Reperfusion strategy in Acute STEMI

1. On the Occasion of World Heart Day 2023 a Scientific Seminar on
 Reperfusion strategy in the management of Acute STEMI
Presented by-
• Dr Seebat Masrur
• D-Card Student
• Cardiology Department
• SZMCH

2. Introduction
World Heart Day is a global initiative
dedicated to uniting people around the world
in the fight against heart disease and
promoting heart-healthy lifestyles. Organized
by the World Heart Federation, World Heart
Day was first observed in the year 2000.Since
then, World Heart Day has been celebrated
annually on September 29th with a different
theme each year. This year's event centers
around the theme 'Use Heart to Know Heart’
P R E S E N T A T I O N T I T L E 2

3. WORLD’S BIGGEST
KILLER
• Cardiovascular disease (CVD) is the world’s
number one killer. Combined, conditions
affecting the heart or blood vessels – such as
heart attack, stroke and heart failure – affect
620 million & kill 20.5 million every year. The
majority of these deaths happen in low- and
middle-income countries.
• 80% of premature deaths from CVD are
preventable. By making small changes to our
lifestyle – what we eat and drink, how much
we exercise, and how we manage stress –
we can better manage our heart health and
beat CVD.
P R E S E N T A T I O N T I T L E 3

4. Biggest Killers Worldwide (GBD 2019 Estimates)
P R E S E N T A T I O N T I T L E 4

5. Reperfusion strategy in the
management of Acute STEMI

6. ST-elevation
myocardial
infarction (STEMI)
The basics

7. ST-elevation myocardial infarction (STEMI) – Pathophysiology
One disease process but different clinical manifestations and different management strategies
7
Acute coronary syndrome (ACS)
First Medical
Contact (FMC)
Working diagnosis
ECG
Biochemistry
Diagnosis
Acute coronary syndrome
Persistent ST-elevation
Normal or
undetermined ECG
ST/T - abnormalities
STEMI
Troponin
rise/fall
Troponin
normal
NSTEMI Unstable
angina
Imaging
Chest pain
STEMI, ST-elevation myocardial infarction
NSTEMI, non ST-elevation myocardial infarction
Hamm et al. Eur Heart J 2011;32:2999-3054.

8. Diagnosis of
STEMI: ECG
changes
• New St-elevation at the J-point two contiguous leads with
cut-point:
≥ 1 mm in all leads other than leads V2-V3 where
following cut points apply
≥ 2 mm in men age ≥ 40 years
≥ 2.5 mm in men < 40 years, or
≥ 1.5 mm in women regardless of age

9. Management of acute MI and rationale for early
reperfusion

10. *First medical contact (FMC) is defined as the time when the patient is initially assessed by a physician, paramedic, nurse or other trained EMS personnel who can
obtain and interpret the ECG and deliver initial interventions, either in the pre-hospital setting or upon arrival at the hospital
Ibanez B et al. Eur Heart J 2018;39:119–77
Diagnosis of STEMI
Key recommendations for initial diagnosis
STEMI
ECG monitoring with defibrillator
capacity as soon as possible in all
patients with suspected STEMI (IB)
12-lead ECG as soon
as possible (target
delay ≤10 min) (IB) Routine sampling for serum markers as
soon as possible in the acute phase, but
should not delay reperfusion (IC)
At FMC*

11. PCI, percutaneous coronary intervention
Steg PG et al. Eur Heart J 2012;33:2569–619
Reperfusion strategies in STEMI
Early reperfusion aims to limit the extent of myocardial damage and
lead to better outcomes in patients with STEMI
Invasive
Primary PCI
Pharmacological
induction of thrombolysis
by thrombolytic agent
Pharmaco-invasive
a combination of both
approaches

12. Influence of
time-to-
treatment on
odds ratio (or)
of mortality

13. Primary Percutaneous
Coronary Intervention
(pPCI)
Primary percutaneous coronary
intervention (pPCI), also known as
primary angioplasty, is an emergency
medical procedure performed to treat
acute ST-elevation myocardial
infarction (STEMI). In this procedure,
a cardiologist uses a catheter to
access the infarct related coronary
artery responsible for the myocardial
infarction. The blockage is then
mechanically opened using
techniques such as balloon
angioplasty and stent placement.

