This document discusses criteria for diagnosing myocardial infarction and risk stratification of STEMI patients. It outlines the definition of MI, criteria for acute/evolving MI, and criteria for established MI. It also discusses risk stratification tools like TIMI risk score and management of STEMI in the initial presentation, in-hospital course, and at discharge. Medical management includes oxygen, nitrates, analgesics, and beta blockers. Fibrinolytic therapy and anticoagulation are also summarized.

1. Dr . Ranjith MP
14-11-2011

2.  Definition of MI
 Risk stratification
 Medical management

3. (Myocardial infarction redefined—a consensus document of The Joint European Society of Cardiology/American College of
Cardiology committee for the redefinition of myocardial infarction:. J. Am. Coll. Cardiol. 2000;36;959-969)
 Criteria for Acute, Evolving, or Recent MI
 Either of the following criteria satisfies
1. Typical rise &/or fall of biochemical markers of myocardial
necrosiswith at least one of the following:
a) Ischemic symptoms
b) ECG changes indicative of new ischemia (new ST elevation or
new/presumed to be new LBBB)
c) Development of pathological Q waves in the ECG
d) Imaging e/o new loss of viable myocardium or new RWMA
2. Pathologic findings of an acute MI

4. (Myocardial infarction redefined—a consensus document of The Joint European Society of Cardiology/American College of
Cardiology committee for the redefinition of myocardial infarction:. J. Am. Coll. Cardiol. 2000;36;959-969)
 PCI periprocedural MI:
increases of biomarkers >3 x 99th percentile URL
 CABG-related MI
Increases of biomarkers >5 x 99th percentile URL
plus either new pathological Q waves or new LBBB,
or angiographically documented new graft or native
coronary artery occlusion, or imaging evidence of
new loss of viable myocardium.

5. (Myocardial infarction redefined—a consensus document of The Joint European Society of Cardiology/American College of
Cardiology committee for the redefinition of myocardial infarction:. J. Am. Coll. Cardiol. 2000;36;959-969)
 Criteria for established MI.
 Either of the following criteria satisfies
1. Development of new pathologic Q waves on serial ECGs.
The patient may or may not remember previous
symptoms. Biochemical markers of myocardial necrosis
may have normalized, depending on the length of time
that has passed since the infarct developed.
2. Pathologic findings of a healed or healing MI.

7.  There is risk stratification within STEMI,
but in general, STEMI is high-risk
 Important to select greater-risk patients
who warrant more aggressive strategies
for prevention of future serious events
such as reinfarction or sudden death

8.  Occurs in several stages
Initial presentation
In-hospital course (CCU, intermediate CU)
At the time of hospital discharge

9.  Prior angina
pectoris
 Prior MI
 Female gender
 Hypertension
 History of CHF
 Hyperlipidemia
 Diabetes
 ECG Criteria
 Markedly elevated
cardiac enzymes
 Elevated BUN
 Complications
 VSR/PMD-rupture
 Myocardial rupture

10.  Anterior MI/ Persisting ST elevation
 Q waves in multiple leads
 RVMI + IWMI
 High sum of ST elevation
 Reciprocal ( anterior ) ST depression
 Persisting ST depression
 Prolonged QT
 Conduction defects/ heart block
 Sinus tachycardia/atrial fibrillation

11. Killip Classification % patients Mortality (%)
I No CHF 30-50 5
II Rales, S3, Pulmonary venous hypertension 33 15-20
III Pulmonary edema 15 40
IV Cardiogenic shock 10 80-100
(Killip T, and Kimball JT: Treatment of myocardial infarction in a coronary care unit: a two year
experience of 250 patients. American Journal of Cardiology 1967; 20: 457-464 )
Left ventricular dysfunction is the single most important predictor of mortality

12.  TIMI
 GRACE
 PURSUIT
 ACI-TIPI
 Goldman
 best used to supplement—not replace—
clinical judgment
 less useful in atypical presentations, but
indeed validated in an ED population . . .

