A 67-year-old male presented with sudden onset of chest pain for 20 minutes. Clinical examination found tachycardia and signs of heart failure. ECG showed ST elevation myocardial infarction (STEMI) involving the anterior wall. The patient was diagnosed with STEMI and underwent primary percutaneous coronary intervention (PCI). During the procedure, the culprit lesion was identified in the left anterior descending artery and treated with stent placement. Post-procedure, the patient was started on dual antiplatelet therapy and anticoagulation medication. He was monitored in the intensive care unit and later transferred to the cardiology ward for further management of risk factors and secondary prevention.

1. ST ELEVATION MI
SPEAKER : Dr. KEERTHANA D S
MODERATOR : Dr. LAXMINARAYANA

2. INDEX
• INTRODUCTION

3. • 67 year male
• Sudden onset retrosternal chest pain since 20 minutes
• Dull aching, radiating to left upper limb, no variation with respiration
• Associated with nausea, vomiting and sweating
• Not associated with palpitations, orthopnea, syncope
• On and off chest pain since 1 week but did not take any medication
• No h/o similar complaints in the past
• Known diabetic since 20 years on T Metformin 500 mg OD
• Known hypertensive since 20 years on T. Amlodipine 5 mg BD
3

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Clinical syndrome Findings
ACS Diaphoresis, tachypnea, tachycardia, hypotension, crackles, S3, MR murmur, normal
PE Tachycardia, dyspnea, pain
Aortic dissection Connective tissue disorders, extremity pulse differential, severe pain, widened
mediastinum
Esophageal rupture Emesis, subcutaneous emphysema, pneumothorax, unilateral decreased breath sounds
Pericarditis Fever, pleuritic chest pain, increased in supine position
Myocarditis Fever, chest pain, heart failure, S3
Esophagitis, peptic ulcer disease, gall
bladder disease
Epigastric tenderness, right upper quadrant tenderness, murphy sign
Pneumothorax Dyspnea, pain on inspiration, unilateral absence of breath sounds
Pneumonia Fever, localised chest pain, friction rub, regional dullness to percussion, egophony
Costochondritis, Tietze syndrome Tenderness of costochondral joints
Herpes zoster Pain in dermatomal distribution, triggered by touch, characteristic rash( unilateral and
dermatomal distribution )

5. ACUTE CORONARY SYNDROME
1. ST ELEVATION MYOCARDIAL INFARCTION
2. NON ST ELEVATION – ACS
3. UNSTABLE ANGINA
5

6. ESC 2020
6
DEFINITION OF MI
Increase and/or decrease of a cardiac biomarker, preferably high-sensitivity cardiac troponin T or I, with
at least one value above the 99th percentile of the upper reference limit and at least one of the following:
(1) Symptoms of myocardial ischaemia.
(2) New ischemic ECG changes.
(3) Development of pathological Q waves on ECG.
(4) Imaging evidence of loss of viable myocardium or new regional wall motion abnormality in a
pattern consistent with an ischemic aetiology.
(5) Intracoronary thrombus detected on angiography or autopsy.

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TYPE I MYOCARDIAL INFARCTION
ATHEROSCLEROTIC PLAQUE
RUPTURE/FISSURE/ULCERATION/
EROSION
INTRALUMINAL THROMBUS IN
CORONARY ARTERY
DECREASED MYOCARDIAL BLOOD
FLOW/ DISTAL EMBOLISATION
MYOCARDIAL NECROSIS

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TYPE 2 MYOCARDIAL INFARCTION
Imbalance between myocardial oxygen supply and demand
• Hypotension/ hypertension
• Tachyarrythmia/ bradyarrythmia
• Anaemia
• Hypoxaemia
• Spontaneous coronary artery dissection
• Coronary artery spasm / embolism
• Coronary microvascular dysfunction

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TYPES 3 – 5 MYOCARDIAL INFARCTION
• Type 3 – resulting in death when biomarkers are not available
• Type 4 – myocardial infarction related to PCI
• Type 5 – myocardial infarction related to coronary artery bypass graft
surgery

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UNSTABLE ANGINA
• Defined as myocardial ischaemia at rest or on minimal exertion in the
absence of acute cardiomyocyte injury/necrosis.
• Substantially have a lower risk of death.
• Derive less benefit from intensified antiplatelet therapy, as well as an
invasive strategy within 72 hours.

