Download STEMI Primer 2016

STEMI Primer: 101
From Presentation to Cath Lab
Michael S. Blanc, FACC, FSCAI
Community Heart & Vascular Center
San Angelo Community Medical Center
San Angelo, TX
 https://youtu.be/9Wmqq3TfV5w
“Vulnerable” Plaque and
“Stable” Plaque
Libby. Circulation. 1995;91:2844-2850.
Most MIs associated with non-flow limiting lesions
Severity of Coronary Artery Stenosis before Acute MI
100%
90%
80%
70%
60%
% of Patients
50%
n = 195
40%
30%
20%
10%
0%
<50%
50-70%
>70%
Circulation Vol 93, No12 June 15, 1996
Ambrose, Giroud, Little, Nobuyoshi, et al
Symptoms of Heart
Attack
Chest discomfort
Jaw or arm discomfort
Shortness of breath
Cold sweat
Upset stomach
Fatigue
Over 25% of patients have no chest
discomfort
Heart is not heavily innervated and pain is
typically not severe
Acute Phase Risk Stratification:
Pre-infarction characteristics
Age > 70
Prior myocardial
infarction
Female gender
Hypertension
History of CHF
Hyperlipidemia
Diabetes
Race
Clinical Criteria
ECG Criteria
Chest x-raycardiomegaly
Markedly elevated
cardiac enzymes
Elevated BUN
Hemodynamic Criteria
Complications
 VSD/PMD-rupture
 Myocardial rupture
Continuing Medical Implementation
…...bridging the care gap
Acute Phase Risk Stratification:
Physical Examination
Clinical assessment of LV dysfunction





No history of CHF
No CHF with index MI
No LBBB, pacemaker or LVH with ST-T’s
Absence of Q waves-site of MI or outside index
territory
91 % predictive value of EF  40%
Killip classification
Hemodynamic classification
Mechanical complications
Continuing Medical Implementation
…...bridging the care gap
Clinical Signs of LV
Dysfunction
Hypotension
Pulsus alternans
Reduced volume
carotid
LV apical
enlargement/displac
ement
Sustained apex - to
S2
Soft S1
Paradoxically split
S2
S3 gallop
(not S4 = impaired
LV compliance)
Mitral regurgitation
Pulmonary
congestion
Continuing Medical Implementation
…...bridging the care
gap
rales
Acute Phase Risk Stratification:
Importance of LV dysfunction
% patients
Mortality (%)
30-50
5
II Rales, S3, Pulmonary venous hypertension
33
15-20
III Pulmonary edema
15
40
IV Cardiogenic shock
10
80-100
Killip Classification
I No CHF
Continuing Medical Implementation
…...bridging the care gap
Figure 6
TIMI Risk Score for STEMI
Historical
Age 65-74
 75
DM/HTN or angina
Exam
SBP < 100
HR >100
Killip II-IV
Weight < 67 kg
2 points
3 points
1 point
3 points
2 points
2 points
1 point
Presentation
Anterior STE or LBBB
Time to rx > 4 hrs
1 point
1 point
Risk Score = Total
(0 -14)
(FRONT)
Risk Score
0
1
2
3
4
5
6
7
8
>8
Odds of death by 30D*
0.1
0.3
0.4
0.7
1.2
2.2
3.0
4.8
5.8
8.8
(0.1-0.2)
(0.2-0.3)
(0.3-0.5)
(0.6-0.9)
(1.0-1.5)
(1.9-2.6)
(2.5-3.6)
(3.8-6.1)
(4.2-7.8)
(6.3-12)
*referenced to average mortality
(95% confidence intervals)
(BACK)
Complications of Acute Myocardial
Infarction
• Arrhythmic Complications
• Mechanical Complications
• Ischemic Complications
• Miscellaneous Complications
[DVT, PE, Pericarditits, TPA complications, Pneumonia]
Mechanical Complications of Acute
Myocardial Infarction
• Papillary Muscle Rupture – Acute MR
• Ventricular Septal Defect
• Right Ventricular MI
• Free Wall Rupture
• Cardiogenic shock
• Cardiac Tamponade
Acute Mortality
Reduction
Early Recognition of Symptoms
Pre -Hospital Resuscitation of Sudden Death
Fast-Track Protocol for Thrombolytic Therapy
Code STEMI – Direct PCI protocols
Optimal Use of Adjunctive Therapy
Monitoring for Complications
Evidence Based Risk Stratification
Appropriate Revascularization for NSTEMI
Continuing Medical Implementation
…...bridging the care gap
Prognosis Post MI
Mortality in the first year post MI
averages 10%
Subsequently mortality 5% per year
85% of deaths due to CAD
50% of these sudden
 50% within first 3 months
 33% within the first three weeks