13. (David A et al. TIMI Risk Score for ………..: An Intravenous nPA for Treatment of Infarcting Myocardium Early II Trial Substudy.
Circulation 2000, 102:2031-2037)

14. (David A et al. TIMI Risk Score for ………..: An Intravenous nPA for Treatment of Infarcting Myocardium Early II Trial Substudy.
Circulation 2000, 102:2031-2037)

15. ( Wiviott SD et al Performance of the TRI in the National Registry of Myocardial Infarction-3 and -4:. J Am Coll Cardiol
2004;44:783–9 )
 Derived from In TIME II trial & validated in TIMI-9
trials
 Based on age and vital signs, in predicting mortality
among a large, community based, unselected,
heterogeneous population
 Heart rate [age/10 ]2 /systolic blood pressure
 A strong and independent predictor of mortality at
24 h and at 30 days (p 0.0001)

17.  Can be used to predict the cumulative risk of
death and death or myocardial infarction in
the period from admission to hospital to six
months after discharge
 The tool is simple and applicable to patients
across the complete spectrum of acute
coronary syndrome

19.  Exercise Testing
 performed either in the hospital or early after discharge in
patients not selected for cardiac catheterization and
without high-risk features to assess the presence and
extent of inducible ischemia Class I (B)
 Exercise testing might be considered before discharge of
patients recovering from STEMI to guide the post discharge
exercise prescription or to evaluate the functional
significance of a coronary lesion previously identified at
angiography Class IIb (C)

20.  Sub maximal protocol
Target workload =5 METS, 70 % MPHR or symptom
limited
 Predictors of poor outcome
Ischemic ST depression > 1 mm is inconsistent
predictor of mortality
poor exercise tolerance < 3 minutes doubles one
year mortality ( 7% to14%)
Inability to exercise or contra-indication to TMT
identifies High Risk patient.

21. Late Risk Stratification - 4 to 8 weeks
(Assessment of residual ischaemia)
 TMT
 Stress echocardiography
 Adenosine/Dipyridamole Perfusion imaging
 Un-interpretable ECG
 Equivocal TMT
 Inability to exercise

23.  Prehospital EMS providers …162 to 325 mg
of aspirin (chewed) …non–enteric-coated
formulations.
(goal is to quickly block thromboxane A2 formation in platelets)
 Previously on NTG take I tab S/L  Not
improving after 5 mts  Seek medical help

24. EMS Transport
Onset of
symptoms of
STEMI
EMS
Dispatch
EMS on-scene
• Encourage 12-lead ECGs.
• Consider prehospital fibrinolytic if
capable and EMS-to-needle within
30 min.
GOALS
PCI
capable
Not PCI
capable
Hospital fibrinolysis:
Door-to-Needle
within 30 min.
Inter-
Hospital
Transfer
Golden Hour = first 60 min. Total ischemic time: within 120 min.
Patient EMS Prehospital fibrinolysis
EMS-to-needle
within 30 min.
EMS transport
EMS-to-balloon within 90 min.
Patient self-transport
Hospital door-to-balloon
within 90 min.
Dispatch
1 min.
5
min.
8
min.

25.  Early presentation (≤3 hr from symptom onset and
delay to invasive strategy)
 Invasive strategy is not an option
 Catheterization laboratory occupied or not available
 Vascular access difficulties
 Lack of access to a skilled PCI laboratory
 Delay to invasive strategy
Prolonged transport
(Door-to-balloon)–(door-to-needle) more than 1 hr
Medical contact-to-balloon or door-to-balloon more
than90 min

26.  Skilled PCI laboratory is available with surgical backup
Medical contact-to-balloon or door-to-balloon
less than 90 min
 High risk from STEMI
Cardiogenic shock
Killip class ≥ 3
 Contraindications to fibrinolysis
 Late presentation (> 3 hr)
 Diagnosis of STEMI is in doubt

27. 1. Airway, Breathing, Circulation (ABC)
2. Vital signs, general observation
3. Presence or absence of jugular venous
distension
4. Pulmonary auscultation for rales
5. Cardiac auscultation for murmurs and
gallops
6. Presence or absence of stroke

