World Heart Day 2023-Reperfusion Strategy.pptx
- 1. On the Occasion of World Heart Day 2023 a Scientific Seminar on Reperfusion strategy in the management of Acute STEMI Presented by- • Dr Seebat Masrur • D-Card Student • Cardiology Department • SZMCH
- 2. Introduction World Heart Day is a global initiative dedicated to uniting people around the world in the fight against heart disease and promoting heart-healthy lifestyles. Organized by the World Heart Federation, World Heart Day was first observed in the year 2000.Since then, World Heart Day has been celebrated annually on September 29th with a different theme each year. This year's event centers around the theme 'Use Heart to Know Heart’ P R E S E N T A T I O N T I T L E 2
- 3. WORLD’S BIGGEST KILLER • Cardiovascular disease (CVD) is the world’s number one killer. Combined, conditions affecting the heart or blood vessels – such as heart attack, stroke and heart failure – affect 620 million & kill 20.5 million every year. The majority of these deaths happen in low- and middle-income countries. • 80% of premature deaths from CVD are preventable. By making small changes to our lifestyle – what we eat and drink, how much we exercise, and how we manage stress – we can better manage our heart health and beat CVD. P R E S E N T A T I O N T I T L E 3
- 4. Biggest Killers Worldwide (GBD 2019 Estimates) P R E S E N T A T I O N T I T L E 4
- 5. Reperfusion strategy in the management of Acute STEMI
- 7. ST-elevation myocardial infarction (STEMI) – Pathophysiology One disease process but different clinical manifestations and different management strategies 7 Acute coronary syndrome (ACS) First Medical Contact (FMC) Working diagnosis ECG Biochemistry Diagnosis Acute coronary syndrome Persistent ST-elevation Normal or undetermined ECG ST/T - abnormalities STEMI Troponin rise/fall Troponin normal NSTEMI Unstable angina Imaging Chest pain STEMI, ST-elevation myocardial infarction NSTEMI, non ST-elevation myocardial infarction Hamm et al. Eur Heart J 2011;32:2999-3054.
- 8. Diagnosis of STEMI: ECG changes • New St-elevation at the J-point two contiguous leads with cut-point: ≥ 1 mm in all leads other than leads V2-V3 where following cut points apply ≥ 2 mm in men age ≥ 40 years ≥ 2.5 mm in men < 40 years, or ≥ 1.5 mm in women regardless of age
- 9. Management of acute MI and rationale for early reperfusion
- 10. *First medical contact (FMC) is defined as the time when the patient is initially assessed by a physician, paramedic, nurse or other trained EMS personnel who can obtain and interpret the ECG and deliver initial interventions, either in the pre-hospital setting or upon arrival at the hospital Ibanez B et al. Eur Heart J 2018;39:119–77 Diagnosis of STEMI Key recommendations for initial diagnosis STEMI ECG monitoring with defibrillator capacity as soon as possible in all patients with suspected STEMI (IB) 12-lead ECG as soon as possible (target delay ≤10 min) (IB) Routine sampling for serum markers as soon as possible in the acute phase, but should not delay reperfusion (IC) At FMC*
- 11. PCI, percutaneous coronary intervention Steg PG et al. Eur Heart J 2012;33:2569–619 Reperfusion strategies in STEMI Early reperfusion aims to limit the extent of myocardial damage and lead to better outcomes in patients with STEMI Invasive Primary PCI Pharmacological induction of thrombolysis by thrombolytic agent Pharmaco-invasive a combination of both approaches
- 12. Influence of time-to- treatment on odds ratio (or) of mortality
- 13. Primary Percutaneous Coronary Intervention (pPCI) Primary percutaneous coronary intervention (pPCI), also known as primary angioplasty, is an emergency medical procedure performed to treat acute ST-elevation myocardial infarction (STEMI). In this procedure, a cardiologist uses a catheter to access the infarct related coronary artery responsible for the myocardial infarction. The blockage is then mechanically opened using techniques such as balloon angioplasty and stent placement.