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RISK FACTORS
Journal of Nuclear Cardiology Effectiveness of cardiac risk assessment models November/December 2020

12. 12
DIAGNOSIS

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Clinical history : sudden onset of
severe chest discomfort
ECG : within 10 minutes of
presentation to emergency
department
High sensitivity troponin

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CLINICAL HISTORY
AND EXAMINATION

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CHEST PAIN

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AHA CHEST PAIN 2021

17. Presentation title 17
AHA CHEST PAIN 2021

18. Presentation title 18
AHA CHEST PAIN 2021

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ECG

20. Presentation title 20

21. ECG
CRITERIA
• ST-segment elevation (measured at the J-point) two contiguous
leads :
1. 2.5mm in men < 40 years
2. 2mm in men 40 years
3. 1.5mm in women in leads V2–V3
4. 1mm in the other leads [in the absence of left ventricular (LV)
hypertrophy or left bundle branch block LBBB)].
• Inferior wall MI :
1. Right precordial leads (V3R and V4R) for ST-segment elevation ( to
identify concomitant right ventricular (RV) infarction ).
• Posterior MI :
1. ST-segment depression in leads V1–V3
2. Concomitant ST-segment elevation 0.5mm in leads V7–V9
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22. ECG LOCALISATION OF
OCCLUDED CORONARY
ARTERY
22

23. ESC 2017
23
ATYPICAL ECG PRESENTATION

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25. Presentation title 25

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BIOMARKERS

27. Presentation title
Schedule Implications Roadblocks
• Investors are planning to see the project
delivered in Q4
• Late delivery will delay future funding for further
projects
• Understaffed in key roles
• Tools to complete project randomly go offline
27

28. MANAGEMENT
• Relief of pain, breathlessness, and anxiety
• Cardiac arrest
• Reperfusion therapy
28

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30. 30

31. 31

32. DELIVERABLES
Main Critical Deliverables
• Product launch
• Software updates
• Press release
• Printed materials
Confidence Rating
• 5/5 confident that we will complete project
on schedule
32

33. IMPORTANT
TIME
TARGETS
Projection Of Costs
• $14,000 projection for project
• Main source from angel investors
Cost Overruns
• $2,000 over budget
• Closed gaps in communication with staff to
present future budget issues
• Project can track to remain on budget based on
planning and current projections
33

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PRIMARY
PERCUTANEOUS
CORONARY
INTERVENTION AND
ADJUVANT
THERAPY

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ACCESS SITE
• Robust evidence in favour of the radial approach as the access site in ACS patients undergoing primary PCI.
• Radial access was associated with lower risks of access site bleeding, vascular complications, need for
transfusion, significant mortality benefit.
• EVIDENCE
1. MATRIX
2. RIVAL
3. RIFLE-STEACS

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STENTING IN PRIMARY PCI
• Compared with balloon angioplasty alone, stenting with a bare-metal stent (BMS) is associated with a
lower risk of reinfarction and target vessel revascularization but is not associated with a reduction in the
mortality rate.
• Drug-eluting stents (DES) reduce the risk of repeated target vessel revascularization compared with BMS.
• New-generation DES lower risks of stent thrombosis and recurrent MI.
• EVIDENCE
1. COMFORTABLE AMI
2. EXAMINATION
3. NORSTENT

37. THROMBUS ASPIRATION
37
• Routine thrombus aspiration is not recommended, but in cases of large residual thrombus burden after opening the
vessel with a guide wire or a balloon, thrombus aspiration may be considered.
• EVIDENCE
1. TOTAL
2. TASTE

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MULTIVESSEL CORONARY
REVASCULARISATION
• EVIDENCE
1. PRAMI
2. CvLPRIT
3. DANAMI-3–PRIMULTI
4. Compare-Acute
• Routine revascularization of non-IRA lesions should be considered in
STEMI patients with multivessel disease before hospital discharge.
• Non-IRA PCI during the index procedure should be considered in
patients with cardiogenic shock.

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IABP
• EVIDENCE
1. CRISP
2. IABP SHOCK 2
• No benefit from a routine intra-aortic balloon
pump (IABP) in anterior MI without shock.

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PERI – PROCEDURAL PHARMACOTHERAPY
ANTIPLATELETS
• Patients undergoing primary PCI should receive DAPT, a combination of aspirin and a P2Y12 inhibitor,
and a parenteral anticoagulant.
• The oral dose of plain aspirin (non-enteric-coated formulation) should preferably be 150–300mg.
• Lower dose range avoids inhibition of cyclooxygenase-2- dependent prostacyclin.
• 300mg - faster and more complete inhibition of thromboxane generation and platelet aggregation at 5
min.

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P2Y12 INHIBITORS
• High clopidogrel loading doses has been demonstrated to achieve
more rapid inhibition of the adenosine diphosphate receptor.
• These drugs have a more rapid onset of action, greater potency, and
are superior to clopidogrel in clinical outcomes.
• Cangrelor is a potent i.v. reversible P2Y12 inhibitor with a rapid
onset and offset of action.
• Cangrelor reduced periprocedural ischaemic complications at the
expense of an increased risk of bleeding.
EVIDENCE
1. ATLANTIC
2. CURRENT OASIS
3. PLATO

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GP IIb/ III a INHIBITORS
• The pre-hospital routine upstream use of glycoprotein
(GP) IIb/IIIa inhibitors before primary PCI has not been
demonstrated to offer a benefit and increases bleeding
risk compared with routine use in the cath lab.
• There is no evidence to recommend the routine use of
GP IIb/IIIa inhibitors for primary PCI.
• The intracoronary administration of GP IIb/IIIa
inhibitors is not superior to its i.v. use.