28.  should be performed, but should not delay the
implementation of reperfusion therapy.
Serum biomarkers for cardiac damage
Complete blood count (CBC) with platelets
International normalized ratio (INR)
Activated partial thromboplastin time (aPTT)
Electrolytes and magnesium
Blood urea nitrogen (BUN),creatinine
Glucose
Complete Lipid Profile

29. 0 1 2 3 4 5 6 7 8
Cardiac troponin-no reperfusion
Days After Onset of STEMI
MultiplesoftheURL
Upper reference limit
1
2
5
10
20
50
URL = 99th %tile of
Reference Control Group
100
Cardiac troponin-reperfusion
CKMB- reperfusion
CKMB- no reperfusion

30.  Pain contribute to the heightened sympathetic
activity
 Typically accomplished with combination of
nitrates, analgesics, oxygen and β-blockers
 Oxygen
Arterial oxygen desaturation (SaO2 < 90%) Class I(B)
Uncomplicated STEMI during the first 6 hours Class II(A)

31.  Nitroglycerin Class I (C)
 Patients with ongoing ischemic discomfort
 0.4 mg every 5 minutes for a total of 3 doses
 Intravenous NTG
 Ongoing ischemic discomfort that responds to nitrate therapy
control of hypertension
management of pulmonary congestion.
 Nitrates should not be administered to patients with:
 systolic pressure < 90 mm Hg or ≥ to 30 mm Hg below baseline
 severe bradycardia (< 50 bpm)
 tachycardia (> 100 bpm)
 suspected RV infarction.
 who have received a phosphodiesterase

32.  Analgesia
Morphine sulfate (2 to 4 mg intravenously)Class I (C)
NSAIDS Increase risk of cardiovascular events so should be discontinued
[A sub study analysis from the ExTRACT TIMI-25 trial showed increased risk
of death, reinfarction, heart failure, or shock among patients on NSAIDs
within 7 days of enrollment].
 Aspirin
Should be chewed by patients who have not taken aspirin
before presentation with STEMI. The initial dose should
be 162 mg Class I (A) to 325 mg. Class I (C)

33.  The principal goal of fibrinolysis is prompt restoration
of full IRA patency
 Streptokinase , tPA,, TNK, rPA
 TNK and rPA - bolus fibrinolytics
 Promote conversion of plasminogen to plasmin, which
subsequently lyses fibrin thrombi

36.  Absolute Contraindications:
Any prior intracranial hemorrhage
Known structural cerebral vascular lesion
Known malignant intracranial neoplasm
Ischemic stroke within 3 months EXCEPT acute ischemic
stroke within 3 hours
 Suspected aortic dissection
Active bleeding or bleeding diathesis (excluding menses)
Significant closed-head or facial trauma within 3 months
Note: Age restriction for fibrinolysis has been removed compared with prior
guidelines.

37.  Relative Contraindications:
Severe uncontrolled hypertension on presentation (SBP > 180
or DBP > 110)
Prior ischemic stroke >3 months
Traumatic or prolonged (> 10 mt.) CPR or major surgery (< 3
weeks)
Recent (< 2 to 4 weeks) internal bleeding
Noncompressible vascular punctures
For streptokinase/anistreplase: prior exposure (> 5 days ago)
or prior allergic reaction to these agents
Pregnancy, Active peptic ulcer
Current use of anticoagulants

38. (Antman EM et al: ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction. Circulation
110:e82, 2004.)
PARAMETER STREPTOKINASE ALTEPLASE RETEPLASE TNK t-PA
Dose 1.5 MU in 30-60 min
Up to 100 mg in
90 min (based on
weight)
10 U ? 2 (30 min
apart) each over
2 min
30-50 mg
based on
weight
Bolus administration No No Yes Yes
Antigenic Yes No No No
Allergic reactions
hypotension most
common
Yes No No No
Systemic fibrinogen
depletion
Marked Mild Moderate Minimal
90-min patency rates
(%)
≈50 ≈75 ≈75 ≈75
TIMI grade 3 flow (%) 32 54 60 63
Cost per dose (Rs) 2500 39375 (50mg)