- 14. BMS, bare-metal stent; DES, drug-eluting stent Ibanez B et al. Eur Heart J 2018;39:119–77 Primary PCI procedures Strategy • Primary PCI of the IRA is indicated (IA) • For patients with signs of recurrent/remaining ischaemia after primary PCI, new coronary angiography is recommended (IC) Infarct-related artery (IRA) Strategy • Revascularization of non- IRA should be considered in STEMI patients with multivessel disease (IIa/A) Non-IRA Technique • Stenting recommended over balloon angioplasty (IA) • DES recommended over BMS (IA) • Radial access recommended over femoral access (IA)
- 15. pPCI is the Best option-Advantages It is the Gold standard reperfusion strategy. Improves survival by re- establishing blood flow within the occluded infarct- related artery and thus reduce mortality It is superior to other reperfusion strategy. Less chance of complications such as Stroke, Reinfarction
- 17. *The previous guidelines recommended 30 min ‘door-to-needle’ (initiation of fibrinolysis within 30 min of arrival at hospital); note that the current guidelines no longer use this terminology Ibanez B et al. Eur Heart J 2018;39:119–77 Choice of reperfusion strategy Injection should be as soon as possible after STEMI diagnosis, ideally in the pre-hospital setting (IA) and within ≤10 min* Primary PCI Recommended over fibrinolysis (IA) Recommended ≤12 hr of symptom onset in the absence of contraindications (IA) Reperfusion is indicated in all patients with ischaemic symptoms for ≤12 h and persistent ST elevation (IA) If timely PCI is not possible Fibrinolytic therapy
- 18. Ibanez B et al. Eur Heart J 2018;39:119–77 Where does fibrinolytic therapy fit within the STEMI treatment pathway? System delay Patient delay If likely to be >120 min, consider pharmaco-invasive strategy if no contraindication for fibrinolysis Transport to PCI centre Transfer to cath lab, bypassing the ED Prepare for PCI STEMI diagnosis (ECG) Within 10 min Symptomatic period FMC: ambulance/ non-PCI centre PCI centre Admission Cath lab Start fibrinolytic therapy within 10 min of diagnosis Start PCI (wire crossing) Within 2 h
- 19. Fibrinolysis in Golder Hour In the golden hour, when symptom duration is within 1 to 2 hours, prompt fibrinolysis may provide clinical benefit compared with primary PCI & should be considered as a potentially preferable option. Absolute benefit (per 1000 treated patients) Treatment delay (h) 0 3 6 9 12 15 18 21 24 0 20 40 60 80
- 20. Thrombolytics 1. Kunandian & Gibson. Cardiovasc Ther 2012;30:e81-e88. 2. Chesebro et al. Circulation 1987;76:142-154. 3. GUSTO investigators. N Engl J Med 1993;329:673-682. 4. GUSTO III investigators. N Engl J Med 1997;337:1118-1123. 5. Cannon CP et al. Circulation 1998;98:2805-2814. 6. ASSENT-2 investigators. Lancet 1999; 354:716-722. Streptokinase (and derivatives) Considered an inferior thrombolytic drug to tPA compounds as it is not given as a bolus and lacks fibrin specificity and antigenicity1 Alteplase (rt-PA) Recombinant form of human tissue plasminogen activator (tPA) with a 4-8 min plasma half-life.1 Improved outcomes in myocardial infarction treatment vs. streptokinase2,3 Reteplase (r-PA) Genetically modified rt-PA with longer half-life (13-16 min)1 and simplified administration. Failed to show clinical benefit over alteplase4 Tenecteplase (TNK) Longer plasma half-life, highest fibrin specificity, and resistance to plasminogen activator inhibitor-1 (PAI-1) vs rt-PA. Single bolus pharmacological reperfusion therapy, with equivalent efficacy and improved safety profile to alteplase5,6
- 21. Ibanez B et al. Eur Heart J 2018;39:119–77 Potential complications of fibrinolysis Risk of stroke Intracranial haemorrhage Risk of bleeding (especially in patients undergoing prolonged or traumatic resuscitation) • Advanced age • Lower weight • Female sex • Prior cerebrovascular disease • Systolic/diastolic hypertension on admission Risk factors for intracranial haemorrhage Intracranial bleeding occurs in 0.9–1.0% of patients
- 22. Ibanez B et al. Eur Heart J 2018;39:119–77. Adapted and reproduced with permission of Oxford University Press on behalf of the European Society of Cardiology. Please see slide notes for full reference information Contraindications to fibrinolysis • Prior intracranial haemorrhage or stroke of unknown origin at anytime • Ischaemic stroke previous 6 months • CNS damage or neoplasms or arteriovenous malformation • GI bleeding within the past month • Known bleeding disorder (except menses) • Aortic dissection • Non-compressible punctures in past 24 h (eg liver biopsy, lumbar puncture) Absolute contraindications • TIA in previous 6 months • Oral anticoagulant therapy • Pregnancy or 1 week postpartum • Refractory hypertension (SBP >180 mmHg and/or DBP >110 mmHg) • Advanced liver disease • Infective endocarditis • Active peptic ulcer • Prolonged or traumatic resuscitation Relative contraindications
- 24. Fibrinolytics still important • Widely available with broad access. • Little dependence on operator experience. • Can be given promptly and on site (Prehospital). • Simple to give in bolus or IV infusion.
