Vous êtes sur la page 1sur 33

CURRENT MANAGEMENT OF STEMI

I GDE RURUS SURYAWAN


GILANG M. RAHMAN

CARDIOVASCULAR EMERGENCIES COURSE

Bumi Surabaya Hotel, November 7-8th, 2015

Acute thrombosis induced by


a ruptured or eroded
atherosclerotic coronary
plaque, with or without
concomitant
vasoconstriction, causing a
sudden and critical reduction
in blood flow

Hamm CW et al. Eur Heart J 2011;32:2999 3054

DEFINITION
STEMI is a clinical syndrome characterized by
ischemic symptom which related to persistent ST
segment elevation in ECG

OGara et al: J Am Coll Cardiol. 2013 ; 29;:61(4)

CARDIOVASCULAR EMERGENCIES COURSE

Bumi Surabaya Hotel, November 7-8th, 2015

PATHOGENESIS
CARDIOVASCULAR RISK FACTOR
Traditional
Non-Traditional
Modifiable

Homocysteine

Dyslipidemia

Lipoprotein (a)

Smoking

C-Reactive Protein (CRP)

Hypertension

Diabetes Mellitus

Lack of physical Activity


Non Modifiable

Advanced age

Male Gender

Hereditary
CARDIOVASCULAR EMERGENCIES COURSE

Bumi Surabaya Hotel, November 7-8th, 2015

PATHOGENESIS
Total Occlusion of Coronary Artery

Vulnerable Plaque Rupture

Thrombus Formation
Endothelial Dysfunction
CARDIOVASCULAR EMERGENCIES COURSE

Bumi Surabaya Hotel, November 7-8th, 2015

2015 ESC Guidelines NSTEMI

CARDIOVASCULAR EMERGENCIES COURSE

Bumi Surabaya Hotel, November 7-8th, 2015

PATHOGENESIS
Myocardial Infarction

Biomarker Release

CARDIOVASCULAR EMERGENCIES COURSE

Bumi Surabaya Hotel, November 7-8th, 2015

DIAGNOSIS
SYMPTOM
Typical chest pain persist >20
min:
Pain, burning or weight sensation
Radiate to the neck, back or arm
Not relieved by rest or nitrate
Other Symptom:
Shortness of breath
Nausea
Diaphoresis
Palpitation

SIGN
Usually normal,
Sign of Complication;
Tachypnea,
Hypotension
Tachycardia-Bradycardia
Jugular veins distention
Gallop S3
Pulmonary Rales
Systolic Murmur

CARDIOVASCULAR EMERGENCIES COURSE

Bumi Surabaya Hotel, November 7-8th, 2015

DIAGNOSIS
ECG

J-point + 0,04 Sec

Baseline

Target:
10 minutes from
First Medical Contact

- ST-Elevation in minimal
two contagious lead
0,1mV
- In lead V2-V3 :
0,2 mV in male 40 y.o
0,25 mV in male<40 y.o
0,15 mV in female

