1) The document discusses acute coronary syndrome and thromolytic therapy for ST-elevation myocardial infarction (STEMI). It defines STEMI and describes typical chest pain symptoms. 2) Pathophysiology of STEMI involves reduced oxygen supply and increased myocardial oxygen demand. Early management focuses on pain relief, establishing early reperfusion, and treating complications to minimize heart muscle death. 3) Thrombolytic therapy with drugs like streptokinase or tenecteplase can reestablish blood flow in the blocked artery and is most effective when administered within 12 hours of symptom onset. Indicators of successful reperfusion and contraindications to thrombolytics are provided.

1. Dr. Rosalya Mohd Wahid
ACUTE CORONARY SYNDROM
&
THROMBOLYTIC THERAPY

2. DEFINITION
CPG – Management of acute STEMI 2014 – 3rd
edtion (page 2)

3. TYPICAL CHEST PAIN
(1) Presence of substernal chest pain
(2) Discomfort that was provoked by exertion or emotional stress
(3) Pain was relieved by rest and/or nitroglycerin
http://emeddoc.org/?p=383

4. MYOCARDIAL INFARCTION
• Clinical diagnosis based on the presence of myocardial injury or necrosis as indicated by a rise and
fall of serum cardiac biomarkers. There should be at least one of the following:
i. Clinical history consistent with chest pain of ischaemic origin
ii. ECG changes of ST segment elevation or presumed new LBBB
iii. Imaging evidence of new loss of viable myocardium/new regional wall motion abnormality
iv. Identification of an intracoronary (IC) thrombus by angiography or autopsy
CPG – Management of acute STEMI 2014 – 3rd
edtion (page 2)

5. PATHOPHYSIOLOGY
• Reduce of O2 supply
• Increase myocardial 02 demand
stable
unstable
video

7. 1) HISTORY TAKING ??

8. PAIN DIFFERENTIATION
SYSTEM SYNDROME Clinical description Presenting features
CARDIOVASCULAR Stable angina Retrosternal pressure,
heaviness, burning; may
radiate to arms, neck,
jaw
Provoked by physical
/emotional stress
Unstable angina Same as stable but
usually more severe
and prolonged
Occur at rest or with
minimal exertion
Acute MI Same as angina but
usually more severe
Usually > 30min, a/w
dyspnea, diaphoresis
Pericarditis Pleuritic pain, worse in
supine position
Fever, pericardial
friction rub
GASTROINTESTINAL Peptic ulcer Burning retrosternal &
epigastric discomfort
Relieved by antacid or
food
MUSCULOSKELETAL Costochondritis Localized pain May be reproducible by
pressure to the affected
site

9. 2) ECG

11. 3) CARDIAC
BIOMARKER
CPG – Management of acute STEMI 2014 – 3rd
edtion

15. MANAGEMENT
Early management of STEMI is directed at:
•Pain relief
•Establishing early reperfusion
•Treatment of complications

16. TIME LOST is
equivalent to
MYOCARDIUM LOST
A)
CPG – Management of acute STEMI 2014 – 3rd
edtion

17. B) CONTRAINDICATIONS TO FIBRINOLYTIC
THERAPY
Absolute contraindications
•Risk of intracranial haemorrhage
- History of intracranial bleed
- History of ischaemic stroke within 3 months
- Known structural cerebral vascular lesion (e.g AVM)
- Known intracranial neoplasm.
•Risk of bleeding
- Active bleeding or bleeding diathesis (excluding menses)
- Significant head trauma within 3 months
- Suspected aortic dissection
CPG – Management of acute STEMI 2014 – 3rd
edtion

18. B) CONTRAINDICATIONS TO FIBRINOLYTIC
THERAPY
Relative contraindications
•Risk of intracranial haemorrhage
- Severe uncontrolled hypertension on presentation (BP > 180/110 mmHg)
- Ischaemic stroke more than 3 months
- History of chronic, severe uncontrolled hypertension
•Risk of bleeding
- Current use of anticoagulation in therapeutic doses (INR > 2)
- Recent major surgery < 3 weeks
- Traumatic or prolonged CPR > 10 minutes
- Recent internal bleeding within 4 weeks
- Non-compressible vascular puncture
- Active peptic ulcer CPG – Management of acute STEMI 2014 – 3rd
edtion

19. C) HIGH-RISK PATIENTS
• Large infarcts
• Anterior infarcts
• Hypotension and cardiogenic shock
• Significant arrhythmias
• Elderly patients
• Post-revascularisation (post-CABG and post-PCI)
• Post-infarct angina
The goals of time to reperfusion therapy should be within:
• 30 minutes DNT
• 90 minutes DBT
CPG – Management of acute STEMI 2014 – 3rd
edtion

20. FIBRINOLYTIC AGENT
1) Streptokinase is antigenic and promotes the production of antibodies. Thus the
utilisation of this agent for reinfarction is less effective if given between 3 days and 1 or even
4 years after the first administration. PCI or fibrin specific agents should then be considered.
Regimen:
-1.5 mega units in 100 ml normal saline or 5% dextrose over 1 hour
2) Tenecteplase (TNK-tPA) causes more rapid reperfusion of the occluded artery
than streptokinase and is given as a single bolus dose
Regimen: single IV bolus 30 mg if < 60 kg
35 mg if 60 to < 70 kg
40 mg if 70 to < 80 kg
45 mg if 80 to < 90 kg
50 mg if > 90 kg

21. INDICATION OF TENECTEPLASE (TNK-TPA)
• To reduce mortality associated with AMI
• Patient < 50 years old
• Patient have an anterior MI
• Chest pain < 12 hours

22. INDICATORS OF SUCCESSFUL REPERFUSION
• Resolution of chest pain (may be confounded by the use of
narcotic analgesics)
• Early return of ST segment elevation to isoelectric line or a
decrease in the height of the ST elevation by 50% (in the lead that
records the highest ST elevation) within 60-90 minutes of initiation
of fibrinolytic therapy
• Early peaking of CK and CK-MB levels
• Restoration and/or maintenance of haemodynamic and/or
electrical stability

23. CONCOMITANT THERAPY
A) Oxygen - indicated in the presence of hypoxaemia (SpO2 < 95%)
B) Antiplatelet agents – Aspirin, Clopidogrel
C) Antithrombotic therapy

24. CONCOMITANT THERAPY
D) B-blocker
Contraindications to B-blockers:
1) Bradycardia < 60/minute
2) SBP < 100 mmHg
3) Pulmonary congestion with crepitations beyond the lung bases
4) Signs of peripheral hypoperfusion
5) Second or third degree atrio-ventricular (AV) block
6) Asthma or chronic obstructive airway disease
7) Severe peripheral vascular disease

25. CONCOMITANT THERAPY
E) ACE-Is and ARBs
The benefits of ACE-Is are greatest in patients with: HF, Anterior infarcts, Asymptomatic LV
dysfunction [LV ejection fraction (LVEF)] < 40% on echocardiography)
Contraindications to ACE-I and ARB therapy:
•SBP < 100 mmHg
•Established contraindications e.g. bilateral renal artery stenosis

26. CONCOMITANT THERAPY
F) Statin – Early and intensive high dose statin in ACS have been proven to
produce superior benefits in reduction of major cardiac events.
G) Calcium channel blocker
H) Nitrates

27. COMPLICATIONS OF STEMI
• Arrhythmias
• LV dysfunction and shock
• Mechanical complications
• RV infarction
• Others e.g. pericarditis

28. TAKE HOME MESSAGE…..

30. • https://www.youtube.com/watch?v=NZ14XjOQoFY