- 26. Ibanez B et al. Eur Heart J 2018;39:119–77 PCI may be indicated or necessary after fibrinolysis All patients should be transferred to a PCI-capable centre immediately after fibrinolysis (IA) Angiography and PCI of the IRA, if indicated, at 2–24 h (IA) Emergency angiography and PCI in case of recurrent ischaemia or re- occlusion (IB) Rescue PCI is indicated immediately when fibrinolysis has failed (<50% ST-segment resolution at 60–90 min) or at any time in the presence of haemodynamic or electrical instability, or worsening ischaemia (IA) Emergency angiography and PCI in patients with heart failure or shock (IA) Fibrinolysis successful? Yes No
- 27. Pharmaco- Invasive Strategy • Pharmacologic reperfusion therapy (Lytics or half dose lytics+ GPIIIb/IIa) followed by transfer to a PCI hospital for urgent Cath/PCI(within 3-24 hrs), regardless of whether fibrinolysis results in successful reperfusion or not, should undergo Angiography. • In the event of fibrinolytic failure, A Rescue PCI should be immediately performed where one need not wait for initial 3-hour window.
- 29. Rationale for Pharmaco-invasive PCI • While thrombolysis re-establishes TIMI 2 or 3 flow in ~70% of the cases, residual stenosis 50-70% frequently persists hence the rationale for Pharmaco-Invasive PCI. • Only ~15-20% are left with no residual stenosis.
- 31. *Patients with fibrinolysis should be transferred to a PCI centre immediately after administration of the lytic bolus Ibanez B et al. Eur Heart J 2018;39:119–77. Adapted and reproduced with permission of Oxford University Press on behalf of the European Society of Cardiology. Please see slide notes for full reference information Where the Strategies fit in? Systems are required to ensure rapid fibrinolysis before transfer to PCI centre if PCI cannot be performed within 120 min FMC EMS Non-PCI centre PCI centre Wire crossing Wire crossing Lytic bolus* Primary PCI Primary PCI Fibrinolysis STEMI diagnosis ≤10 min <90 min <10 min <60 min ≤10 min Reperfusion Patient delay EMS/system delay Total ischaemic time >120 min ≤120 min Time to PCI? Strategy
- 32. Reperfusion strategy in STEMI
- 33. Ibanez B et al. Eur Heart J 2018;39:119–77. Adapted and reproduced with permission of Oxford University Press on behalf of the European Society of Cardiology. Please see slide notes for full reference information Summary of important time targets in acute STEMI Maximum delay/intervals Time targets FMC to ECG and diagnosis ≤10 min STEMI diagnosis to primary PCI (wire crossing) – if this cannot be met, consider fibrinolysis ≤120 min STEMI diagnosis to wire crossing in patients presenting at primary PCI hospitals ≤60 min STEMI diagnosis to wire crossing in transferred patients ≤90 min STEMI diagnosis to fibrinolysis in patients for whom primary PCI target time cannot be met ≤10 min Start of fibrinolysis to evaluation of its efficacy (success or failure) 60–90 min Start of fibrinolysis to angiography (if fibrinolysis is successful) 2─24 h
- 34. *Alteplase is injected as an initial bolus over 1 min followed by infusion over 60 min, reteplase is injected as two boluses 30 min apart, and tenecteplase is injected as a single bolus over ~10 s Ibanez B et al. Eur Heart J 2018;39:119–77 Fibrinolysis and pharmaco-invasive strategy Key recommendations Fibrinolysis should be initiated as soon as possible after STEMI diagnosis, preferably in the pre-hospital setting (IA) A fibrin-specific agent (ie alteplase, reteplase or tenecteplase) is recommended (IB) A half-dose of tenecteplase should be considered in patients ≥75 years old (IIa/B) The fibrinolytic bolus should be administered within 10 min of STEMI diagnosis*