14. BMS, bare-metal stent; DES, drug-eluting stent
Ibanez B et al. Eur Heart J 2018;39:119–77
Primary PCI procedures
Strategy
• Primary PCI of the IRA
is indicated (IA)
• For patients with signs
of recurrent/remaining
ischaemia after primary
PCI, new coronary
angiography is
recommended (IC)
Infarct-related artery (IRA)
Strategy
• Revascularization of non-
IRA should be considered
in STEMI patients with
multivessel disease (IIa/A)
Non-IRA
Technique
• Stenting recommended over
balloon angioplasty (IA)
• DES recommended over BMS
(IA)
• Radial access recommended
over femoral access (IA)

15. pPCI is the Best option-Advantages
It is the Gold standard
reperfusion strategy.
Improves survival by re-
establishing blood flow
within the occluded infarct-
related artery and thus
reduce mortality
It is superior to other
reperfusion strategy.
Less chance of
complications such as
Stroke, Reinfarction

17. *The previous guidelines recommended 30 min ‘door-to-needle’ (initiation of fibrinolysis within 30 min of arrival at hospital); note that the current guidelines no
longer use this terminology
Ibanez B et al. Eur Heart J 2018;39:119–77
Choice of reperfusion strategy
Injection should be as soon as possible after STEMI
diagnosis, ideally in the pre-hospital setting (IA) and
within ≤10 min*
Primary PCI
Recommended over
fibrinolysis (IA)
Recommended ≤12 hr of symptom onset in the
absence of contraindications (IA)
Reperfusion is indicated in all patients with ischaemic symptoms
for ≤12 h and persistent ST elevation (IA)
If timely PCI is not possible
Fibrinolytic therapy

18. Ibanez B et al. Eur Heart J 2018;39:119–77
Where does fibrinolytic therapy fit within the STEMI
treatment pathway?
System delay
Patient delay
If likely to be >120 min, consider pharmaco-invasive
strategy if no contraindication for fibrinolysis
Transport to
PCI centre
Transfer to cath lab,
bypassing the ED
Prepare for PCI
STEMI
diagnosis
(ECG)
Within
10 min
Symptomatic
period
FMC: ambulance/
non-PCI centre
PCI centre
Admission Cath lab
Start fibrinolytic therapy within
10 min of diagnosis
Start PCI
(wire
crossing)
Within
2 h

19. Fibrinolysis in Golder Hour
In the golden hour, when symptom
duration is within 1 to 2 hours, prompt
fibrinolysis may provide clinical benefit
compared with primary PCI & should be
considered as a potentially preferable
option.
Absolute
benefit
(per
1000
treated
patients)
Treatment delay (h)
0 3 6 9 12 15 18 21 24
0
20
40
60
80

20. Thrombolytics
1. Kunandian & Gibson. Cardiovasc Ther 2012;30:e81-e88.
2. Chesebro et al. Circulation 1987;76:142-154.
3. GUSTO investigators. N Engl J Med 1993;329:673-682.
4. GUSTO III investigators. N Engl J Med 1997;337:1118-1123.
5. Cannon CP et al. Circulation 1998;98:2805-2814.
6. ASSENT-2 investigators. Lancet 1999; 354:716-722.
Streptokinase (and derivatives)
Considered an inferior thrombolytic drug to
tPA compounds as it is not given as a bolus
and lacks fibrin specificity and antigenicity1
Alteplase (rt-PA)
Recombinant form of human tissue
plasminogen activator (tPA) with a 4-8 min
plasma half-life.1 Improved outcomes in
myocardial infarction treatment vs.
streptokinase2,3
Reteplase (r-PA)
Genetically modified rt-PA with longer half-life
(13-16 min)1 and simplified administration.
Failed to show clinical benefit over alteplase4
Tenecteplase (TNK)
Longer plasma half-life, highest fibrin specificity,
and resistance to plasminogen activator inhibitor-1
(PAI-1) vs rt-PA. Single bolus pharmacological
reperfusion therapy, with equivalent efficacy and
improved safety profile to alteplase5,6

21. Ibanez B et al. Eur Heart J 2018;39:119–77
Potential complications of fibrinolysis
Risk of stroke
Intracranial haemorrhage
Risk of bleeding (especially in
patients undergoing prolonged or
traumatic resuscitation)
• Advanced age
• Lower weight
• Female sex
• Prior cerebrovascular disease
• Systolic/diastolic hypertension on
admission
Risk factors for
intracranial haemorrhage
Intracranial bleeding occurs in
0.9–1.0% of patients