39.  WP-4 hr. t-PA is the preferred treatment
 streptokinase t-PA equivalent choices -risk of
death is low , and increased risk of ICH .
 WP-4 to 12 hr . streptokinase and t-PA are
equivalent options, but streptokinase is
probably preferable to t-PA because of cost
considerations

40.  LATE and EMERAS trials
 Fibrinolytics between 12 and 24 hours
 No mortality benefit
 Increases risk of cardiac rupture

41.  Noninvasive findings s/o reperfusion include:
 Relief of symptoms
 Maintenance and restoration of hemodynamic
and/or electrical instability
 Reduction of ≥ 50% of the initial STE pattern on
follow-up ECG 60 to 90 minutes after initiation of
therapy.
Class II(A)

42.  Flow in the IRA angiographically
 Gd. 0, compl. Occlussion
 Gd. 1, some penetration
 Gd.2, entire vessel with
Impaired flow
 Gd.3, entire vessel with
Normal flow

43.  Prevention of DVT, pulmonary embolism,
ventricular thrombus, cerebral embolization.
 Establishing & maintaining patency of IRA.
 Trials shown that more prolonged anticoagulant
therapy is beneficial (duration of index hospita-
lization) in patients receiving thrombolytic
therapay

45.  IV Unfractionated Heparin
 Selective Fibrinolytic – Bolus of 60 U/kg (maximum 4000 U)
followed by an infusion of 12 U/kg/hr (maximum 1000 U)
(Level of Evidence: C)
 Nonselective fibrinolytic agents- who are at high risk for
systemic emboli (large or anterior MI, atrial fibrillation (AF),
previous embolus, or known LV thrombus).
(Level of Evidence: B)
 LMWH- 30mg iv followed by 1mg/kg every 12hr.

46.  Aspirin should be given indefinitely to all STEMI
pts. without a true aspirin allergy.
Class I (A)
 Patients undergoing PCI are also given aspirin
loading
Class I (B)
 Patients not on aspirin therapy should be given
nonenteric aspirin 325 mg before PCI.
Class I(B)
 After PCI, use of aspirin should be continued
indefinitely
Class I (A)

47.  Addition of P2Y12 inhibitor to aspirin warranted for most
patients with STEMI (COMMIT & CLARITY-TIMI22)
 In patients for whom PCI is planned, clopidogrel should
be started and continued: Class I (B)
Patients receiving a stent (BMS or DES) clopidogrel 75 mg daily
or prasugrel 10 mg for at least 12 months;
 If the risk of bleeding outweighs the anticipated benefit
afforded by thienopyridine therapy, earlier discontinuation .
 Continuation of thienopyridines beyond 15 months may
be considered in patients undergoing DES placement

48.  Prior history of stroke and TIA for whom primary PCI is
planned, prasugrel is not recommended
 CABG planned ?... the drug should be withheld for at
least 5 days in patients receiving clopidogrel and at
least 7 days in patients receiving prasugrel, Class I (B)
 Probably indicated in patients receiving fibrinolytic
therapy who are unable to take aspirin because of
hypersensitivity or GI intolerance Class I (C)

49.  It is reasonable to start abciximab as early as
possible before primary PCI (with or without
stenting) in patients with STEMI.
 Tirofiban or eptifibatide may be considered
before primary PCI (with or without stenting)
in patients with STEMI.

50.  Relieve ischemic pain, reduce need for analgesics,
reduce infarct size and life-threatening arrhythmias
 Contra indications:
 signs of heart failure
 evidence of a low output state
 increased risk for cardiogenic shock
 other relative contraindications (PR interval > 0.24 S. 2nd or
3rd degree AV block, or reactive airway disease)

52.  Favorable effects with metoprolol, atenolol,
carvedilol and timolol,
 Beta blockers with intrinsic sympathomimetic
activity probably should not be chosen.
 Trial of esmolol in the presence of relative
contraindications.