- 35. DAPT, dual antiplatelet therapy Ibanez B et al. Eur Heart J 2018;39:119–77 Antiplatelet co-therapy with fibrinolysis Antiplatelet therapy Administration details Oral or iv ASA (IB) Loading dose of 150–300 mg orally (or 75–250 mg iv if oral ingestion is not possible) followed by a maintenance dose of 70–100 mg/day Clopidogrel (plus ASA) (IA) For clopidogrel: loading dose of 300 mg (or 75 mg in patients ≥75 years of age) orally followed by a maintenance dose of 75 mg/day
- 36. Ibanez B et al. Eur Heart J 2018;39:119–77 Anticoagulant co-therapy with fibrinolysis Antiplatelet therapy Administration details Enoxaparin (IA) Given iv followed by sc (preferred over UFH); dose dependent on age/eGFR UFH (IB) Given as a weight-adjusted iv bolus followed by infusion Fondaparinux (IIa/B) Indicated in patients treated with streptokinase Given by iv bolus followed by sc dose 24 h later Anticoagulation is recommended in patients treated with lytics until revascularization or for the duration of hospital stay up to 8 days (IA)
- 37. Summary of rationale for pre-hospital thrombolysis (PHT) and pharmaco-invasive strategy Not all medical centres are PPCI-capable1,2 &/or pre-hospital delays often prevent patients from receiving timely PPCI3,4 No specialist equipment required and PHT has been established as a safe and effective treatment for STEMI5 PHT reduces time to reperfusion and improves outcomes if PPCI is not possible within 2h6,7 1. Steg et al. Eur Heart J 2012;33:2569-2619. 2. Pinto et al. Circulation 2006;114:2019-2025. 3. Armstrong, Bowden. Ann Intern Med 2011;155:389-391. 4. Armstrong et al. N Engl J Med 2013;368(15):1379-1387. 5. O’Gara et al. J Am Coll Cardiol 2013;61:e78-e140. 6. Morrison et al. JAMA 2000;283(20):2686–2692. 7. Wallentin et al. Circulation 2003;108:135-142. 8. Gershlick et al. N Engl J Med 2005;353:2758-2768. Pharmaco-invasive strategy may achieve reperfusion directly; in case of thrombolysis failure, reperfusion can be achieved with subsequent rescue PCI8
- 38. Some Cases done in SZMCH Cath Lab
- 39. Cathlab
- 40. Case 1
- 41. Before Stent After Stent
- 42. Take home points STEMI is a time-critical medical emergency: clinical outcomes improve with reduced time to reperfusion. Every effort should be made to reduce ischaemic time. Implementation of STEMI networks is guideline-recommended and has been shown in studies and registries to reduce delays in reperfusion strategies and improve clinical outcomes. PPCI is considered the gold-standard of care if performed ≤2 h of FMC (first medical contact). A pharmaco-invasive strategy is recommended whenever PPCI cannot be performed within recommended timelines (<120 min), and may be followed by transfer for angiography and mechanical intervention if indicated.
- 43. Thank You
- 44. Case 2
- 45. Take Home Message Tenecteplase with its specificity, ease of administration and tolerability is an excellent choice for thrombolysis in acute MI where indicated. There is a definite role of pharmaco – invasive strategy with definite benefits in the form of better myocardial reperfusion and early 1 year survival rates. There is a distinct difference in the in – vitro thrombolysis potential when the innovator tenecteplase is compared to currently available biosimilars of tenecteplase. Various guidelines recommend thrombolysis with tenecteplase for early reperfusion to save every patient live and gives a window period for PCI.
