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Primary PCI
Management
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.
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.
Treatment
 Thrombolysis
 Primary percutaneous coronary intervention
(PPCI)
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.
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.
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.
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
Complications
 Risk of bleeding is higher
 Risk of death, stroke and cardiac
tamponade
Patient needs to be closely monitored
post procedure
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
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
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.
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
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
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
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
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
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
Any Questions?

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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
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  • 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