PRESENTED BY DR. RAMESH THAKUR IN STEMI 2018 LUCKNOW

1. Evaluation & management of
Supra-ventricular Tachycardia
in Myocardial Infarction
1

2. No Disclosure
2

3. How much time would you take to react?
3

4. How much time would you take to react?
4

5. How much time would you take to react?
5

6. Well known
Early/ late
Bad consequences
Ventricular Arrhythmia
in Myocardial Infarction
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7. Supra-ventricular Arrhythmia
in Myocardial Infarction
How common?
When does it happen?
How bad it is?
7

8. How common?
Cristal et al, Annals of Internal Medicine, 1975
N =
154/ 350
44%
Serrano et al, Clin. Cardiol. 1995
25%
N = 131
8

9. AF + hyper-acute AWMI
AF: 10-20%
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10. Which subset of MI?
SVT in AWMI carries high mortality
Cristal et al, Annals of Internal Medicine, 1975
N = 350
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11. PSVT in IWMI
Chest pain After adenosine
Subramanian et al, IPEJ 2012
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12. However! AF in IWMI
Sugiura et al, The American Journal Of Cardiology , 1991
More in RVMI
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13. Holter’s POV
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Incidences
ST: AWMI AF: IWMI/ PWMI/ RVMI
Rajhans R et al. Int J Adv Med. 2017
STEMI
50 patients
24 hours

14. Atrial infarction
Right atrial infarction + atrial arrhythmia + inferior myocardial infarction
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15. How to diagnose atrial infarction?
Liu et al, Circulation 1961 Sivertssen et al, Am J Cardiol 1973
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16. Complications of atrial infarction
Shakir et al, Can J Cardiol 2007
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17. When does it happen?
N = 350
Mostly within 24 hrs
Cristal et al, Annals of Internal Medicine, 1975
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18. How long is actually bad?
N= 35/ 340
AFL lasting >48 hrs is 100% killer
Blumlein et al, The Western Journal Of Medicine , 1981
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19. AFL + AWMI
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20. The later the deadlier!
AWMI/ LAD/ MVD/ LVF/ IABP
Serrano et al, Clin. Cardiol. 1995
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21. After PCI! Reperfusion arrhythmia
AVN blockers in APC
Carey et al, American Journal Of Critical Care 2015
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22. Reperfusion arrhythmia
after Primary PCI in STEMI
Gorenek et al, EuroIntervention 2014
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23. How bad it is?
2/3 patients with SVT have pulmonary edema or shock
Cristal et al, Annals of Internal Medicine, 1975
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24. Which is first?
SVT
Pulm edema
Shock
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25. Why does it happen?
Ischemia to atrium,
conduction system
Primary
IWMI
Secondary
AWMI
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26. Aftermath of SVT in MI
Atrial boosting lost/ high atrial pressure
Increased O2 demand/ supply
shear stress/ plaque rupture
Low BP promoting stasis & coagulation
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27. Coronary blood supply to
the cardiac conduction system
Ramanathan et al, Arq. Bras. Cardiol 2009
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28. LBBB + AWMI
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29. SGARBOSA is not enough!
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Sgarbosa et al, N Engl J Med 1996 Smith et al, Annals of Emergency Medicine 2012
Sp 95-98%, Sn 15-20% Sp 95-98%, Sn 60-80%

30. RBBB + AWMI
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31. BBB in MI
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IWMIAWMI
Shah et al, J Clin Diagn Res. 2014N = 100

32. ALCAPA
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Mimickers # 1

33. 33
Mimickers # 2
WPW

34. 34
Mimickers # 3
Hyperkalaemia

35. Mimicker # 4
Coronary embolism/ thrombosuction 35

36. Terminator 3
36
Beta
blockers
Within
24 hours
Amiodarone
If persistent
DC
shock
if
hemodynamic
instability
DCC = direct-current cardioversion,
D+Q = combination digitalis and quini- dine, V = verapamil Serrano et al, Clin. Cardiol. 1995

37. AF/ AFL in MI: DAPT VS TAPT
Steffel et al, EHJ 2018
37
PIONEER
REDUAL
ENTRUST
AUGUSTUS

38. Choose Your Weapon Wisely!
NORSTENT: Bønaa et al, N Engl J Med. 2016
BMS is as good as DES
LEADERS FREE: Morice et al, Int J Cardiol. 2017
LAA occluders
BIOFREEDOM
RFA 38

39. What we have learned?
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25-44%
AF
worst
The later
the worse
More in
IWMI
Worse in
AWMI
Poor
hemo
dynamics
Masquerading
morphology

40. SVT in MI: Ten Commandments
• Ignorance is NOT bliss!
• Not so uncommon
• Mimickers: WPW/ coronary embolism/ ALCAPA/ electrolytes
• Which MI: AWMI/ IWMI?
• When: <12 hrs/ >12 hours?
• What: AF is worst.
• How bad: pulm edema/ shock?
• How long: normalised/ persistent?
• Antiarrhythmics: beta blockers/ Amiodarone/ DC shock
• Management: ischemic risk/ bleeding risk
40
Thank you