STEMI MANAGEMENT

THEN & NOW IN 2017

Dr. Naresh kumar

MU-9
• Advances in the management of STEMI have been remarkable in last
25 years .

• Although there have been dramatic changes in the diagnostic and

therapeutic interventions used & impressible decline in morbidity &
mortality ,the management remain a challenging as it was 25 years
ago.

• It is our humble endeavor today to give a bird’s eye view of how

physician of 1990 ‘s managed it & correlate it with current evidence
based knowledge & interventions.
 Evolution of Guidelines for ACS
1990 1996 1999 2004 2007 2009 2012 2013 2017
1990
ACC/AHA 1996
ACC/AHA 1999
AMI
Update
ACC/AHA

2004
ACC/AHA 2007
update
ACC/AHA

2009
update
ACC/AHA

2012
Rev ESC

2013 2017
ACC/AHA NEW
STEMI/PCI ESC
STEMI/PCI
 Definition

Term STEMI – 1st introduced- 2004

Clinical syndrome of

Characteristic symptoms
+
Persistent ST elevation
+
Release of biomarkers of myocardial necrosis
 ECG Criteria
1990 1mm ST elevation in 2 contiguous leads

1996-2009 New LBBB taken as STEMI equivalent

2013 LBBB not considered in diagnosis of MI

ESC 2017-

New ST elevation at J point in 2 contiguous leads in absence of LVH or

LBBB

men

≥2.5 mm <40 yrs & ≥ 2mm >40 yrs

women

1.5 mm in V2 & V3 & / or 1 mm in other 2 contiguous leadsis

 STEMI diagnosis in the presence of LBBB

ST segment elevation ≥1mm , concordant with QRS complex (5 pt.)

Concordant ST segment depression ≥1 mm in V1 –V3 (3 pt)

ST segment elevation ≥5 mm, discordant with QRS complex (2 pt)

if score ≥3 98% specificity of acute MI

 Biomarkers
BIOMARKERS ESC 2017
Up to1996- CKMB was marker of choice

LDH

2017

Routine blood sample for serum markers is indicated as soon as possible but

should not delay reperfusion treatment

Troponin T or I - biomarker of choice

CK-MB isoforms- detect reinfarction

Myoglobin

Obsolete markers LDH

Trop I- better due to higher sensitivity & specificity

Other cause of ↑Troponin

Congestive heart failure
Myocarditis
Renal failure
Pulmonary embolism
Sepsis
 Management an overview
Emergency care
Oxygen
Analgesia
Nitrates
Prehospital logistics of care
Reperfusion therapy
PCI
Thrombolytics
Long term therapy for STEMI
 Oxygen:
1990 - Recommended for all patients
1996 - Routinely in all patients during 1st 2-3 hrs.
2004 - Patients with STEMI during 1st 6hrs.
In 2017
O2 is not recommended routinely
Used for hypoxemic (SpO2<90% ) patients only
Evidences suggest that hyperoxia may be harmful due to
increased myocardial injury
 Management for Pain and Anxiety

2004- Role of meperidine was accepted in inferior wall MI

patients

2007 - Patients routinely taking NSAIDS before STEMI should

discontinue it

A mild tranquillizer usually benzodiazepine should be

considered in anxious pt.
 Nitrates
1990 - 1996 I.V . for first 24 – 48 hrs in acute MI & Hypertension

2004 I.V. for ongoing ischemic discomfort, control of Hypertension

& heart failure.

NOW nitrates are used for pain relief .

3 doses of 0.4 mg sub lingual nitroglycerin at 5 min. interval which act by
decreasing preload and dilate coronary vessels.

Nitrates should not be given to patients with

 Hypotension,
 Marked bradycardia or tachycardia,
 RV infarction
 5-PDE inhibitor (sildenafil) use within the previous 24 to 48 hours .
In previous years iv morphine was given to all patients of acute MI
(depending upon availability )

Till date Drug of choice .

i.v 2 to 4 mg, repeat if required every 5 min.

However it is associated with ,slower uptake ,delayed onset of

action & diminished effect of oral anti platelet agents ,which
may lead to early treatment failure .
 Beta blocker

I.V. with in 24 hrs if not contraindicated

Commonly used metoprolol 5 mg I.V. every 2 to 5 minutes for

total 3 doses

15 min. after the last intravenous dose, an oral

regimen is initiated of 50 mg every 6 h for 48 h, followed by
100 mg every 12 h.
 Reperfusion therapy
PCI
Thrombolysis

1990 - thrombolytics was the recommended reperfusion

therapy .
1996 - primary PCI as an alternative to thrombolytic therapy
only if performed timely & by skilled personnel.
2004 - primary PCI became choice of reperfusion therapy .
2017 - primary PCI is the preferred method till date
 Systemic goals for reperfusion therapy
includes
• Assessment and improvement of
EMS(emergency medical system) and hospital-
based activities.