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ANTICOAGULANTS
• Anticoagulant options for primary PCI include UFH,
enoxaparin, and bivalirudin.
• No placebo-controlled trial evaluating UFH in primary
PCI
• Initial bolus 70–100U/kg
• ATOLL TRIAL

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UFH VS BIVALIRUDIN
• 5 RCTS - no mortality advantage with bivalirudin
- reduction in the risk of major bleeding
- increased risk of acute stent thrombosis
• EVIDENCE - MATRIX trial - bivalirudin did not reduce the incidence of the primary endpoint (composite of
death, MI, or stroke) compared to UFH.
• Bivalirudin should be considered in STEMI
1. High bleeding risk
2. Heparin induced thrombocytopenia

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POST-PROCEDURAL
ANTICOAGULANT THERAPY
INDICATIONS
1. Atrial fibrillation
2. Mechanical valves
3. LV thrombus
4. Prevention of venous thromboembolism - prolonged bed rest.

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FIBRINOLYSIS
• Fibrinolytic therapy is an important reperfusion strategy in settings where primary PCI
cannot be offered in a timely manner.
• Prevents 30 early deaths per 1000 patients treated within 6 h after symptom onset.
• Fibrinolytic therapy is recommended within 12 h of symptom onset if primary PCI
cannot be performed within 120 min from STEMI diagnosis and there are no
contraindications.
• STREAM trial
• Following initiation of lytic therapy, it is recommended to transfer the patients to a PCI
centre
• In cases of failed fibrinolysis, or if there is evidence of reocclusion or reinfarction with
recurrence of ST-segment elevation, immediate angiography and rescue PCI is indicated
• A fibrin-specific agent should be preferred.

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48. 48
CONTRAINDICATIONS

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• RISK FACTORS -Advanced age, lower weight, female sex, previous cerebrovascular
disease, and systolic and diastolic hypertension
• STREAM trial - intracranial haemorrhage in patients 75 years was reduced after the
reductionof the dose of tenecteplase by 50%.
• Administration of streptokinase - hypotension.
• Readministration of streptokinase should be avoided because of antibodies that can
impair its activity, and because of the risk of allergic reactions.

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CABG
• Emergent coronary artery bypass graft
surgery (CABG)
1. Patent IRA but with unsuitable anatomy
for PCI
2. large myocardial area at jeopardy or with
cardiogenic shock.
3. MI-related mechanical complications who
require coronary revascularization
4. In STEMI patients with failed PCI
5. coronary occlusion not amenable to PCI

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FURTHER
HOSPITAL
MANAGEMENT

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SPECIAL
PATIENT
SUBSETS
PATIENTS ON ORALANTICOAGULANTS
• Triaged for primary PCI strategy regardless of the anticipated time to PCI-
mediated reperfusion.
• Additional parenteral anticoagulation, regardless of the timing of the last dose
of oral anticoagulant.
• GP IIb/IIIa inhibitors should be avoided.
• Loading of aspirin should be done as in all STEMI patients, and clopidogrel is
the P2Y12 inhibitor of choice ( 600mg) loading dose.
• Prasugrel and ticagrelor are not recommended.
• Chronic anticoagulation regimen should not be stopped during admission.
• Triple therapy (in the form of oral anticoagulation, aspirin, and clopidogrel)
should be considered for 6months.
• Oral anticoagulation plus aspirin or clopidogrel should be considered for an
additional 6months.
• After 1 year, it is indicated to maintain only oral anticoagulation.

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ELDERLY
• Present with atypical symptoms, the diagnosis of MI may be delayed or
missed.
• more comorbidities and are less likely to receive reperfusion therapy
compared with younger patients.
• Increased risk of bleeding
• Decrease in renal function
RENAL DYSFUNCTION
• Renal dysfunction (eGFR) <30mL/min/1.73 m2
• The type and dose of antithrombotic agent (see Table 9) and the amount of
contrast agent should be considered based on renal function
• Ensuring proper hydration during and after primary PCI and limiting the dose
of contrast agents, preferentially low-osmolality contrast agents, are
important steps in minimizing the risk of contrast-induced nephropathy

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RISK ASSESSMENT
• The Global Registry of Acute Coronary Events (GRACE) risk score is recommended for risk assessment
and adjustment.
• Short term risk - extent of myocardial damage, the occurrence of successful reperfusion, and the
presence of clinical markers of high risk of further events including older age, fast heart rate, hypotension,
Killip class >I, anterior MI, previous MI, elevated initial serum creatinine, history of heart failure, or
peripheral arterial disease.
• Long-term risk LVEF, severity of CAD and completeness of coronary revascularization, residual
ischaemia, occurrence of complications during hospitalization, and levels of metabolic risk markers,
including total cholesterol, low-density lipoprotein cholesterol (LDLC), high-density lipoprotein cholesterol

55. REFERENCES
1. 2020 ESC Guidelines for the management of acute coronary
syndromes
2. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/ SCMR Guideline for the
Evaluation and Diagnosis of Chest Pain
3. Text Book Of Critical Care 8th Edition – Fink

56. THANK YOU

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