22. Ibanez B et al. Eur Heart J 2018;39:119–77. Adapted and reproduced with permission of Oxford University Press on
behalf of the European Society of Cardiology. Please see slide notes for full reference information
Contraindications to fibrinolysis
• Prior intracranial haemorrhage or stroke
of unknown origin at anytime
• Ischaemic stroke previous 6 months
• CNS damage or neoplasms or arteriovenous
malformation
• GI bleeding within the past month
• Known bleeding disorder (except menses)
• Aortic dissection
• Non-compressible punctures in past 24 h
(eg liver biopsy, lumbar puncture)
Absolute contraindications
• TIA in previous 6 months
• Oral anticoagulant therapy
• Pregnancy or 1 week postpartum
• Refractory hypertension (SBP >180 mmHg and/or
DBP >110 mmHg)
• Advanced liver disease
• Infective endocarditis
• Active peptic ulcer
• Prolonged or traumatic resuscitation
Relative contraindications

23. Primary PCI> Fibrinolytics

24. Fibrinolytics still
important
• Widely available with broad
access.
• Little dependence on
operator experience.
• Can be given promptly and
on site (Prehospital).
• Simple to give in bolus or IV
infusion.

26. Ibanez B et al. Eur Heart J 2018;39:119–77
PCI may be indicated or necessary after fibrinolysis
All patients should be transferred to a PCI-capable centre
immediately after fibrinolysis (IA)
Angiography and PCI of the IRA, if
indicated, at 2–24 h (IA)
Emergency angiography and PCI in
case of recurrent ischaemia or re-
occlusion (IB)
Rescue PCI is indicated immediately
when fibrinolysis has failed (<50%
ST-segment resolution at 60–90 min) or
at any time in the presence of
haemodynamic or electrical instability,
or worsening ischaemia (IA)
Emergency
angiography and PCI
in patients with heart
failure or shock (IA)
Fibrinolysis successful?
Yes No

27. Pharmaco-
Invasive
Strategy
• Pharmacologic reperfusion therapy (Lytics or half
dose lytics+ GPIIIb/IIa) followed by transfer to a PCI
hospital for urgent Cath/PCI(within 3-24 hrs),
regardless of whether fibrinolysis results in
successful reperfusion or not, should undergo
Angiography.
• In the event of fibrinolytic failure, A Rescue PCI
should be immediately performed where one need
not wait for initial 3-hour window.

29. Rationale for
Pharmaco-invasive PCI
• While thrombolysis re-establishes
TIMI 2 or 3 flow in ~70% of the
cases, residual stenosis 50-70%
frequently persists hence the
rationale for Pharmaco-Invasive
PCI.
• Only ~15-20% are left with no
residual stenosis.

31. *Patients with fibrinolysis should be transferred to a PCI centre immediately after administration of the lytic bolus
Ibanez B et al. Eur Heart J 2018;39:119–77. Adapted and reproduced with permission of Oxford University Press on behalf of the European Society of Cardiology.
Please see slide notes for full reference information
Where the Strategies fit in?
Systems are
required to ensure
rapid fibrinolysis
before transfer to
PCI centre if PCI
cannot be
performed within
120 min
FMC
EMS
Non-PCI centre
PCI centre
Wire crossing
Wire crossing
Lytic bolus*
Primary PCI
Primary PCI
Fibrinolysis
STEMI
diagnosis
≤10
min
<90
min
<10
min
<60
min
≤10
min
Reperfusion
Patient delay EMS/system delay
Total ischaemic time
>120
min
≤120
min
Time to
PCI?
Strategy

32. Reperfusion strategy in STEMI

33. Ibanez B et al. Eur Heart J 2018;39:119–77. Adapted and reproduced with permission of Oxford University Press on behalf of the European Society of Cardiology.
Please see slide notes for full reference information
Summary of important time targets
in acute STEMI
Maximum delay/intervals Time targets
FMC to ECG and diagnosis ≤10 min
STEMI diagnosis to primary PCI (wire crossing) – if this cannot be met, consider
fibrinolysis
≤120 min
STEMI diagnosis to wire crossing in patients presenting at primary PCI hospitals ≤60 min
STEMI diagnosis to wire crossing in transferred patients ≤90 min
STEMI diagnosis to fibrinolysis in patients for whom primary PCI target time
cannot be met
≤10 min
Start of fibrinolysis to evaluation of its efficacy (success or failure) 60–90 min
Start of fibrinolysis to angiography (if fibrinolysis is successful) 2─24 h