- 46. ASA, acetylsalicylic acid (aspirin); GP IIb/IIIa, glycoprotein IIb/IIIa inhibitors; UFH, unfractionated heparin Ibanez B et al. Eur Heart J 2018;39:119–77 Peri- and post-procedural antithrombotic therapy in PCI Key recommendations: antiplatelet therapy • Potent P2Y12 inhibitor before PCI and maintained over 12 months (IA) • ASA as soon as possible (IB) • GP IIb/IIIa inhibitors considered for ‘bailout’ if no-reflow or thrombotic complications (IIa/C) Key recommendations: anticoagulant therapy • Anticoagulation for all patients in addition to antiplatelet therapy during primary PCI (IC) • Routine use of UFH is recommended (IC)
- 47. *If fibrinolysis is contraindicated, use primary PCI strategy regardless of time to PCI †10 min is the maximum target delay time from STEMI diagnosis to fibrinolytic bolus administration, however it should be given as soon as possible Ibanez B et al. Eur Heart J 2018;39:119–77. Adapted and reproduced with permission of Oxford University Press on behalf of the European Society of Cardiology. Please see slide notes for full reference information Maximum target times depend on chosen reperfusion strategy ≥120 min 60–90 min Primary PCI strategy Alert and transfer to PCI centre Fibrinolysis strategy* Rescue PCI No Strategy clock (maximum target times) 0 h 10 min 90 min 2 h 24 h >120 min ≤120 min STEMI diagnosis Wire crossing (reperfusion) Yes Meet reperfusion criteria? Routine PCI strategy Transfer to PCI centre Time to PCI? Bolus of fibrinolytic†
- 48. Strategy based on expected delay to PCI (wire crossing) from STEMI diagnosis *At 3–12 h, more consideration should be given to primary PCI over fibrinolytic therapy Ibanez B et al. Eur Heart J 2018;39:119–77. Adapted and reproduced with permission of Oxford University Press on behalf of the European Society of Cardiology. Please see slide notes for full reference information Overview of reperfusion strategies in patients with STEMI Early phase of STEMI Recent STEMI Evolved STEMI Symptom onset 0 h 3 h 12 h 48 h Primary PCI (IA) Fibrinolysis (IA) only if PCI cannot be performed within 120 min of diagnosis Primary PCI (IA) Primary PCI (IC) if patient has symptoms, haemodynamic instability, or arrhythmias Fibrinolysis (IA)* only if PCI cannot be performed within 120 min of diagnosis Primary PCI (IIa/B) for asymptomatic stable patients Routine PCI (IIA) for asymptomatic stable patients
- 49. *Within 12 h of symptom onset Ibanez B et al. Eur Heart J 2018;39:119–77 Seeking to minimize delayed reperfusion in pre- hospital settings Key recommendations Any reperfusion strategy • Pre-hospital management should be based on regional networks to deliver reperfusion quickly and effectively, and to make primary PCI available to as many patients as possible (IB) • Ambulance teams should transfer STEMI patients to a PCI-capable centre, bypassing non-PCI centres (IC) • Patients should be transferred directly to the catheterization lab (IB) • Primary PCI centres should deliver a 24/7 service (IB) Pharmaco-invasive strategy • Pre-hospital fibrinolysis is recommended if primary PCI cannot be performed within 120 min from STEMI diagnosis*(1A) • Ambulance teams should be equipped to identify STEMI and administer fibrinolysis where applicable (IC)
- 51. Global Heart & Circulatory Diseases Factsheet P R E S E N T A T I O N T I T L E 51
- 52. Global Heart & Circulatory Diseases Factsheet P R E S E N T A T I O N T I T L E 52
- 53. World Heart Day is a reminder to everyone around the world to take care of their hearts. This year’s campaign focuses on the essential step of knowing our hearts first. BECAUSE WE LOVE AND PROTECT ONLY WHAT WE KNOW. In a world where knowledge about heart health is limited and policies are insufficient or lacking, we aim to shatter barriers and empower individuals to take control of their well-being. BECAUSE WHEN WE KNOW MORE , WE CAN TAKE BETTER CARE. P R E S E N T A T I O N T I T L E 53
