This document discusses treatment strategies for ST elevation myocardial infarction (STEMI). It outlines that primary percutaneous coronary intervention (PCI) is the recommended reperfusion method for STEMI when it can be performed within 90 minutes of first medical contact. Fibrinolytic therapy is an alternative if PCI is not available or is associated with unacceptable delays exceeding 120 minutes. The document reviews fibrinolytic drug options and indicates primary PCI has lower mortality compared to fibrinolysis based on meta-analyses. It provides guidance on selecting the best reperfusion strategy based on time factors, patient risk characteristics, and institutional PCI capabilities.

1. ST ELEVATIONST ELEVATION
MIMI
MANAGEMENTMANAGEMENT

2. ACUTE CORONARY SYNDROMES
No ST elevation ST elevation
Unstable
angina
NSTEMI STEMIStable
angina

3. Epidemiology
• Mortality rate of STEMI - 25% to 50%
• Short-term mortality rate in STEMI with pharmacologic
reperfusion therapy - 6.5% to 7.5%
• In-hospital or 30-day mortality rates were 13 percent with medical
therapy alone, 6 to 7 percent with optimal fibrinolytic therapy, and
as low as 2 percent with primary PCI when performed within
two hours of chest pain onset

4. Acute STEMI - REVASCULARIZATION
Primary PCI is the recommended method of
reperfusion
Pharmacological treatment –
Fibrinolytic therapy
• Fibrin-specific:Tenecteplase (TNK-tPA), Reteplase
(rPA), Alteplase (tPA)
• Non–fibrin-specific: Streptokinase

7. Primary PCI - Definition
Primary PCI consists of
 To open the infarct -related artery during an acute
myocardial infarction with ST– segment elevation
 It can be with or without stenting

8. Reperfusion Therapy for Patients with STEMI
*Patients with cardiogenic shock or severe heart failure initially seen at a non–PCI-capable hospital should be transferred for cardiac
catheterization and revascularization as soon as possible, irrespective of time delay from MI onset (Class I, LOE: B). †Angiography and
revascularization should not be performed within the first 2 to 3 hours after administration of fibrinolytic therapy.

9. Fibrinolysis
Primary PCI
Noninvasive Risk
Stratification
Late
Hospital Care
and Secondary
Prevention
PCI or CABG
Not
PCI Capable
PCI Capable
Rescue Ischemia
driven
9
STEMI <12 hrs of Symptom OnsetSTEMI <12 hrs of Symptom OnsetSTEMI <12 hrs of Symptom OnsetSTEMI <12 hrs of Symptom Onset

18. P=0.0002
P=0.0003 P<0.0001
P=0.0004
P<0.0001
Grines et al 2003;NEJM361:13-20

19. 0%
5%
10%
15%
20%
Meta analysis London 30 d London 1 year
Mortality
PCI Lysis
P<0.001 P<0.001 P<0.001
20 lives /1000 78 lives/1000 130 lives/ 1000

20. Selecting the Best ReperfusionSelecting the Best Reperfusion
StrategyStrategy
 Fibrinolysis is not unreasonable when:Fibrinolysis is not unreasonable when:
 PCI associated with unacceptable delay (Class I)
 Short time from symptom onset (<2 hr) (Class I) with anticipated door-
to-balloon >2 hours
 Primary PCI is superior to Fibrinolysis inPrimary PCI is superior to Fibrinolysis in
several clinical situations, particularly if:several clinical situations, particularly if:
 Competent personnel involvedCompetent personnel involved
 DB times are <90 Min, PCI related Delay AcceptableDB times are <90 Min, PCI related Delay Acceptable
 High Risk for Bleeding or Complication from MIHigh Risk for Bleeding or Complication from MI
 Late PresentationLate Presentation

21. Rescue PCI
•If evidence of
 cardiogenic shock,
 severe heart failure
 hemodynamically compromising ventricular
arrhythmias.
•If fibriolysis has failed
 Evaluate 90 minutes for a <50% ST resolution in
lead with greatest elevation

23. Summary of Acute STEMI Treatment

40. Thank you
Thank you