This document provides information on primary percutaneous coronary intervention (PPCI) for ST-segment elevation myocardial infarction (STEMI). It describes the clinical presentation of STEMI and time-sensitive treatment with either thrombolysis or PPCI. PPCI is shown to reduce mortality, reinfarction, and need for bypass surgery compared to thrombolysis. The document outlines the PPCI procedure, complications, post-procedure observations and care including monitoring for arrhythmias, puncture site bleeding, vital sign changes, pain, and left ventricular failure. Psychological support is also emphasized.

1. Primary PCI
Management

2. Introduction
Acute ST segment elevation myocardial
infarction (STEMI) occurs:
 when a thrombus forms and occludes a
coronary artery.
 Patients must be treated promptly as
myocardial necrosis commences within
30min and affects full myocardial
thickness within six hours.

3. Clinical presentation of STEMI
 Severe central chest pain, radiating to
arm,neck,jaw or shoulder blade.
 Shortness of breath, dizziness, anxiety, nausea
and vomiting.
 ECG changes include >1mm ST elevation on
two consecutive limb leads and >2mm in two
consecutive chest leads.
 ECG shows sign of suspected new LBBB or
isolated ST segment depression in leads V1-V3,
indicated a potential posterior infarct.

4. Treatment
 Thrombolysis
 Primary percutaneous coronary intervention
(PPCI)

5. Evidence
 Myocardial Infarction Audit Project (MINAP)
shows that PPCI saves more lives then
Thrombolysis.
 Reduces mortality by approx one third in the first
six months, reinfarction is reduced by over a
half, stroke reduced by two-thirds.
 The need for coronary artery bypass grafting is
reduced by approx one-third compared with
Thrombolysis.

6. PPCI procedure
 Patient requiring PPCI should be
transferred to the Cath Lab.
 should be loaded with 300mg of aspirin
and Clopidogrel 600mg or 180mg ticreglor.

7. PPCI Procedure (cont)
 Patient nursed in supine position
 Local anaesthetic administered either
groin or the wrist
 Procedure carried out via the radial or
femoral artery
 Heparin administered
 Guiding catheter is used and a contrast
medium to visualise the arteries.

8. PPCI Procedure (cont)
 Affected coronary arteries are identified.
 A balloon is inflated at the site of the
blockage. (a thrombus extraction catheter
may also be used)
 Drug coated stent used at lesion.
 Closure device deployed once procedure
completed

13. Complications
 Risk of bleeding is higher
 Risk of death, stroke and cardiac
tamponade
Patient needs to be closely monitored
post procedure

14. Observations following PPCI
 Identify cardiac arrhythmias
 Observe puncture site for haematomas
 Observe limb for early signs of ischaemia
including: loss of colour, sensation and
movement
 Monitor vital signs of deterioration
 Assess chest pain using a validated pain
assessment tool

15. Arrhythmias
 Approx 90% of patients will experience some
sort of arrhythmia particularly in the first 24
hours after a STEMI.
Rhythm disturbances include:
 Ventricular tachycardia
 Ventricular fibrillation
 Heart blocks
 Atrial fibrillation
 Bradycardia

16. Puncture site
 Site should be assessed every 15min-
30min for 4hours (depending on hospital
protocol)
 Heparin is administered during procedure
to prevent thrombus formation but can
increase risk of bleeding from site
 Colour, warmth, movement, pulses and
sensation of the limb should also be
assessed.

17. Monitoring vital signs
Patients may have a vasovagal reaction
post procedure. This will result in a:
 Fall in heart rate
 Fall in blood pressure
 Compromises coronary perfusion pressure

18. Pain
 Level of pain must be assessed post
procedure
 Chest pain can occur in up to 40% of
patients post procedure. Causes could be
 In-stent re-stenosis
 New disease
 vasospasm

19. Pain
Prompt treatment of pain includes:
 Prescribed oxygen to prevent hypoxia
 Nitrates to alleviate acute cardiac chest
pain by vasodilatation
 Analgesia to increase oxygen supply to
the heart, reduce oxygen demand and
reduce anxiety and restlessness
 REPEAT ECG

20. Left ventricular failure (LVF)
 LVF is a complication following STEMI and
PPCI
 Can affect 25%-50% of patients
presenting with cardiac instability.
 LVF arises from loss of myocardial tissue
and reduce contractility of damaged
myocardium.
 It is important that we recognise signs
of LVF

21. Treatment of LVF
 Sitting the patient up in bed to reduce pulmonary
congestion
 Administer high concentration of oxygen- may
need continuous positive airway pressure
(CPAP)
 IV diuretics, which may lower the ventricular
filling pressure and resolve pulmonary and
systemic congestion
 Administer iv antianginal drugs such as GTN-
decreases venous dilation and venous return
and thus pre-load on the heart allowing left
ventricle to shrink

22. Psychological Care
 On going communication with the patient
and their family is essential
 This allows us to update the patient on the
proposed plan of care, as well as allow
them and their families to ask questions
 Referral to the cardiac rehab team

23. Any Questions?