• 12-lead ECG at the site of first medical contact

• Reperfusion therapy to all eligible STEMI patients

with symptom onset within 12 hours

• Primary PCI - recommended method of reperfusion

STEMI diagnosis is the time when ECG shows ST segment
elevation and it is the time ZERO to guide appropriate
therapy.

Goal- To reduce the delay between First medical contact and

STEMI diagnosis to ≤ 10 min .

When STEMI diagnosis is made & patient is triaged for primary

PCI, the emergency department is bypassed (results in 20 min
saving) and the patient should be taken directly to
 Primary PCI in STEMI
I.
 Ischemic symptoms < 12 hour

 Ischemic symptoms < 12 h and contraindications to

fibrinolytic therapy irrespective of time delay from FMC.

 Cardiogenic shock or acute severe HF irrespective of delay

from MI onset.

 Evidence of ongoing ischemia 12 to 24 h after symptom onset

 PCI of a non infarct artery at the time of primary pci in

patients without hemodynamic compromise .(previously it
was done only in infarct related artery)
 Coronary stenting is the technique of choice during primary PCI.

 Radial access is preferred over femoral access due to lower risk of

access site bleeding ,vascular complication .

 Compared with balloon angioplasty alone stenting with a bare metal

stent (BMS) is associated with a lower risk of reinfarction and target

vessel revascularization
New generation drug eluting stent (DES)
Reduce the risk of target vessel restenosis &
Superior safety and efficacy as compared to
BMS.

BMS should be used in patients

High bleeding risk
Inability to comply with 1 year of dual anti
platelet therapy
Anticipated invasive procedures in the next
year.
 Biodegradable stents :A step forwards or a
pitfall ??
In Asia first biodegradable stent used in 2010

• Once widely publicized as substitute for metallic drug eluting

stents, these auto digest after a period of 9 to12 months and
were once globally considered as a next step PCI technology.

• However in sense of lacking evidence of its superiority it’s use

in ,majority of European centers has been withheld and is used
only at few designated centers to complete the post marketing
surveillance.(lancet 2017)
• In India it was prescribed in few
centers because of affordability
concerns ( cost was more than 2
lacs)

• However recently a committee of

16 cardiologists from leading
government institutes has
discouraged their use in view of
dearth of any clear evidence over
conventional drug eluting stents.
 Rescue PCI

Refers to the transfer for PCI of patients who demonstrate

findings of failed reperfusion with fibrinolysis (<50% ST

segment resolution at 60 to 90 min.)

2004 : term introduced & recommended in cardiogenic shock .

2007: new recommendations includes-

Failed reperfusion with fibrinolytic therapy

Severe congestive heart failure

Hemodynamically compromising ventricular arrhythmias(IC
 Fibrinolytic therapy

• 1990 < 6hrs duration & <70 yrs of age

• 1996 New or presumably new LBBB included.

• duration was < 12 hrs

• 2004 Age excluded from criteria.

• 2013 New or presumably new LBBB excluded .

 Fibrinolytic therapy
2017
When >120-Minute Delay From FMC to Primary PCI –then
fibrinolysis is indicated as

• Ischemic symptoms ≤ 12 hour

• Ongoing ischemia 12 to 24 hour

after symptom onset and a large area
of myocardium at risk , hemodynamic
instability

ACC/ACC 2013/ESC 2017

 Fibrinolytic Agents
Fibrinolytic-Specific Dose Fibrin Antigenicity Patency
Specificity Rate
Single IV weight-
1.Tenecteplase (TNK-tPA) based bolus ( 0.53 ++++ No 85%
2.Reteplase mg/kg)

10 U + 10 U IV ++ 84%
boluses given 30 min No
3.Alteplase apart)

Non-fibrin specific 90-min weight-based ++

infusion No 73-84%
1.Streptokinase

1.5 milion units IV No

2.Urokinase given over 30-60 Yes 60-68%
mins

Either 2MUas a No No Equal to

bolus or 3 MU over STK
90 mins.
 CONTRAINDICATIONS
ABSOLUTE

• Previous intracranial haemorrhage or stroke of unknown origin at anytime

• Ischemic stroke in preceding 3 months (except ischaemic stroke with in 4.5 hrs)