53.  Favorable impact on ventricular remodeling,
improvement in hemodynamics, and
reductions in congestive heart failure
Angiotensin-converting enzyme inhibitors
Angiotensin II receptor blockers
Aldosterone blockade

58.  EPHESUS trial: Eplerenone, 25 mg/day titrated to
50 mg/day for high-risk patients following STEMI (EF
≤40%, clinical HF, DM)
 Mean follow-up 16 months, there was a 15% reduction in
the RR of mortality

59.  Immediate-release preparation of nifedipine increased
risk of in-hospital mortality
 Verapamil & diltiazem can be given for relief of
ongoing ischemia or slowing of a rapid ventricular
response in AF in patients with contraindication to
beta blockers.
 INTERCEPT trial compared 300 mg of diltiazem with
placebo and Diltiazem did not reduce cardiac death,
nonfatal reinfarction, during a 6-month follow-up

60.  It is reasonable to use an insulin based regimen to
achieve and maintain glucose levels less than 180
mg/dl while avoiding hypoglycemia for patients
with STEMI with either a complicated or
uncomplicated course Class IIa(B)

61.  In the absence of complications patients need
not be confined to bed for more than 12 hours
 Progression of activity should be individualized

62.  first day and as late as 6 weeks after STEMI
 Radiation of the pain to either trapezius ridge.
 Treatment consists of aspirin doses of 650 mg
orally every 4 to 6 hours may be necessary.
 NSAIDs and steroids should be avoided

63.  Anticoagulation- heparin to elevate the aPTT to
1.5 to 2 times that of control, followed by a
minimum of 3 to 6 months of warfarin in the
following clinical situations:
 An embolic event has already occurred or
 The patient has a large anterior infarction whether or
not a thrombus is visualized echocardiographically

64.  More in older patients, women , hypertensive
 More frequently in the left than right ventricle
 1 day and 3 weeks, most commonly 1 to 4 days
 Near the junction of infarct and normal muscle
 Most often in patients without previous infarcts
 Fibrinolytic therapy more than PCI

65. CATEGORY ARRHYTHMIA OBJECTIVE OF TREATMENT
THERAPEUTIC
OPTIONS
Electrical
instability
Ventricular
premature beats
Correction of electrolyte deficits and
increased sympathetic tone
Potassium and
magnesium solutions,
beta blocker
Ventricular
tachycardia
Prophylaxis against ventricular
fibrillation, restoration of
hemodynamic stability
Antiarrhythmic agents;
cardioversion/defibrillatio
n
Ventricular
fibrillation
Urgent reversion to sinus rhythm
Defibrillation; bretylium
tosylate
Accelerated
idioventricular
rhythm
Observation unless hemodynamic
function is compromised
Increase sinus rate
(atropine, atrial pacing);
antiarrhythmic agents
Nonparoxysmal
atrioventricular
junctional
tachycardia
Search for precipitating causes (e.g.,
digitalis intoxication); suppress
arrhythmia only if hemodynamic
function is compromised
Atrial overdrive pacing;
antiarrhythmic agents;
cardioversion relatively
contraindicated if digitalis
intoxication present

66. CATEGORY ARRHYTHMIA
OBJECTIVE OF
TREATMENT
THERAPEUTIC OPTIONS
Pump
failure,
excessive
sympathetic
stimulation
Sinus
tachycardia
Reduce heart rate to
diminish myocardial
oxygen demands
Antipyretics; analgesics; consider
beta blocker unless congestive
heart failure present; treat latter if
present with anticongestive
measures (diuretics, afterload
reduction)
Atrial
fibrillation
and/or atrial
flutter
Reduce ventricular
rate; restore sinus
rhythm
Verapamil, digitalis glycosides;
anticongestive measures
(diuretics, afterload reduction);
cardioversion; rapid atrial pacing
(for atrial flutter)
Paroxysmal
supraventricul
ar tachycardia
Reduce ventricular
rate; restore sinus
rhythm
Vagal maneuvers; verapamil,
cardiac glycosides, beta-
adrenergic blockers;
cardioversion; rapid atrial pacing