Continuing Medical Implementation
…...bridging the care gap
Early Mortality After AMI
Mortality at 25 - 30 Days
% Mortality
25
20
15
10
5
0
1967
1970
1979
Pre-CCU
CCU
b-Block
1986
1990
1993
1997
1999
GISSI-1 ISIS-2 GUSTO GUSTO-3 ASSENT-2
tPA &
SK
tPA &
SK+ASA
tPA
rPA
TNK
Continuing Medical Implementation
…...bridging the care gap
Medications
ASA 325 mg po chewed
Ticagrelor (Brilinta) 180 mg
Alternative-Clopidogrel (Plavix) 600 mg
 Alternative-Prasugrel (Effient) 60 mg

Heparin 5000 unit IV
Atorvastatin 80 mg
Primary endpoint: CV death, MI or stroke
12
Clopidogrel
K-M estimated rate (% per year)
11
11.0
10
9.3
9
Ticagrelor
8
7
6
5
4
3
2
HR: 0.85 (95% CI = 0.74–0.97), p=0.02
1
0
0 1
No. at risk
Ticagrelor 4,201
Clopidogrel 4,229
2
3
3,887
3,892
4
5
3,834
3,823
6
7
Months
3,732
3,730
8
9
3,011
3,022
10
11
2,297
2,333
12
1,891
1,868
Beta-Blockers
COMMIT: Study design
INCLUSION:
>45,000 patients with suspected acute MI
(ST change or LBBB) within 24 h of
symptom onset
TREATMENT:
Metoprolol 15 mg iv over 15 mins, then
200 mg oral daily vs matching placebo
EXCLUSION:
Shock, systolic BP <100 mmHg, heart rate
<50/min or II/III AV block
1 OUTCOMES:
Death & death, re-MI or VF/arrest up to 4
weeks in hospital (or prior discharge)
Mean treatment and follow-up: 16 days
Effects of Metoprolol
COMMIT (N = 45,852)
Totality of Evidence (N = 5
Death
13%
P=0.0006
30% relative
increase in
*cardiogenic
shock
ReMI
22%
P=0.0002
VF
15%
P=0.002
*Risk factors for cardiogenic shock :heart failure, age > 70 , systolic blood
pressure < 120, sinus tachycardia > 110 or heart rate < 60, increased time since
onset of STEMI symptoms
Lancet. 2005;366:1622.
Beta-Blockers
Recommendations - Class Ia (B)
• ORAL beta-blocker therapy SHOULD BE initiated in the first
24 hours for patients who DO NOT have any of the
following:
1) signs of heart failure,
2) evidence of a low output state,
3) increased risk for cardiogenic shock, or
4) relative contraindications to beta blockade
 1AVB > 0.24 sec,
 2nd- or 3rd-degree heart block
 reactive airway disease
** There is no study evaluating oral beta blockers alone
*Risk factors for cardiogenic shock :heart failure, age > 70 , systolic blood pressure < 120,
sinus tachycardia > 110 or heart rate < 60, increased time since onset of STEMI symptoms
Beta-Blockers
Recommendations - Class IIa (B)
• It is reasonable to administer an IV BETA BLOCKER at the
time of presentation to STEMI patients who are
HYPERTENSIVE and who do not have any of the following:
1) signs of heart failure,
2) evidence of a low output state,
3) increased risk for cardiogenic shock, or
4) relative contraindications to beta blockade
 1AVB > 0.24 sec,
 2nd- or 3rd-degree heart block
 reactive airway disease
*Risk factors for cardiogenic shock :heart failure, age > 70 , systolic blood pressure < 120, sinus
tachycardia > 110 or heart rate < 60, increased time since onset of STEMI symptoms
Beta-Blockers
Recommendations - Class III (A)
• IV beta blockers SHOULD NOT be administered to STEMI
patients who have any of the following:
1) signs of heart failure
2) evidence of a low output state
3) increased risk* for cardiogenic shock
4) relative contraindications to beta blockade
 1AVB > 0.24 sec,
 2nd- or 3rd-degree heart block
 reactive airway disease