34. *Alteplase is injected as an initial bolus over 1 min followed by infusion over 60 min, reteplase is injected as two boluses 30 min apart, and tenecteplase is injected
as a single bolus over ~10 s
Ibanez B et al. Eur Heart J 2018;39:119–77
Fibrinolysis and pharmaco-invasive strategy
Key
recommendations
Fibrinolysis should be initiated as soon as possible after STEMI
diagnosis, preferably in the pre-hospital setting (IA)
A fibrin-specific agent (ie alteplase, reteplase or tenecteplase) is
recommended (IB)
A half-dose of tenecteplase should be considered in patients ≥75
years old (IIa/B)
The fibrinolytic bolus should be administered within 10 min of
STEMI diagnosis*

35. DAPT, dual antiplatelet therapy
Ibanez B et al. Eur Heart J 2018;39:119–77
Antiplatelet co-therapy with fibrinolysis
Antiplatelet therapy Administration details
Oral or iv ASA (IB)
Loading dose of 150–300 mg orally (or 75–250 mg iv if oral
ingestion is not possible) followed by a maintenance dose of
70–100 mg/day
Clopidogrel (plus ASA)
(IA)
For clopidogrel: loading dose of 300 mg (or 75 mg in patients
≥75 years of age) orally followed by a maintenance dose of
75 mg/day

36. Ibanez B et al. Eur Heart J 2018;39:119–77
Anticoagulant co-therapy with fibrinolysis
Antiplatelet therapy Administration details
Enoxaparin (IA)
Given iv followed by sc (preferred over UFH); dose dependent
on age/eGFR
UFH (IB) Given as a weight-adjusted iv bolus followed by infusion
Fondaparinux (IIa/B)
Indicated in patients treated with streptokinase
Given by iv bolus followed by sc dose 24 h later
Anticoagulation is recommended in patients treated with lytics until
revascularization or for the duration of hospital stay up to 8 days (IA)

37. Summary of rationale for pre-hospital thrombolysis (PHT) and
pharmaco-invasive strategy
Not all medical centres are PPCI-capable1,2 &/or pre-hospital delays often prevent patients
from receiving timely PPCI3,4
No specialist equipment required and PHT has been established as a safe and effective
treatment for STEMI5
PHT reduces time to reperfusion and improves outcomes if PPCI is not possible within
2h6,7
1. Steg et al. Eur Heart J 2012;33:2569-2619.
2. Pinto et al. Circulation 2006;114:2019-2025.
3. Armstrong, Bowden. Ann Intern Med 2011;155:389-391.
4. Armstrong et al. N Engl J Med 2013;368(15):1379-1387.
5. O’Gara et al. J Am Coll Cardiol 2013;61:e78-e140.
6. Morrison et al. JAMA 2000;283(20):2686–2692.
7. Wallentin et al. Circulation 2003;108:135-142.
8. Gershlick et al. N Engl J Med 2005;353:2758-2768.
Pharmaco-invasive strategy may achieve reperfusion directly; in case of thrombolysis
failure, reperfusion can be achieved with subsequent rescue PCI8

38. Some Cases done in SZMCH
Cath Lab

39. Cathlab

40. Case 1

41. Before Stent After Stent

42. Take home points
STEMI is a time-critical medical emergency: clinical outcomes improve with reduced time to
reperfusion. Every effort should be made to reduce ischaemic time.
Implementation of STEMI networks is guideline-recommended and has been shown in studies
and registries to reduce delays in reperfusion strategies and improve clinical outcomes.
PPCI is considered the gold-standard of care if performed ≤2 h of FMC (first medical contact).
A pharmaco-invasive strategy is recommended whenever PPCI cannot be performed within
recommended timelines (<120 min), and may be followed by transfer for angiography and
mechanical intervention if indicated.

43. Thank You

44. Case 2

45. Take Home Message
Tenecteplase with its specificity, ease of administration and tolerability is an excellent choice
for thrombolysis in acute MI where indicated.
There is a definite role of pharmaco – invasive strategy with definite benefits in the form of
better myocardial reperfusion and early 1 year survival rates.
There is a distinct difference in the in – vitro thrombolysis potential when the innovator
tenecteplase is compared to currently available biosimilars of tenecteplase.
Various guidelines recommend thrombolysis with tenecteplase for early reperfusion to save
every patient live and gives a window period for PCI.