ESC Guidelines, 2012


CARDIOVASCULAR EMERGENCIES COURSE

Bumi Surabaya Hotel, November 7-8th, 2015

DIAGNOSIS
Biomarker
Biomarker

Specificity

Peak
CK-MB orOnset
Troponin

Duration

CK-MB

Less

3-4 hrs

12-24 hrs

48-72 hrs

Troponin T

Specific

3-12 hrs

12-24 hrs

8-21 days

Troponin I

Specific

3-12 hrs

12-24 hrs

7-11 days

ACLS, 2012

CARDIOVASCULAR EMERGENCIES COURSE

Bumi Surabaya Hotel, November 7-8th, 2015

MANAGEMENT

CARDIOVASCULAR EMERGENCIES COURSE

Bumi Surabaya Hotel, November 7-8th, 2015

CARDIOVASCULAR EMERGENCIES COURSE

Bumi Surabaya Hotel, November 7-8th, 2015

Emergency Medical System


Hospital fibrinolysis :
Door-to-Needle within 30 min
Not PCI
capable

Onset of
symptoms
of STEMI

9-1-1
EMS
Dispatch

EMS on-scene

Encourage 12-lead ECGs


Consider prehospital fibrinolytic if
capable and EMS-to-needle within 30 min

Goals
Patient

Dispatch

5 min after
symptom onset

1 min

EMS on
scene
P:
Within
8 min

EMS
Triage
Plan
PCI
capable

EMS transport
Pre hospital Fibrinolytic EMS-toHandle within 30 min

EMS transport:EMS-to-Balloon within 90 min

Patient self-transport:Hospital Door-to-Balloon


within 90 min

Total ischemic time: Within 120 min*


*Golden Hour = First 60 minutes

CARDIOVASCULAR EMERGENCIES COURSE

Bumi Surabaya Hotel, November 7-8th, 2015

EMERGENCY ROOM
OXYGENATION

Indicated in patient with hypoxia (Sa02 <95%), dyspnea, and heart failure
INTRAVENOUS OPIOID

Morphine 4-8 mg i.v


Relieve pain and anxiety
Adverse reaction: Hypotension, respiratory depression, and vomiting

ASPIRIN
Aspirin oral (chewable) or i.v should be given in STEMI
Loading dose 300-325 mg , maintenance dose 75-100 mg od

CARDIOVASCULAR EMERGENCIES COURSE

Bumi Surabaya Hotel, November 7-8th, 2015

EMERGENCY ROOM
P2Y12 RECEPTOR BLOCKER

Ticagrelor & Prasugrel are preferable and recommended in patients


who planned for Primary PCI
Loading dose Ticagrelor 180 mg or Prasugrel 60 mg
Loading dose Clopidogrel 600 mg (Primary PCI) or 300 mg (Fibrinolysis)
NITRATE

Short acting nitrates (Nitroglyserin 0,4 mg or ISDN 5 mg S.L) is recommended


Should not be given in : RV infarction is suspected, hypotension, still in effect of
sildenafil/viagra, aorta stenosis, & HOCM
BETA BLOCKERS

Reduce myocardial oxygen demand and incident of lethal arrhythmia


Should not be given in: acute heart failure (Killip >2), significant AV Block,
hypotension (SBP<90mmHg) and bradycardia (<60bpm)
CARDIOVASCULAR EMERGENCIES COURSE

Bumi Surabaya Hotel, November 7-8th, 2015

REPERFUSION THERAPY
STRATEGY
Primary PCI

Fibrinolysis

VS

CARDIOVASCULAR EMERGENCIES COURSE

Bumi Surabaya Hotel, November 7-8th, 2015

ESC GUIDELINES,2012

CARDIOVASCULAR EMERGENCIES COURSE

Bumi Surabaya Hotel, November 7-8th, 2015

Primary-PCI Capable Centre


PCI is indicated for all STEMI patient in onset less
than 12 hours
Door to baloon time target is <90 minutes or <60
minutes in new onset STEMI with large area at risk
PCI procedure with balloon angioplasty+stent is
more recommended than balloon angioplasty alone
Periprocedural antithrombotic therapy should be
given in Primary PCI
ESC Guidelines 2012; ACC/AHA Guidelines 2013

CARDIOVASCULAR EMERGENCIES COURSE

Bumi Surabaya Hotel, November 7-8th, 2015

Non Primary-PCI Capable Centre

Fibrinolysis is recommended for all patient with onset 12 hours if estimating


time transfer to PCI capable centre >120 minutes, unless contraindicated

In new onset STEMI (<2 hours) with large infarcted area and low bleeding
risk, Fibrinolysis is recommended if estimating time transfer to PCI capable
centre >90 minutes

Fibrin specific agent (Alteplase, Reteplase, atau Tenecleptase) is more


recommended than nonspecific agent (Streptokinase)