67. CATEGORY ARRHYTHMIA OBJECTIVE OF TREATMENT
THERAPEUTIC
OPTIONS
Bradyarrhyth
mias and
conduction
disturbances
Sinus
bradycardia
Acceleration of heart rate only
if hemodynamic function is
compromised
Atropine; atrial pacing
Junctional escape
rhythm
Acceleration of sinus rate only
if loss of atrial “kick” causes
hemodynamic compromise
Atropine; atrial pacing
Atrioventricular
block and
intraventricular
block
Insertion of pacemaker

71. At time of discharge patient should be on:
 ASA unless contra-indication
 Clopidogrel if PCI/NSTEMI (duration minimum1 year)
 Longer duration of clopidogrel if DES in critical location or
complex lesion
 -blocker unless contra-indication
 ACE inhibitor for CHF or LV dysfunction
 All for vascular protection?
 Statin for LDL to < 70mg%(minimum 50% reduction)

72.  High Risk
 extensive ECG changes
 anterior/ infero-posterior/
prior MI
 Residual ischaemia
 post MI angina
 positive TMT/ perfusion
scan
 non-Q MI
 ischaemia at a distance
 Complicated MI
 CHF/ flash pulmonary
edema
 shock
 heart block
 RBBB
 sustained ventricular
arrhythmias
 Anxiety/ physical
labor/ young age

74.  Smoking Goal: Complete Cessation
 With in 2yrs risk of nonfatal MI falls to normal
 Blood pressure control:
 Goal: < 140/90 mm Hg or <130/80 mm Hg if chronic
kidney disease or diabetes
 Physical activity:
 Minimum goal: 30 minutes 3 to 4 days per week; Optimal
daily

75.  Weight management:
 Goal: BMI 18.5 to 24.9 kg/m2
 Waist circumference: Women < 35 in. Men: < 40 in.
 Diabetes management:
 Goal: HbA1c < 7%
 Lipid management: Primary goal: LDL-C <70mg%
 Start dietary therapy in all patients (< 7% of total calories as
saturated fat and < 200 mg/d cholesterol). Promote physical activity
and weight management. Encourage increased consumption of
omega-3 fatty acids.
 Assess fasting lipid profile in all patients, preferably within 24 hours
of STEMI. Add drug therapy according to the following guide:

76.  LDL-C < 100 mg/dL (baseline or on treatment):
 Statins should be used to lower LDL-C.
 LDL-C ≥ 100 mg/dL (baseline or on treatment):
 Intensify LDL-C–lowering therapy with drug treatment, giving preference to statins.
 If TGs are ≥ 150 mg/dL or HDL-C is < 40 mg/dL:
 Emphasize weight management and physical activity. Advise smoking cessation.
 If TG is 200 to 499 mg/dL:
 After LDL-C–lowering therapy, consider adding fibrate or niacin.
 If TG is ≥ 500 mg/dL:
 Consider fibrate or niacin before LDL-C–lowering therapy.
 Consider omega-3 fatty acids as adjunct for high TG.

77.  Hormone therapy:
 with estrogen plus progestin should not be given de novo to postmenopausal
women after STEMI for secondary prevention of coronary events. Class III (A)
 Postmenopausal women who are already taking estrogen plus progestin at the
time of STEMI should not continue hormone therapy. Class II (B)
 However, women who are beyond 1 to 2 years after initiation of hormone
therapy who wish to continue such therapy for another compelling indication
should weigh the risks and benefits. Class III (A)
 Antioxidant vitamins:
 such as vitamin E and/or vitamin C supplements should not be prescribed to
patients recovering from STEMI to prevent cardiovascular disease

78.  Psychosocial status of the patient should be evaluated,
including inquiries regarding symptoms of depression,
anxiety, or sleep disorders and the social support
environment. Class I (C)
 Treatment with cognitive-behavioral therapy and selective
serotonin reuptake inhibitors can be useful for STEMI
patients with depression that occurs in the year after
hospital discharge. Class IIa (A)

79. RRR 2yr Event Rate
None 8%
ASA 25% 6%
 -Blockers 25% 4.5%
Lipid lowering 30% 3.0%
ACE-
inhibitors
25% 2.3%
( Yusuf, S. Two decades of progress in preventing vascular disease. Lancet 2002; 360: 2-3).
Cumulative relative risk reduction if all four drugs are used is about 75%