- 54. ASSENT trial series summary: ASSENT-2, ASSENT-3/ASSENT-3 PLUS, ASSENT-4 PCI For more information on the ASSENT trials, please visit http://www.metalyse.com/studies or refer to the original publications. ASSENT-2: Tenecteplase is equivalent to alteplase in the treatment of AMI with respect to: • 30-day mortality1 and 1-year mortality outcomes2 • Combined outcomes for mortality and non-fatal stroke1 Significantly fewer bleeding complications occurred with tenecteplase, reducing the need for blood transfusions.1 ASSENT-3/ ASSENT-3 PLUS: Results support association between earlier treatment and improved 30-day mortality3,4 • Low-molecular-weight heparins (LMWHs), e.g. enoxaparin, were superior to unfractionated heparin (UFH) as concomitant anticoagulation4 ASSENT-4 PCI: Investigated whether full-dose tenecteplase administered prior to PCI (facilitated PCI) could mitigate negative effect of delay to PCI5 • Study was stopped prematurely due to higher mortality in facilitated PCI group vs. standard PCI5 • Facilitated PCI as performed in the trial was associated with more major adverse events than primary PCI alone and cannot be recommended5 1. ASSENT-2 Investigators. Lancet 1999;354:716-722. 2. Sinnaeve et al. Am Heart J 2003;146:27-32. 3. ASSENT-3 Investigators. Lancet 2001;358:605-613. 4. Wallentin et al. Circulation 2003;108:135-142. 5. ASSENT-4 PCI Investigators. Lancet 2006;367:569–578.
- 55. Percutaneous coronary intervention (PCI) & primary PCI (PPCI) 1. Choi et al. Prehosp Emerg Care 2016;20:66-75. 2. Sinnaeve & Van de Werf. Eur Heart J 2016;37:1041-1043. 3. Keeley & Hillis. N Engl J Med 2007;356:47-54. Stent in coronary artery Stent Guide wire Catheter PPCI is the gold standard in STEMI care – IF performed within 120 min of FMC1,2 • Timely PPCI is difficult to achieve in many regions, when patients do not present directly to a PCI- capable facility via EMS or arrival at a facility is delayed 1,2 PCI involves revascularisation of the blocked coronary artery by mechanical means • Using the femoral or radial artery as an access point, a catheter with a balloon (and often a stent) is passed through the occlusion3 • The balloon is then inflated to open up the vessel, and the stent is put in place to maintain the revascularisation3 EMS, emergency medical services FMC, first medical contact PPCI, primary percutaneous coronary intervention
- 56. How to address the practice gap between optimal and actual care? STEMI networks should aim to improve the quality of care by using well- defined and validated quality indicators Structural (organizational) measures Performance measures Clinical and patient-reported outcomes Ibanez B et al. Eur Heart J 2018;39:119–77
- 57. Ibanez B et al. Eur Heart J 2018;39:119–77 How to address the practice gap between optimal and actual care? Structural (organizational) measures Performance measures for reperfusion therapy Rapid and efficient STEMI management network with written protocols including: • Single emergency phone number • Pre-hospital ECG interpretation, diagnosis and cath lab activation Systematic recording and reviewing of times to reperfusion Proportion of STEMI patients arriving in the first 12 h receiving reperfusion therapy Proportion of patients with timely reperfusion therapy (consistent with guidelines)
- 58. ST-elevation myocardial infarction (STEMI) – Pathophysiology Any one of the following criteria meets the diagnosis for AMI according to the Joint ESC/ACCF/AHA/WHF Task Force: 58 Diagnostic criteria for AMI A rise and/or fall of cardiac biomarkers (preferably troponin (cTn)) with at least one value above the 99th percentile upper reference limit (URL) together with at least one of the following: • Symptoms of ischaemia • New or presumed-new significant ST-segment-T wave (ST-T) changes or new left bundle branch block (LBBB) • Development of pathological Q waves in the ECG • Imaging evidence of new loss of viable myocardium or new regional wall motion abnormality • Identification of an intracoronary thrombus by angiography or autopsy + Cardiac death with prior new ischaemic ECG changes and symptoms suggestive of myocardial ischaemia, without definitive biomarker evidence PCI-related MI* Stent thrombosis associated with MI* Coronary artery bypass grafting (CABG)-related MI* *See notes Thygesen et al. J Am Coll Cardiol 2012;60(16):1581-1598.