• structural cerebral vascular disease

• Malignant intracranial neoplasm

• Known bleeding diathesis

• Aortic dissection

• Significant facial or head trauma within 3 months

 RELATIVE

• History of chronic ,severe , poorly controlled hypertension

• Refractory hypertension systolic (BP> 180 mm Hg & or Diastolic BP>110

mm Hg )

• History of ischaemic stroke > 3 months

• Major surgery within 3 weeks

• Active peptic ulcer

• Oral anti coagulant therapy

• Pregnancy or within 1 week of postpartum

 Adjunctive Antithrombotic therapy
1.Antiplatlet Agents 2.Anticoagulants
Aspirin UFH
P2Y12 inhibitors Enoxaparin
 Clopidogrel Bivalirudin
 Prasugrel Fondaparinux
 Ticagrelor
GPIIb/IIIa inhibitors
 Abciximab
 Tirofiban
 Eptifibatide
 ASPIRIN
 2004: 75-162 mg orally daily dose indefinitely –primary
prevention

 2013 - 160-325 mg loading before procedure followed by 80

- 325 mg maintenance dose

 2017 recommended in all patients as soon as possible

Loading dose of 150 -300 mg orally (non-enteric coated)
or followed by maintenance dose of 75-100 mg/day.
 Data support that aspirin has a clear net benefit in secondary
prevention of cardiovascular diseases . however benefit of
aspirin in primary prevention remain unclear and is not
routinely recommended

 FDA has not approved use of aspirin as primary prevention

 European guidelines also do not recommend aspirin as a

primary prevention due to unfavorable risk benefit ratio.
• However in diabetic male >50yr & female >60yr, ADA recommends
aspirin as primary prevention if 10 yr cardiovascular risk is >10%
at least 1 risk factor out of-
– HTN
– Smoking
– Family history
– Dyslipidemia
– Albuminuria
 P2Y12 inhibitors

 1990-1999: no recommendation

 2004: clopidogrel came in recommendation

 2017 ESC
Clopidogrel:
with PCI - loading dose of 600 mg Followed by 75 mg /day only if
other p2y12 inhibitors are not available or contraindicated .

with FIBRINOLYSIS – loading dose is 300 mg

 withdrawal at least 5 days before planned CABG

 Prasugrel
1990-2007 no recommendation

2009 - Recommended with PCI. Not used in case of fibrinolysis.

Now with PCI

Loading dose 60 mg followed by 10 mg maintenance dose.
if patient weight is ≤60 kg or age ≥75 reduce maintenance
dose to 5mg/day .

not to be given in prior stroke or TIA.

withdrawal at least 7 days before the planned CABG.

 Ticagrelor
2009- Recommended with PCI. Not used in case of
fibrinolysis.

NOW with PCI

Loading dose 180 mg orally followed by 90 mg bid

maintenance dose upto 1 year.

withdrawal 3 days before planned CABG.

 Anticoagulants
UNFRACTIONATED HEPARIN
With PCI

- With GP IIb/IIIa receptor antagonist : 50- to 70-U/kg iv bolus

-Without GP IIb/IIIa receptor antagonist 70- to 100U/kg iv bolus

With fibrinolytics
IV bolus of 60 U/kg (max. 4000 U) f/b an infusion of 12 U/kg/h
(max.1000 U) initially, to maintain aPTT at 1.5 to 2.0 times
control to be monitored at 3,6,12 and 24 hrs.
 UNFRACTIONATED HEPARIN
1990 -duration-for several days

1996 - i.v. Recommended with PCI & nonselective thrombolytic

in high risk patients .

2004- recommended in high risk patients, & who were not

administered reperfusion therapy

2013- 2017- in all STEMI patients without contraindicated for

48 hrs or until revascularization
 GPIIb/IIIa receptor antagonist
• 1990-1999: NO recommendation

• 2004: recommended with PCI

• 2017 Recommended with primary PCI.

- Abciximab: 0.25-mg/kg IV bolus, then 0.125 mcg/kg/min for 12 hrs.

- Tirofiban: 25-mcg/kg IV bolus, then 0.15 mcg/kg/min for 18 hrs.

-Eptifibatide: 180-mcg/kg IV bolus , then 2 mcg/kg/min for 18 hrs.

 Bivalirudin
• 1990-1999: NO recommendation

• 2007: added in recommendation

• Since 2009: as an acceptable alternative to UFH

DOSE-- 0.75-mg/kg IV bolus, then 1.75–mg/kg/h infusion with or

without prior treatment with UFH with PCI
.
 Enoxaparin
1990-1999: NO recommendation.

2004: alternative to UFH with fibrinolytic ≤ 75 yr in absence of

renal dysfunction.

