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St elevation myocardial infarction
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St elevation myocardial infarction

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  • 1. ST Elevation Myocardial Infarction Salah Abusin, MD, MRCP Cardiology Fellow Chicago, IL Secretary General Sudanese American Medical Association
  • 2. Outline• Definition• STEMI – Definition – H&P DD – ECG DD• Reperfusion therapy – Fibrinolysis – Primary PCI
  • 3. Acute Coronary Syndromes• Refers to any constellation of clinical symptoms that are compatible with acute myocardial ischemia
  • 4. ACS SpectrumAHA.ACC 2004 STEMI guidelines
  • 5. STEMI
  • 6. Case• A 56 year old male with no PMH presents with sudden onset of severe crushing retrosternal chest pain that woke him from sleep. It radiated down his left arm.• It was accompanied with sweating, and shortness of breath
  • 7. Physical Examination• HR 70/min, BP 130/80, RR 22/min• JVP not raised• Chest clear• Normal S1 and S2, ?S3• Soft non tender abdomen• No LE edema
  • 8. Differential Diagnosis of Acute Chest Pain• Cardiac • Chest wall – ACS – Rib fracture – Aortic Dissection* – Costochondritis – Pericarditis – Herpes zoster (before rash)• Pulmonary • Gastrointestinal – Pulmonary Embolism* – Biliary – Pneumonia – Esophageal – Pneumothorax* • Spasm • Rupture – Pancreatitis – Peptic Ulcer*
  • 9. Pneumothorax
  • 10. Pulmonary Embolism
  • 11. Aortic Dissection
  • 12. ECG Criteria for STEMI• New ST elevation – >0.1 mV in 2 contiguous leads – Any 2 (II, III, aVF) or (V2-V6, I, aVL) – Not aVR or V1• In V2 & V3 – >=0.2 mV in men – >= 0.15mV in women• New LBBB Thygsen et al. Universal Definition of MI Circulation 2010
  • 13. Proposed Criteria to determine who gets ECG in ER STAT• >30 with chest pain• >50 with dyspnea, altered mental status, upper extremity pain, syncope or weakness• >80 with abdominal pain, nausea and vomitingDOESN’T REPLACE CLINICAL JUDGEMENT Glickman et al Am Heart J 2012
  • 14. Anteroseptal wall STEMI
  • 15. Anterolateral STEMI
  • 16. Inferior Wall STEMI
  • 17. Evolution of ECG changes in STEMI
  • 18. Not Every ST Elevation is a STEMI!!!
  • 19. Early Repolarization
  • 20. Pericarditis
  • 21. Left Bundle Branch Block
  • 22. Back to our patient - ECG PATIENT HAS A STEMI!!!
  • 23. Management• Initial measures • Medication – IV access – Antiplatelet Agents – Continuous cardiac – Anticoagulants monitoring – Beta Blockers – Oxygen – Statin• Reperfusion therapy – Fibrinolysis – Primary PCI – Bypass Surgery
  • 24. Fibrinolysis- Streptokinase• First generation• Given as a 60 minute infusion• 1.5 million unit• 25% relative risk reduction in mortality compared to Aspirin* *ISIS 2 Lancet, 1988
  • 25. Additional advantages of Streptokinase• Low bleeding rates/Less strokes compared to newer agents• Cheap , 150 Sudanese pounds• Most widely used agent worldwide
  • 26. Other features• Highly antigenic so can only be used once, otherwise patient develops allergic reactions• Achieves TIMI 3 flow in only 1/3 of patients• Less efficacious compared to newer agents
  • 27. Alteplase• 100mg infusion over 90minutes (1/2 dose within first 30minutes)• Superior to Streptokinase in GUSTO trial*• Fibrin specific (no antibody formation)• More bleeding *GUSTO 1 NEJM 1993
  • 28. Reteplase, Tenecteplase• Given as IV bolus• Comparable to alteplase in GUSTO-III and ASSENT• Convenient for administration prehospital setting
  • 29. Contraindications• Absolute Contraindications – Intracranial neoplasm – Recent (<3 months) intracranial surgery or trauma – recent (<3 months) ischemic stroke – h/o hemorrhagic stroke – Active or recent bleeding
  • 30. • Relative Contraindications – BP > 180 systolic – H/o ischemic stroke – Recent (<4 weeks) internal bleeding – Thrombocytopenia
  • 31. Additional Notes• Treatment window – Within 12 hours of onset of chest pain – Never give after 24 hours – If ongoing chest pain after 12 hours and low risk of bleeding may give thrombolysis• Success of thrombolysis is assessed by – Resolution of Chest pain – >50% reduction in ST elevation – Development of accelerated idioventricular rhythm
  • 32. 50% reduction in mortality with lytics if given promptly
  • 33. Fibrinolytics-Risk of ICH • Elderly • <70kg • Uncontrolled hypertension • Lowest risk with streptokinase
  • 34. Primary Percutaneous Coronary Intervention• Superior to thrombolysis in most cases• Less reinfarction, death• Less stroke, bleeding
  • 35. CoronaryAngiography
  • 36. Normal Coronary Angiogram
  • 37. Back to our patient
  • 38. Limited Availability
  • 39. Targets
  • 40. Beyond Reperfusion• Aspirin – For all patients• Clopidogrel for one year – For all patients regardless of type of reperfusion therapy, and if no reperfusion performed• Heparin – All patients who receive the newer thrombolytic agents – Use maybe considered with streptokinase (II b indication)
  • 41. Further Investigations• Electrolytes• CBC• LFTs• Fasting Blood Sugar• Fasting lipid profile• Echocardiography
  • 42. After STEMI Care• All patients should be admitted to a bed with continuous cardiac monitoring• All patients should be given (if no contraindications) – Beta Blocker (lifelong) – ACE inhibitor (lifelong) – Statin (lifelong)• Additional medication – Spironolactone (if low EF, diabetic)
  • 43. Post STEMI Risk Assessment• Coronary Angiography after STEMI – Patients who fail thrombolysis (continued chest pain, failure of ST segment resolution) – Patients who have high risk features • Heart failure (either clinical or Low EF) • Serious Arrhythmias• Patients who don’t have high risk features after STEMI should undergo Exercise ECG stress testing for risk stratification