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Treatment of STEMI

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18 views7 pages

Treatment of STEMI

Uploaded by

roouhansh0108
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Treatment of STEMI (ST-Elevation Myocardial Infarction)

Initial Goals of Therapy


1. Quickly identify if the patient is a candidate for reperfusion therapy.
2. Relieve pain and reduce myocardial oxygen consumption.
3. Prevent and treat arrhythmias and mechanical complications.

Initial Assessment
1. Aspirin Administration:
o Administer immediately upon presentation.
o Dose: 162–325 mg chewed at presentation, followed by 75–162
mg daily.
o Avoid in aspirin-intolerant patients.
2. Perform Targeted History and Physical Examination:
o Assess for risk factors, symptoms (chest pain, dyspnea), and
contraindications to reperfusion or anticoagulant therapy.
3. ECG Criteria for STEMI:
o ST-elevation ≥1 mm in at least two contiguous limb leads.
o ST-elevation ≥2 mm in at least two contiguous precordial leads.
o New left bundle branch block (LBBB) with clinical suspicion of
ischemia.
o Reciprocal ST depression in opposing leads may further confirm
the diagnosis.
4. Biochemical Markers:
o Obtain cardiac biomarkers (e.g., troponin I or T) to confirm
myocardial injury, though diagnosis of STEMI is primarily clinical
and ECG-based.
Reperfusion Therapy
1. Primary Percutaneous Coronary Intervention (PCI):
o Preferred Strategy if available within 120 minutes of first medical
contact.
o Benefits:
▪ Reduces infarct size.
▪ Improves left ventricular (LV) function.
▪ Reduces mortality.
o Indications:
▪ Persistent chest pain or ST-elevation.
▪ Cardiogenic shock or severe heart failure.
▪ High bleeding risk (where fibrinolysis is contraindicated).
2. Fibrinolytic Therapy (if PCI unavailable):
o Administer if PCI cannot be performed within 120 minutes.
o Door-to-Needle Time: <30 minutes for maximum benefit.
o Best outcomes if initiated within 1–3 hours of symptom onset.
o Agents:
▪ Alteplase, Reteplase, Tenecteplase, or Streptokinase.
o Contraindications (absolute):
▪ Active bleeding or bleeding disorders.
▪ Recent hemorrhagic stroke.
▪ Significant head trauma or brain surgery within 3 months.
o Complications: Bleeding, reperfusion arrhythmias, allergic
reactions (streptokinase).
o Administer anticoagulation (e.g., heparin or enoxaparin)
concurrently.
3. Rescue PCI:
o Indicated if:
▪ Chest pain or ST-elevation persists >90 minutes after
fibrinolysis.
▪ Signs of failed reperfusion (e.g., persistent ischemia).
4. Coronary Angiography:
o Perform post-fibrinolysis in patients with:
▪ Recurrent angina or high-risk features (e.g., extensive ST
elevation, heart failure, low systolic BP, LVEF ≤35%).

Standard Treatment (Regardless of Reperfusion)


1. Hospitalization:
o Admit to a CCU or intermediate care unit with continuous ECG
monitoring.
o Establish IV access for emergency treatments.
2. Pain Management:
o Morphine Sulfate: 2–4 mg IV every 5–10 minutes as needed.
▪ Side effects: nausea, respiratory depression, hypotension
(treat with naloxone or fluids).
o Nitroglycerin:
▪ Sublingual 0.3 mg if systolic BP >100 mmHg.
▪ IV infusion for refractory pain (start at 10 µg/min, titrate to
a max of 200 µg/min).
▪ Avoid nitrates if recent use of phosphodiesterase inhibitors
(e.g., sildenafil within 24 hours).
3. Oxygen Therapy:
o Provide supplemental oxygen (2–4 L/min via nasal cannula) only if
O₂ saturation <90%, dyspnea, or signs of hypoxia.
4. Beta-Blockers:
o Reduce myocardial oxygen demand, infarct size, and mortality.
o Example: IV metoprolol 5 mg every 2–5 minutes (up to 15 mg) for
hypertensive patients.
o Contraindications: systolic BP <95 mmHg, bradycardia (HR <50
bpm), acute heart failure, or bronchospasm history.
5. Anticoagulation:
o Unfractionated Heparin (UFH):
▪ 60 U/kg bolus (max 4000 U), then 12 U/kg/h infusion (max
1000 U/h).
▪ Maintain aPTT 1.5–2.0× control.
o Enoxaparin: 1 mg/kg SC every 12 hours (for up to 8 days or
discharge).
o Bivalirudin: For PCI, discontinue at procedure completion.
6. Antiplatelet Therapy:
o Continue aspirin (162–325 mg daily) and add a P2Y12 receptor
antagonist:
▪ Clopidogrel, Prasugrel (for PCI), or Ticagrelor.
7. ACE Inhibitors/ARBs:
o Start within 24 hours of hospitalization to reduce mortality and
improve LV function.
o Example: Captopril 6.25 mg PO initially, titrated to 50 mg PO thrice
daily.
o Use ARBs (e.g., Valsartan) if intolerant to ACE inhibitors.
8. Aldosterone Antagonists:
o Indicated for LVEF ≤40% with heart failure or diabetes.
o Avoid in advanced renal insufficiency (creatinine ≥2.5 mg/dL) or
hyperkalemia.
9. Magnesium Replacement:
o Check and correct magnesium levels to prevent arrhythmias.
Summary Table: STEMI Treatment

Aspect Intervention

Reperfusion PCI (preferred) or fibrinolysis (if PCI unavailable within


Therapy 120 min); rescue PCI for failed fibrinolysis.

Aspirin 162–325 mg immediately; 75–162 mg daily thereafter.

Morphine 2–4 mg IV; Nitroglycerin (SL or IV for


Pain Control
refractory pain).

Oxygen 2–4 L/min nasal cannula (if O₂ <90%).

Metoprolol IV (hypertensive) or PO if stable; avoid in


Beta-Blockers
hypotension or bradycardia.

Anticoagulants UFH or Enoxaparin during fibrinolysis; Bivalirudin for PCI.

Antiplatelet Aspirin + P2Y12 inhibitors (Clopidogrel, Prasugrel,


Therapy Ticagrelor).

Start within 24 hours; continue long-term for LVEF ≤40%


ACE Inhibitors/ARBs
or heart failure.

Aldosterone Spironolactone or Eplerenone for LVEF ≤40% with heart


Antagonists failure/diabetes.

Magnesium Correct to reduce arrhythmias.

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