- 60. World Heart Day 2023 Use Heart to Know Heart Presented by- • Dr Seebat Masrur • D-Card Student • Cardiology Department • SZMCH
Editor's Notes
- #8: Following with the Joint ESC/ACCF/AHA/WHF Task Force definition of acute myocardial infarction, any one of the listed criteria meets the diagnosis for MI:1 A rise and/or fall of cardiac biomarkers (preferably troponin (cTn)) with at least one value above the 99th percentile upper reference limit (URL) together with at least one of the following: Symptoms of ischaemia New or presumed new significant ST-segment–T wave (ST–T) changes or new left bundle branch block (LBBB) Development of pathological Q waves in the ECG Imaging evidence of new loss of viable myocardium or new regional wall motion abnormality Identification of an intracoronary thrombus by angiography or autopsy Cardiac death with prior new ischaemic ECG changes and symptoms suggestive of myocardial ischaemia, without definitive biomarker evidence. PCI-related MI Stent thrombosis associated with MI Coronary artery bypass grafting (CABG) related MI
- #11: Some factors may hinder ECG diagnosis: Bundle branch block Ventricular pacing Non-diagnostic ECG Isolated posterior MI Left main coronary obstruction Additional leads may aid in the diagnosis of STEMI in some cases: The use of additional posterior chest wall leads (V7–V9) in patients with high suspicion of posterior MI (circumflex occlusion) should be considered (IIa/B) The use of additional right precordial leads (V3R and V4R) in patients with inferior MI should be considered to identify concomitant RV infarction (IIa/B) Reference Ibanez B et al. Eur Heart J 2018;39:119–77
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- #18: The ESC 2017 guidelines recommend reperfusion therapy in all patients with symptoms of ischaemia of ≤12 h duration and ST-elevation Primary PCI should is recommended over fibrinolysis if the patient is admitted within the indicated timeframe However, if primary PCI cannot be performed, fibrinolytic therapy should be performed within 12 h of symptom onset in patients without contraindications The fibrinolytic agent should be injected ≤10 min after STEMI diagnosis Reference Ibanez B et al. Eur Heart J 2018;39:119–77
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- #23: Reference Ibanez B, et al. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC), European Heart Journal (2017) 00, 1–66 doi:10.1093/eurheartj/ehx393. Adapted and reproduced with permission of Oxford University Press on behalf of the European Society of Cardiology. Oxford University Press and the ESC are not responsible or in any way liable for the accuracy of the adaptation, for any errors, omissions or inaccuracies, or for any consequences arising therefore. Boehringer Ingelheim is solely responsible for the adapted material in this work. Please visit: www.escardio.org/Guidelines/Clinical-Practice-Guidelines/Acute-Myocardial-Infarction-in-patients-presenting-with-ST-segment-elevation-Ma. Boehringer Ingelheim was not involved in the development of this ESC Guidelines article and in no way influenced its content.
- #27: This slide summarizes the recommendations for post-fibrinolytic management of STEMI patients It is particularly important that all patients are immediately transferred to a PCI centre after fibrinolysis If fibrinolysis is successful, PCI should be performed if indicated and in patients with recurrent ischaemia or re-occlusion Rescue PCI should be performed promptly if fibrinolysis was unsuccessful Emergency PCI may be necessary/indicated in patients with heart failure/shock Reference Ibanez B et al. Eur Heart J 2018;39:119–77
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- #34: Key target times for the diagnosis and initiation of reperfusion therapy in STEMI patients If performed, fibrinolysis should be started ≤10 min after the diagnosis of STEMI and its efficacy should be determined 60–90 min later If fibrinolysis was successful, angiography should be performed 2–24 h later Reference Ibanez B, et al. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC), European Heart Journal (2017) 00, 1–66 doi:10.1093/eurheartj/ehx393. Adapted and reproduced with permission of Oxford University Press on behalf of the European Society of Cardiology. Oxford University Press and the ESC are not responsible or in any way liable for the accuracy of the adaptation, for any errors, omissions or inaccuracies, or for any consequences arising therefore. Boehringer Ingelheim is solely responsible for the adapted material in this work. Please visit: www.escardio.org/Guidelines/Clinical-Practice-Guidelines/Acute-Myocardial-Infarction-in-patients-presenting-with-ST-segment-elevation-Ma. Boehringer Ingelheim was not involved in the development of this ESC Guidelines article and in no way influenced its content.