2012: recommended with PCI.

2013: recommendation with PCI has been deleted.

 NOW 2017

With fibrinolytic:
● If age< 75 yrs: 30-mg IV bolus, f/b 1 mg/kg s/c every 12 hrly.

● If age ≥75 y: no bolus, 0.75 mg/kg s/c every 12 hrly .

● If CrCl 30 mL/min: 1 mg/kg subcutaneously every 24 hrly

Duration: For the index hospitalization, up to 8 days or until

revascularization

With PCI : 0.5 mg /kg iv bolus

 Fondaparinux:
•

2007: Recommended with PCI. .

2017 : Not recommended as sole anticoagulant for primary PCI

With fibrinolytic:
- Initial dose 2.5 mg IV, then 2.5 mg s/c daily, for the index
hospitalization up to 8 Days or until revascularization

- Contraindicated if CrCl ≤ 30 mL/min

 Maintenance Long Term Therapy:
Antithrombotics

• DAPT (dual anti platelet therapy ) in form of low dose aspirin

(75 -100 mg) plus ticagrelor or prasugrel (or clopidoglrel if
these two are not available or contraindicated ) is
recommended for 12 months after PCI.

• Ticagrelor (60 mg bd) with aspirin may be considerd for up to

36 months in patients at high ischaemic risk who have
tolerated DAPT without a bleeding complication.
• In patients who are at high risk of severe bleeding
complications discontinuation of p2y12 inhibitor after 6 month
should be considered

• Patient who did not go under reperfusion therapy , DAPT may

be used up to 12 months unless contraindicated.
• Anticoagulant therapy may be used up to 3 months in
following conditions

history of embolism
evidence of mural & LV thrombus
atrial fibrillation
 BETA BLOCKERS

• 2007 - details of contraindications were introduced.

• 2013 - Continuation in post hospitalization added

• 2017 - Early i.v. beta blocker to patients of STEMI with

hypertension or ongoing ischemia without contraindications.
 BETA BLOCKERS
• Oral beta blockers in the first 24 hours who do not have :
signs of HF, cardiogenic shock, or other contraindications.

 1.PR interval more than 0.24 seconds,

 second- or third-degree heart block,
 3.active asthma, or
 4. reactive airways disease

• Continued for all patients with STEMI after hospitalisation and

with no contraindications

• Early I.V. beta blockers at the time of presentation who are

hypertensive or have ongoing ischaemia.
Renin Angiotensin-Aldosterone inhibitors
1990 -role of ACE inhibitors/ARBs NOT mentioned

1996 - ACE inhibitors recommended in anterior wall MI, heart

failure & LVEF<40%

2004-
• ACE inhibitors recommended in convalescence phase & then
long term.
• ARBs & Aldosterone antagonists introduced.

2013- ACE inhibitors to be started in first 24 hrs.

 Renin Angiotensin-Aldosterone inhibitors
2017

ACE inhibitor administered within the first 24 hours to all patients

with STEMI with anterior location, HF,diabetes, or EF ≤ 40%

unless contraindicated .

An ARBs (preferably VALSARTAN ) who are intolerant of ACE

inhibitors .

An Aldosterone antagonist with EF ≤ 40 % and symptomatic HF

or DM if no renal failure or hyperkalemia.

 Lipid Management

 High-intensity statin therapy in all patients as early as

possible and maintain it for long term.

 An LDL –C goal of < 1.8 mmol /l (70mg/dl) or reduction of at

least 50% if the baseline LDL-C is between 70 -135 mg/dl .

 Obtain a lipid profile as soon as possible .

 If LDL-C is ≥1.8mmol/lt (≥70 mg/dl) despite a maximum
tolerated dose of statin & pt is at high risk, further therapy
to reduce LDL-C should be considered.

 In patients intolerant of statin, treatment with ezetimibe

should be considered.
 Glucose control
 Blood glucose levels should be maintained below 180
mg/d.

 Glucose lowering therapy should be considered with

blood glucose level > 180.

 Episode of hypoglycemia (<70 mg/dl) should be

avoided.

