2017 esc guideline on management of stemi

1. 2017 ESC GUIDELINE ON
MANAGEMENT OF STEMI
Presenter
Dr. Ahmed Mamunul Huq
MD Cardiology
NICVD
Moderator
Dr. Aminur Razzaque
Junior Consultant
NICVD

2. Emergency care
• Working diagnosis of STEMI
• Persistent chest pain
And
• ST segment elevation at J point in at least 2 contiguous leads in12 lead ECG
• In lead V2 – V3
• ≥ 2.5 mm in men < 40 yrs age
• ≥ 2mm in men > 40 years age
• ≥ 1.5 mm in women
• And/ or
• ≥ 1 mm in other leads
• ≥ 0.5 mm in posterior leads (V7 – V9) (ST depression and upright T in V1 – V3)

3. Emergency care
Hypoxia SaO2 < 90% or PaO2 < 60 mmHg Oxygen indicated class I
SaO2 > 90% or PaO2 > 60 mmHg oxygen not indicated class III
Pain iv opioid Class IIa
Anxiety benzodiazepine Class IIa

4. Few definitions
First medical contact (FMC) The time point when the patient is either initially assessed by a physician,
paramedic, nurse or other trained EMS personnel who can obtain and interpret
the ECG and deliver initial interventions(defibrillation). FMC can be either in the
pre hospital setting or upon patient arrival at the hospital (emergency
department)
STEMI diagnosis The time at which the ECG of a patient with ischaemic symptoms is interpreted
as presenting ST segment elevation or equivalent
Primary PCI strategy Emergent coronary angiography and PCI of the IRA if indicated
Pharmacoinvasive strategy Fibrinolysis combined with rescue PCI or routine early PCI strategy

5. FMC
FMC
Within 10
mins

6. Reperfusion strategy
If PCI not possible < 120
min of STEMI diagnosis
If PCI possible < 120 mins
of STEMI diagnosis If symptomatic, heamodynamic instability,
arrythmia
If asymptomatic and stable (IIa)
12 h 48 h
If symptomatic, heamodynamic instability,
arrythmia
If asymptomatic and stable (III)
fibrinolysis
Primary PCI
0Time since
symptom onset

7. Procedural aspects of primary PCI
IRA
Non IRA
• Primary PCI
• Stenting with new generation DES
• Radial access preferred if done by
experienced radial operator
• Routine thrombus aspiration not recommended
• Routine use of deferred stenting not
recommended
• Revascularization considered in STEMI patients
with MVD before hospital discharge
• Considered during index procedure in patients
with cardiogenic shock

8. Periprocedural pharmacotherapy during PCI
DAPT IV anticoagulant
A T/ P CLO CAN UFH ENX
BIV FON
Before and
during PCI
After PCI
OralorIVforminallpatientswithout
contraindication
Upto12monthsunlessexcessive
bleedingrisk
IfT/Pcontraindicated
GPI
NotpretreatedwithP2Y12inhibitorsat
thetimeofPCI
Bailouttherapyineventofno-reflowor
athromboticcomplication
Routineuseis
recommended
IncasesofHIT
Routineuseisconsidered
notrecommendedfor
primaryPCI
Routine use of post procedural anticoagulant is not
indicated after primary PCI except AF, mechanical
valve, LV thrombus, prophylaxis for DVT

9. pharmacoinvasive strategy
Fibrinolysis Transfer to PCI capable center Angiogram and PCI
When fibrinolysis is the option then
it should be started within 10 mins
of STEMI diagnosis, preferably pre-
hospital setting.
Indicated in all patients immediately
after fibrinolysis
Emergency PCI
When heart failure/ shock present
Fibrin specific agent should be used
• Retaplase
• Altaplase
• Tenecteplase
Rescue PCI (90 min – 120 min) when
Failed fibrinolysis
Heamodynamic instability
Arrythmia
Half dose tenectaplase if age > 75 y Routine PCI (2 hrs – 24 hrs)
All patients after successful
fibrinolysis

10. Adjunctive therapies with fibrinolysis
DAPT Anticoagulant
It is recommended in patients with fibrinolysis until
revascularization (if done) or for the duration of
hospital stay up to 8 days
Enoxaparin i.v. followed by s.c. is preferred over UFH
Fondaparinux i.v. then s.c. if streptokinase is used as
fibrinolytic agent
aspirin clopT/P
48 hrs after fibrinolysis if
subsequent PCI is done
and continued for 12
months