Periprocedural antithrombotic therapy should be given as well

ESC Guidelines 2012; ACC/AHA Guidelines 2013

CARDIOVASCULAR EMERGENCIES COURSE

Bumi Surabaya Hotel, November 7-8th, 2015

CARDIOVASCULAR EMERGENCIES COURSE

Bumi Surabaya Hotel, November 7-8th, 2015

CARDIOVASCULAR EMERGENCIES COURSE

Bumi Surabaya Hotel, November 7-8th, 2015

Coronary Artery Bypass Graft


The number of patients who require CABG
In acute phase of STEMI is relatively small
Urgent CABG is indicated in patients
with STEMI and coronary anatomy
not amenable to PCI who have
ongoing or recurrent ischemia,
cardiogenic shock, severe HF, or
other high-risk features
CABG is recommended in patients
with STEMI at time of operative repair
of mechanical defects.[
ACC/AHA Guidelines 2013
CARDIOVASCULAR EMERGENCIES COURSE

Bumi Surabaya Hotel, November 7-8th, 2015

NON REPERFUSED STEMI


Present 12 hours onset

Present >12 hours onset

Common Cause:
Spontaneus Reperfusion
Contraindicated to any reperfusion
therapy

Common Cause:
Late presenters
Resource limitation

Hemodinamically and/or Electrically unstable


Ongoing Ischemia in onset 12-24 hours

Cohen, et al 2012

NO
Viability & Functional
Assestment

Adjuvant Therapy

No Reperfusion
Therapy

YES

CARDIOVASCULAR EMERGENCIES COURSE

Urgent PCI
Elective
PCI
Bumi Surabaya Hotel, November 7-8th, 2015

CASE ILUSTRATION
A 63 Years old gentleman with history of hypertension
and diabetic came to ER of primary hospital with
prolonged typical chest pain with 2 hours onset

Vital sign: BP 150/90 mmHg, HR 95 bpm, RR 24, axillar


temp 370C, with no abnormality in other physical
examination

ECG Shows ST-segment elevation (V1-V6) at anterior


leads

CARDIOVASCULAR EMERGENCIES COURSE

Bumi Surabaya Hotel, November 7-8th, 2015

Question??
1. We have to confirm the diagnosis with serum marker
to establish the diagnosis.. (T/F)

2. At the moment your diagnosis is ?


a. Unstable Angina
b. Non STEMI
c. STEMI

CARDIOVASCULAR EMERGENCIES COURSE

Bumi Surabaya Hotel, November 7-8th, 2015

Management
DUAL ANTIPLATELETS: Aspirin 300-325 mg plus ?
Clopidogrel 600 mg loading then 75 mg od
Ticagrelor 180 mg loading, then 90 bid mg
Prasugrel 60 mg loading, then 10 mg od

NITRATE
BETA-BLOCKER
THROMBOLYTIC vs PPCI
CARDIOVASCULAR EMERGENCIES COURSE

Bumi Surabaya Hotel, November 7-8th, 2015

CARDIOVASCULAR EMERGENCIES COURSE

Bumi Surabaya Hotel, November 7-8th, 2015

CARDIOVASCULAR EMERGENCIES COURSE

Bumi Surabaya Hotel, November 7-8th, 2015

CARDIOVASCULAR EMERGENCIES COURSE

Bumi Surabaya Hotel, November 7-8th, 2015

CARDIOVASCULAR EMERGENCIES COURSE

Bumi Surabaya Hotel, November 7-8th, 2015

SUMMARY
Acute emergency care is very important, the key point of
STEMI management is reperfusion therapy

Determining the appropriate reperfusion therapy strategy is


highly depend on the clinical setting and resource availability
in each medical center

Time to perform reperfusion is the most important variable


to get a better outcomes

Guidelines of STEMI management can guide the

practitioners to perform a good acute emergency care and


to choose the most appropriate reperfusion therapy
strategy
CARDIOVASCULAR EMERGENCIES COURSE

Bumi Surabaya Hotel, November 7-8th, 2015

LONGTERM MANAGEMENT
To improve long term outcome and as a secondary
prevention of reccurent MI, hospitalization, and chronic
heart failure

Should be started at Pre-Hospital Discharge


Long management including : Lifestyle management,
Antiplatelet, Beta Blocker, RAAS Inhibitor, Statin, and Nitrate

CARDIOVASCULAR EMERGENCIES COURSE

Bumi Surabaya Hotel, November 7-8th, 2015

CARDIOVASCULAR EMERGENCIES COURSE

Bumi Surabaya Hotel, November 7-8th, 2015