 In patients on metformin &/or SGLT 2 inhibitors,

renal function should be carefully monitored for at least
3 days after coronary angiography /PCI.
 MINOCA
(Myocardial infarction with non-onstructive coronary arteris)
Diagnosis
• Diagnosis made immediately upon coronary angiography

In a patient with features consistent with an acute MI by criteria:-

1. Universal AMI criteria

2 No Coronary angiography stenosis ≥ 50 % in any infarct related

artery

3 No clinically overt specific for the acute presentation

 ETIOLOGY

Coronary causes non coronary causes

- plaque disruption -myocarditis

-epicardial artery spasm -takotsubo cardiomyopathy
-micro vascular spasm -other cardiomyopathies
-coronary embolism ( eg. DCMP,HOCM)
-
 Management

Identify the underlying cause of this

heterogeneous syndrome & that will
decide the appropriate therapy” .
 However
The latest discussion across
the world cardiology forum
is
Health paradox of the year
2017
• Described by many as the
“health paradox of the year
2017”, 52-year-old
cardiologist John Warner,
president of the American
Heart Association (AHA),
suffered a heart attack on
Nov.13, 2017 in the middle of
a health conference.
 Food for Thought ??
• In all likelihood, Warner followed AHA recommendations
regarding diet and lifestyle modifications for prevention of CV
diseases.

• Yet having MI at the age of 52 has only fuelled the age long
opinion clashes between the AHA and other cardiology
societies regarding a few of AHA’s dietary recommendations
 The Biochemical Basis
• AHA supports ample grain consumption,

• It recommends eating fats such as canola, corn, soybean &

sunflower oil. “Blends or combinations of these oils, often sold
under the name ‘vegetable oil,’ and cooking sprays made from
these oils are also good choices,” the AHA says.

• AHA also insists saturated fats are to be avoided.

 Contradictory parallel research
• University of British Columbia in a recent research has shown that
mitochondria cannot easily use polyunsaturated fatty acids (PUFAs)
for fuel due to the fats’ unique molecular structure and the
recommendations of AHA in it self is harmful .

• PUFAs are also not readily stored in subcutaneous fat. Instead,

PUFAs tend to get deposited in liver, where they contribute to fatty
liver disease, and in arteries, where they contribute to
atherosclerosis.

• AHA claims saturated fat is pro-inflammatory and causes arterial

plaque and heart attacks — but there is no biochemically plausible
explanation for the argument. According to a few researches
“Saturated fat is very stable, and will not react with oxygen the
way PUFA fat does, ”
 Conclusion
• In concluding we agree what AHA CEO Nancy brown said “ This incidence
underscores the important message that much progress has been made but
much remains to be done.

• However ending on a positive note “Patients with a high humor score have a
reduced risk of coronary artery disease”

• Clark A, Seidler A, Miller M. Inverse association between

sense of humor and coronary heart disease. Int J Cardiol.
2001;80:87–88.
 The way forward ?
• All these
contradictory
evidences make us
wonder if we are
proceeding in the
right direction in
terms of our
preventive strategies.
First time there is a clear definition of when to start the clock for
management of STEMI ( should start at the time of STEMI
diagnosis by ECG).

Complete revascularization should be considered with non infarct

related artery treated during the index procedure or another time
point before discharge from hospital.

The term door-to-balloon has been removed from today’s

guidelines

Treatment used to be initiated in the hospital but now it can start in

the ambulance so the door varies according to the situation .
Q. Bare metallic stent should preferred in pt with?
A. high bleeding risk
B. unable to complete 1 yr DAPT
C. anticipated surgery in next year
D. All

ANS -D
Q. What should be the minimum time for thrombolise a STEMI
pt .?
A. 20 min
B. 10 min.
C. 30 min
D 40 min.

ANS-B
Q. Best possible intervention for acute MI ?
A. Thrombolytic
B. Thrombolytic & aspirin
C. Thrombolytic & heparin
D. Early PCI

ANS -D
Q. Dose of streptokinase used in MI ?
A 0.15 million units
B 1.5 million units
C 15 million units
D 150 million units

Ans – B
Q. Which is not a contraindication for fibrinolysis

A . Aortic desection
B. malignant intracranial neoplasm
C .A-V fistula
D. known bleeding diathesis

• ANS -C
Q. Dual antiplatet therapy used up to
A.6 months
B. 12 months
C. 18 months
D . 24 months

Ans - B
• Q. According to ESC 2017 guidlines what should be the
minimun time for PCI if pt. diagnosed STEMI at PCI centre ?
A 30 min
B 60 min
C 90 min
D 120 min

• Ans B
Q. Dose of tenecteplase?

A. .53 mg/kg single iv bolus

B. 10 u+ 10 u 30 min. apart
C. 1.5 million units
D. 2 million unit bolus

ANS - A
 Q .Which is not a diagnostic critaria for MINOCA ?
A. Universal MI criteria
B. Coronary stenosis > 50 %
C. Coronary stenosis < 50 %
D. No overt specific cause of acute presentation

Ans -B
THANK YOU !