11. Length of hospital stay
Successful
reperfusion
Kept in CCU for at
least 24 hours
Early discharge(within
48 – 72 hrs) if low risk
and early follow up
and rehabilitation can
be arranged
May be moved to step
down monitored bed
for an additional
24 – 48 hours
Same day transfer of
selected patients to
non PCI center

12. Recommendations about imaging and stress
testing
At presentation After primary PCI After discharge
Emergency echo without delaying
angiogram for cases of cardiogenic
shock, hemodynamic instability,
mechanical complication
routine echo for all patients Repeat echo 6 – 12 weeks after MI
in patients who have pre discharge
LVEF < 40%
Emergency echo before angiogram
when diagnosis is uncertain
Emergency echo in
hemodynamically unstable patients
Routine echo delaying angiogram
not recommended

13. Lifestyle intervention and risk factor control
• Smoking cessation
• Diet, alcohol, weight control
• Exercise based rehabilitation
• Resumption of activities
• Blood pressure control
• Adherence to treatment

14. Long term drug therapies
Lipid lowering therapy Beta blocker ACE inhibitors/ ARB MRA (eplenorone)
High intensity statin asap
and maintain long term
IV beta blocker in patients
undergoing PCI if no HF,
SBP > 120 mmHg
ACEI in patients HF or
LVEF <40%, DM, anterior
infarct.
Patients with HF and LVEF
< 40% or DM who are
already receiving ACEI +
BB but no renal failure or
↑K+Do lipid profile asap (non
fasting)
Oral beta blocker in
patents with HF and/ or
LVEF < 40% if no
contraindication
All patients without
contraindication
Goal LDL < 70 mg/ dl
Or
50% reduction if 70 – 135
mg/dl Routine oral beta blocker
in all patients without
contraindication and
continued
ARB (valsartan) in
patients with ACEI
intolerance
If goal not reached
despite max tolerated
dose then add non statin

15. MINOCA
• Myocardial infarction with non – obstructive coronary arteries
• Incidence 1 – 14%
• Diagnosis
• Universal AMI criteria
• Non obstructive coronaries on angiogram (no coronary artery stenosis > 50%
in any potential IRA)
• No specific cause for acute presentation

16. MINOCA
• Cause
• Epicardial coronary artery disorder
(atherosclerotic plaque rapture, ulcer, fissure or dissection with non obstructive or no CAD)
• Imbalance between oxygen supply and demand
(coronary spasm, pulmonary embolism)
• Coronary endothelial dysfunction
(micro vascular spasm)
• Secondary to other medical disorders
(myocarditis, takotsubo syndrome)

17. MINOCA
MINOCA diagnosed
Further investigations
to determine cause
Treatment according
to cause
• TTE
• Contrast echo
• CMR
• D – dimer
• CT scan
• Blood tests
• Endomyocardial
biopsy
• IVUS/ OCT
• Ergonovine/ ach
test
• Pressure/
Doppler wire

18. What changed in 2017 version
Recommendation 2012 2017
Oxygen SpO2 < 95% SpO2 < 90%
Radial access IIa I
DES over BMS IIa I
Complete revascularization III IIa
Thrombus aspiration IIa III
Early hospital discharge IIb IIa

19. What’s new in 2017 version
Recommendation COR
Additional lipid lowering therapy IIa
Complete revascularization during 1oPCI if pt is in shock IIa
Cangrelor if P2Y12 inhibitors not given before PCI IIb
Switch to P/T 48 hrs after fibrinolysis IIb
Extend ticagrelor upto 36 months in high risk pt IIb
Use of polypill to increase adherence IIb
Routine use of deferred stenting III

20. New or revised concepts
• MINOCA
• Strategy clock starts from ‘STEMI diagnosis’
• Maximum delay from STEMI diagnosis to bolus of fibrinolytics is 10
min
• ‘door to balloon’ term eliminated
• Time limit for opening of IRA (within 12h I, within 48 h IIa, > 48h III)
• Time of CAG after thrombolysis 2- 24 hrs
• LBBB and RBBB considered equal for recommending CAG in presence
of ischemia.

21. THANKS