*Risk factors for cardiogenic shock :heart failure, age > 70 , systolic blood
pressure < 120, sinus tachycardia > 110 or heart rate < 60, increased time since
onset of STEMI symptoms
Statin Evidence: MIRACL Study
Primary Efficacy Measure
Placebo
Cumulative Incidence (%)
15
17.4%
14.8%
Atorvastatin
10
Time to first occurrence of:
• Death (any cause)
• Nonfatal MI
• Resuscitated cardiac arrest
• Worsening angina with new
objective evidence and urgent
rehospitalization
5
Relative risk = 0.84
P = .048
95% CI 0.701-0.999
0
0
4
8
12
Time Since Randomization (weeks)
Schwartz GG, et al. JAMA. 2001;285:1711-1718.
16
Reperfusion
“Time is Muscle”
Brief Review of
Thrombolytic Trials
GISSI-1: Streptokinase 18% reduction in mortality at 21 d
GUSTO-1: tPA. 15% reduction in 30-day mortality compared
to Streptokinase
GUSTO-3: Reteplase had no benefit over tPA but is easier to
use (double bolus)
ASSENT: TNKase is similar to tPA but with less non-cerebral
bleeding and better mortality with symptoms>4 hrs: Single
bolus, fibrin selective, resistance to PAI-1
*Overall risk of ICH is 0.7%; Strokes occurred in 1.4%
Anticoagulants
•Patients undergoing reperfusion with fibrinolytics
should receive anticoagulant therapy for a minimum of
48 hours (unfractionated heparin) or up to 8 days
•Anticoagulant regimens with established efficacy
include:
♥ UFH (LOE: C)
♥ Enoxaparin (LOE:A)
♥ Fondaparinux (LOE:B)
PCI vs Fibrinolysis for STEMI:
Frequency (%)
Short-Term Clinical Outcomes
35
PCI
30
Fibrinolysis
N=7739
P<.0001
25
21
20
15
10
P<.0001
P=.0002
9
13
P=.0003
P<.0001
7
7
7
5
5
2
Death
Death,
no shock
data
P=.032
6
P<.0001
1
ReMI
2
Rec.
Total
Ischemia Stroke
8
7
P=.0004
5
1
Hem.
Stroke
Major
Bleed
Death
MI
CVA
Keeley E, et al. Lancet . 2003;361:13-20.
Reperfusion Therapy fr 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 onsetClass I, LOE: B). †Angiography and
revascularization should not be performed within the first 2 to 3 hours after administration of fibrinolytic therapy.
Reperfusion at a Non–PCI-Capable Hospital
Transfer of Patients With
STEMI to a PCI-Capable
Hospital for Coronary
Angiography After Fibrinolytic
Therapy
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
SACMC Standards
EMS SENDS EKG TO ER MD FROM
FIELD

Scene time 15 min for STEMI.
ER MD MAKES DX and ACTIVATES
CATH LAB TEAM

One phone call activation
ER PRESENTATION-EKG < 5 MIN
ER MED BOX
DIRECT ADMIT TO CATH LAB
SACMC
SACMC average DBT 54 min
Five years of DBT < 90 min
Helicopter
Transfer
Local EMS should generally be used if available and 30 minute
time to destination hospital
Whenever possible, helipad adjacent to ED
Ground/Air Transfer:
Enhance First
Responders
transportation
Early activation of Air
Onsite Helipad:
Availability of Transport
Helicopter capable of transporting patients on 10 minute notice 24/7. When
available alternate transport options identified.
When Helicopter Not
not Available:
Identify Plan B: Who is
next
Immediately activate helicopter transport during initial communication between
referring hospital ED and receiving hospital regarding need for reperfusion
Referral team activates:
Establish a system whereby all patient transfers of any type can be specified as
time critical within one hour versus diversion possible