STEMI DIAGNOSIS IS IMPORTANT. TIME IS MUSCLE

1. ROLE OF PRIMARY CARE
PHYSICIAN IN
MANAGEMENT OF ACUTE MI

2. Contents
• Introduction
• Epidemiology
• Physiology of ST elevation
• Role of PCP
• Management
• ECGs
• Take Home Message

3. Introduction
• Of the cardiovascular diseases (CVDs), the leading cause of death globally,
Ischemic Heart Disease (IHD) accounts for the majority of the deaths.
• Sudden occlusion of the coronary artery due to thrombus, is an emergency and
clinically manifests as ST segment elevation myocardial infarction (STEMI)
• Opening an occluded artery is main motto either by balloon or by drug.
• Biggest Hurdle in management of STEMI is time duration from First Medical
Contact (FMC) to management.
• Despite the management, some patients have detrimental course based on their
initial presentation.

4. Epidemiology
• India accounts for one fifth of the deaths worldwide especially in younger
population (WHO).
• The Indians have CVDs a decade earlier than the western population.
• The conventional risk factors fail to explain this increased risk.
• In 2016, CVDs contributed to 28.1% of total deaths and 14.1% of total disability
adjusted life years (DALYs) compared with 15.2% and 6.9%, respectively in 1990
(Almost double).

5. Time is Muscle
• Introduced by Eugene Braunwald
• “….the more time a heart-related issue goes untreated, the more damage the
heart may endure.”
• Almost half of the STEMI patients die before reaching the hospital.
• When not intervened either medically or percutaneously, another half
would die in the first 24 hours.
• Timely identification and management aimed at salvaging the myocardium
decides the further course of STEMI.

6. 9 = 9/10

7. Unique risk factors
• High homocysteine levels
• Ambient air pollution
• Psychosocial factors
• Mental health and
• Higher high sensitivity C reactive protein (hs CRP) levels
indicating chronic infection and inflammation.

8. Role of PCP
• Usually the FMC
• 1.Identification
• 2.Diagnosis based on ECG
• 3.Necessary Investigations
• 4.Management
• 5.Preventive aspects
• 6.Maintaining the patient records

9. Chest pain of cardiac origin

11. Why does ST elevation occur ?

12. Diagnosing STEMI

14. Localising the MI – Culprit artery localisation

16. Evolution of STEMI

18. Management
• Loading doses of
• Antiplatelets and Statins
• Soluble Aspirin 325 mg
• Clopidogrel 300 mg
• Atorvastatin 80mg stat
• Injection UFH 5000 IU IV stat.
• Check whether can be sent to nearby PPCI or Not < 120 minutes.
• If not there, check whether TLT can be done or not.
• If TLT. Monitor after 90min of TLT
• Check for clinical signs
• Send to nearby cathlab.

20. Thrombolysis

21. Contraindications

23. Monitoring during TLT
• Saturations
• Blood Pressure
• Bleeding manifestations
• Embolic phenomenon
• Rhythm

24. Clinical signs of Complicated STEMI
• Crepitations
• Hypotension
• LVS3

25. CHECK LIST OF THE MEDICATIONS IN A PATIENT WITH ACUTE MI
Not applicable to all, contraindications to be kept in mind.
Nitrates and betablockers contraindicated in complicate IWMI and RVMI

26. Education
• Healthy lifestyle
• Timely assessment of risk factors in presence of premature
CAD.
• Exercise for 30minutes for atleast five days in a week
• Meditation
• Yoga
• Sleep

27. Tele
Medicine

28. Pre hospital thrombolysis
• In 108 ambulance
• Patient with chest pain, ECG will be taken in ambulance and
send to physician and confirm diagnosis of STEMI.
• Loading doses will be given.
• Vitals will be checked.
• Based on time duration, TLT will be done.
• Tenecteplase is the drug used.
• Shifted to nearby PCI center.
• STREAM Trial showed positive results.

29. STEMI INDIA
• Pharmacoinvasive strategy.
• Initiated in Goa and
subsequently in southern
states of India.
• SPOKE AND HUB MODEL
• Early diagnosis
• Timely TLT
• And later on PCI with effective
results.

30. ECGs

31. 57- year female, without previous heart disease except hypertension, presents
with chest pain.

32. History of CAD, presented with SOB

33. STEMI or False STEMI?

34. Pericarditis

35. To thrombolyse or not?

36. Artefact

38. Thrombolyse or no TLT?

39. Young male, participated in running for selection,
chest pain

40. Don’t Panic.. Successful thrombolysis
Post TLT ECG showed this rhythm

41. Take home message
• The STEMI, when timely managed we can salvage the myocardium
from necrosis.
• Fibrin specific thrombolytics are more efficacious in retaining the
patency of the occluded artery.
• Pharmacoinvasive strategy is of uprising trend in India.
• Identifying false STEMI cases is also of equal importance.
• Educating the public regarding the prevention is of utmost importance.

42. Thank you