- #35: This slide summarizes the key recommendations for fibrinolysis and the pharmaco-invasive strategy Of particular note, if fibrinolysis is the chosen strategy, it should be initiated as soon as possible (ideally within 10 min) after STEMI diagnosis The fibrinolytic bolus may need to be administered in pre-hospital settings by the first medical contact (eg ambulance staff) Reference Ibanez B et al. Eur Heart J 2018;39:119–77
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- #47: Peri-procedural and post-procedural antithrombotic therapy is an integral part of the management of STEMI patients, and should include antiplatelet and/or anticoagulant therapy Dose adjustments may be necessary for antiplatelet and anticoagulant therapies in patients undergoing fibrinolysis Reference Ibanez B et al. Eur Heart J 2018;39:119–77
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- #49: Primary PCI is the reperfusion strategy of choice in early presenters (ie those with STEMI diagnosis <3 h from symptom onset) Immediate fibrinolysis is indicated if the anticipated time from STEMI diagnosis to PCI-mediated reperfusion is >120 min At 3–12 h after symptom onset, more consideration should be given to a primary PCI strategy as opposed to administering fibrinolytic therapy In evolved STEMI (12–48 h after symptom onset), a routine primary PCI strategy (urgent angiography and subsequent PCI if indicated) should be considered in all patients After 48 h (recent STEMI), angiography should be performed but routine PCI of a total occluded infarct-related artery is not recommended The presence of ongoing symptoms suggestive of ischaemia, haemodynamic instability, or life-threatening arrhythmias, regardless of the time from symptom onset, is an indication for primary PCI Reference Ibanez B et al. Eur Heart J 2018;39:119–77
- #56: Keeley EC and Hillis LD. Primary PCI for Myocardial Infarction with ST-Segment Elevation. N Engl J Med 2007;356:47-54. Choi SW et al. Effect of Emergency Medical Service Use and Inter-hospital Transfer on Time to Percutaneous Coronary Intervention in Patients with ST Elevation Myocardial Infarction: A Multicenter Observational Study. Prehosp Emerg Care 2016; 20(1):66-75. Sinnaeve PR and Van de Werf F. Transporting STEMI patients for primary PCI: a long and winding road paved with good intentions? Eur Heart J 2016; 37(13):1041-1043.
- #57: The ESC guidelines acknowledge there is a wide practice gap between optimal and actual care of STEMI patients worldwide To reduce this gap and improve quality of care, it is recommended that STEMI networks and their individual components establish measurable quality indicators; this will help to ensure that every patient with STEMI receives the best possible care and has the best possible outcomes Proposed quality indicators to assess the quality of the care for patients include: Structural/organizational measures Performance measures for reperfusion therapy, risk assessment, antithrombotic therapy, discharge medication and counselling Clinical outcomes: 30-day adjusted mortality and readmission rates Patient-reported outcomes to record the patient’s experience and quality of information received including: angina control, HCP explanations (disease, benefit/risk of discharge treatments, and medical follow-up), and discharge information (covering recurrence and rehabilitation programmes) Reference Ibanez B et al. Eur Heart J 2018;39:119–77
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- #59: PCI-related MI is arbitrarily defined by elevation of cTn values (< 5 x 99th percentile URL) in patients with normal baseline values (≤99th percentile URL) or a rise of cTn values >20% if baseline values are elevated and stable or falling. In addition, either: symptoms suggestive of myocardial ischaemia, or new ischaemic ECG changes, or angiographic findings consistent with a procedural complication, or imaging demonstration of new loss of viable myocardium or new regional wall motion abnormality are required. Stent thrombosis associated with MI when detected by coronary angiography or autopsy in the setting of myocardial ischaemia with a rise and/or fall of cardiac biomarker values with at least one value above the 99th percentile URL. Coronary artery bypass grafting (CABG) related MI is arbitrarily defined by elevation of cardiac biomarker values (>10 x 99th percentile URL) in patients with normal baseline cTn values (≤99th percentile URL). In addition, either: new pathological Q waves or new LBBB, or angiographic documented new graft or new native coronary artery occlusion, or imaging evidence of new loss of viable myocardium or new regional wall motion abnormality.