46. ASA, acetylsalicylic acid (aspirin); GP IIb/IIIa, glycoprotein IIb/IIIa inhibitors; UFH, unfractionated heparin
Ibanez B et al. Eur Heart J 2018;39:119–77
Peri- and post-procedural antithrombotic therapy in
PCI
Key recommendations:
antiplatelet therapy
• Potent P2Y12 inhibitor before PCI and maintained over
12 months (IA)
• ASA as soon as possible (IB)
• GP IIb/IIIa inhibitors considered for ‘bailout’ if no-reflow or
thrombotic complications (IIa/C)
Key recommendations:
anticoagulant therapy
• Anticoagulation for all patients in addition to antiplatelet
therapy during primary PCI (IC)
• Routine use of UFH is recommended (IC)

47. *If fibrinolysis is contraindicated, use primary PCI strategy regardless of time to PCI
†10 min is the maximum target delay time from STEMI diagnosis to fibrinolytic bolus administration, however it should be given as soon as possible
Ibanez B et al. Eur Heart J 2018;39:119–77. Adapted and reproduced with permission of Oxford University Press on behalf of the European Society of Cardiology.
Please see slide notes for full reference information
Maximum target times depend on chosen reperfusion
strategy
≥120 min
60–90 min
Primary PCI
strategy
Alert and
transfer to
PCI centre
Fibrinolysis
strategy*
Rescue PCI
No
Strategy clock (maximum target times)
0 h 10
min
90
min 2 h 24 h
>120
min
≤120
min
STEMI
diagnosis
Wire crossing
(reperfusion)
Yes
Meet reperfusion
criteria?
Routine PCI strategy
Transfer to
PCI centre
Time to
PCI?
Bolus of
fibrinolytic†

48. Strategy based on
expected delay to PCI
(wire crossing) from
STEMI diagnosis
*At 3–12 h, more consideration should be given to primary PCI over fibrinolytic therapy
Ibanez B et al. Eur Heart J 2018;39:119–77. Adapted and reproduced with permission of Oxford University Press on behalf of the European Society of Cardiology.
Please see slide notes for full reference information
Overview of reperfusion strategies in patients with
STEMI
Early phase of
STEMI
Recent STEMI
Evolved
STEMI
Symptom
onset
0 h
3 h
12 h
48 h
Primary PCI (IA)
Fibrinolysis (IA)
only if PCI cannot be performed
within 120 min of diagnosis
Primary PCI (IA)
Primary PCI (IC)
if patient has symptoms,
haemodynamic instability,
or arrhythmias
Fibrinolysis (IA)*
only if PCI cannot be performed
within 120 min of diagnosis
Primary PCI (IIa/B)
for asymptomatic stable
patients
Routine PCI (IIA)
for asymptomatic stable
patients

49. *Within 12 h of symptom onset
Ibanez B et al. Eur Heart J 2018;39:119–77
Seeking to minimize delayed reperfusion in pre-
hospital settings
Key
recommendations
Any reperfusion strategy
• Pre-hospital management should be based on regional networks to deliver
reperfusion quickly and effectively, and to make primary PCI available to as
many patients as possible (IB)
• Ambulance teams should transfer STEMI patients to a PCI-capable centre,
bypassing non-PCI centres (IC)
• Patients should be transferred directly to the catheterization lab (IB)
• Primary PCI centres should deliver a 24/7 service (IB)
Pharmaco-invasive strategy
• Pre-hospital fibrinolysis is recommended if primary PCI cannot be performed
within 120 min from STEMI diagnosis*(1A)
• Ambulance teams should be equipped to identify STEMI and administer
fibrinolysis where applicable (IC)

50. Improving
time to
treatment

51. Global Heart & Circulatory Diseases
Factsheet
P R E S E N T A T I O N T I T L E 51

52. Global Heart & Circulatory Diseases Factsheet
P R E S E N T A T I O N T I T L E 52

53. World Heart Day is a reminder to everyone around the world to take care
of their hearts. This year’s campaign focuses on the essential step of
knowing our hearts first.
BECAUSE WE LOVE AND PROTECT ONLY WHAT WE KNOW. In a world
where knowledge about heart health is limited and policies are
insufficient or lacking, we aim to shatter barriers and empower
individuals to take control of their well-being.
BECAUSE WHEN WE KNOW MORE , WE CAN TAKE BETTER CARE.
P
R
E
S
E
N
T
A
T
I
O
N
T
I
T
L
E
53

