogenic shock, or • relative contraindications to beta blockade • 1AVB > 0.24 sec, • 2nd- or 3rd-degree heart block • reactive airway disease • ** There is no study evaluating oral beta blockers alone *Risk factors for cardiogenic shock :heart failure, age > 70 , systolic blood pressure < 120, sinus tachycardia > 110 or heart rate < 60, increased time since onset of STEMI symptoms

  21. Beta-Blockers • Recommendations - Class IIa (B) • It is reasonable to administer an IV BETA BLOCKER at the time of presentation to STEMI patients who are HYPERTENSIVE and who do not have any of the following: • signs of heart failure, • evidence of a low output state, • increased risk for cardiogenic shock, or • relative contraindications to beta blockade • 1AVB > 0.24 sec, • 2nd- or 3rd-degree heart block • reactive airway disease *Risk factors for cardiogenic shock :heart failure, age > 70 , systolic blood pressure < 120, sinus tachycardia > 110 or heart rate < 60, increased time since onset of STEMI symptoms

  22. Beta-Blockers • Recommendations - Class III (A) • IV beta blockers SHOULD NOT be administered to STEMI patients who have any of the following: • signs of heart failure • evidence of a low output state • increased risk* for cardiogenic shock • relative contraindications to beta blockade • 1AVB > 0.24 sec, • 2nd- or 3rd-degree heart block • reactive airway disease *Risk factors for cardiogenic shock :heart failure, age > 70 , systolic blood pressure < 120, sinus tachycardia > 110 or heart rate < 60, increased time since onset of STEMI symptoms

  23. Statin Evidence: MIRACL Study Primary Efficacy Measure Placebo 17.4% 15 14.8% Atorvastatin 10 • Time to first occurrence of: • Death (any cause) • Nonfatal MI • Resuscitated cardiac arrest • Worsening angina with new objective evidence and urgent rehospitalization Cumulative Incidence (%) 5 Relative risk = 0.84P = .048 95% CI 0.701-0.999 0 0 4 8 12 16 Time Since Randomization (weeks) Schwartz GG, et al. JAMA. 2001;285:1711-1718.

  24. Reperfusion

  25. “Time is Muscle”

  26. Brief Review of Thrombolytic Trials GISSI-1: Streptokinase 18% reduction in mortality at 21 d GUSTO-1: tPA. 15% reduction in 30-day mortality compared to Streptokinase GUSTO-3: Reteplase had no benefit over tPA but is easier to use (double bolus) ASSENT: TNKase is similar to tPA but with less non-cerebral bleeding and better mortality with symptoms>4 hrs: Single bolus, fibrin selective, resistance to PAI-1 *Overall risk of ICH is 0.7%; Strokes occurred in 1.4%

  27. Anticoagulants • Patients undergoing reperfusion with fibrinolytics should receive anticoagulant therapy for a minimum of 48 hours (unfractionated heparin) or up to 8 days • Anticoagulant regimens with established efficacy include: ♥ UFH (LOE: C) ♥ Enoxaparin (LOE:A) ♥ Fondaparinux (LOE:B)

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