54. ASSENT trial series summary:
ASSENT-2, ASSENT-3/ASSENT-3 PLUS, ASSENT-4
PCI
For more information on the ASSENT trials, please visit http://www.metalyse.com/studies or refer to the original publications.
ASSENT-2:
Tenecteplase is equivalent to
alteplase in the treatment of
AMI with respect to:
• 30-day mortality1 and 1-year
mortality outcomes2
• Combined outcomes for
mortality and non-fatal stroke1
Significantly fewer bleeding
complications occurred with
tenecteplase, reducing the
need for blood transfusions.1
ASSENT-3/
ASSENT-3 PLUS:
Results support association
between earlier treatment and
improved 30-day mortality3,4
• Low-molecular-weight heparins
(LMWHs), e.g. enoxaparin, were
superior to unfractionated
heparin (UFH) as concomitant
anticoagulation4
ASSENT-4 PCI: Investigated
whether full-dose tenecteplase
administered prior to PCI
(facilitated PCI) could mitigate
negative effect of delay to PCI5
• Study was stopped prematurely due
to higher mortality in facilitated PCI
group vs. standard PCI5
• Facilitated PCI as performed in the
trial was associated with more major
adverse events than primary PCI
alone and cannot be recommended5
1. ASSENT-2 Investigators. Lancet 1999;354:716-722.
2. Sinnaeve et al. Am Heart J 2003;146:27-32.
3. ASSENT-3 Investigators. Lancet 2001;358:605-613.
4. Wallentin et al. Circulation 2003;108:135-142.
5. ASSENT-4 PCI Investigators. Lancet 2006;367:569–578.

55. Percutaneous coronary intervention (PCI)
& primary PCI (PPCI)
1. Choi et al. Prehosp Emerg Care 2016;20:66-75.
2. Sinnaeve & Van de Werf. Eur Heart J 2016;37:1041-1043.
3. Keeley & Hillis. N Engl J Med 2007;356:47-54.
Stent in coronary artery
Stent
Guide
wire
Catheter
PPCI is the gold standard in STEMI care –
IF performed within 120 min of FMC1,2
• Timely PPCI is difficult to achieve in many regions,
when patients do not present directly to a PCI-
capable facility via EMS or arrival at a facility is
delayed 1,2
PCI involves revascularisation of the blocked
coronary artery by mechanical means
• Using the femoral or radial artery as an access
point, a catheter with a balloon (and often a stent)
is passed through the occlusion3
• The balloon is then inflated to open up the vessel,
and the stent is put in place to maintain the
revascularisation3
EMS, emergency medical services
FMC, first medical contact
PPCI, primary percutaneous coronary intervention

56. How to address the practice gap between optimal and
actual care?
STEMI networks should aim to improve the quality of care by using well-
defined and validated quality indicators
Structural
(organizational)
measures
Performance
measures
Clinical and
patient-reported
outcomes
Ibanez B et al. Eur Heart J 2018;39:119–77

57. Ibanez B et al. Eur Heart J 2018;39:119–77
How to address the practice gap between optimal and
actual care?
Structural (organizational)
measures
Performance measures for reperfusion
therapy
Rapid and efficient STEMI management
network with written protocols including:
• Single emergency phone number
• Pre-hospital ECG interpretation, diagnosis
and cath lab activation
Systematic recording and reviewing of times
to reperfusion
Proportion of STEMI patients arriving in the first
12 h receiving reperfusion therapy
Proportion of patients with timely reperfusion
therapy (consistent with guidelines)

58. ST-elevation myocardial infarction (STEMI) – Pathophysiology
Any one of the following criteria meets the diagnosis for AMI according to the
Joint ESC/ACCF/AHA/WHF Task Force:
58
Diagnostic criteria for AMI
A rise and/or fall of cardiac biomarkers (preferably
troponin (cTn)) with at least one value above the
99th percentile upper reference limit (URL)
together with at least one of the following:
• Symptoms of ischaemia
• New or presumed-new significant ST-segment-T wave
(ST-T) changes or new left bundle branch block (LBBB)
• Development of pathological Q waves in the ECG
• Imaging evidence of new loss of viable myocardium or new
regional wall motion abnormality
• Identification of an intracoronary thrombus by angiography or
autopsy
+
Cardiac death with prior new ischaemic ECG changes and symptoms suggestive of myocardial ischaemia, without
definitive biomarker evidence
PCI-related MI*
Stent thrombosis associated with MI*
Coronary artery bypass grafting (CABG)-related MI*
*See notes
Thygesen et al. J Am Coll Cardiol 2012;60(16):1581-1598.

59. Time delay
elements in
thrombolysis

60. World Heart Day 2023
Use Heart to Know Heart
Presented by-
• Dr Seebat Masrur
• D-Card Student
• Cardiology Department
• SZMCH