Workshop on Surabaya Cardiology Update 2013

THE MANAGEMENT OF
ST-SEGMENT-ELEVATION MYOCARDIAL INFARCTION

dr. Bambang Herwanto, SpJP(K) FIHA

Department of Cardiology and Vascular Medicine

Airlangga School of Medicine dr.Soetomo Teaching Hospital Surabaya
 PATHOPHYSIOLOGY OF ACS

Complicated
Plaque

Fibroatheroma

Intermediate
Lesion

Fatty Streak
Thrombus
Lipid
Intimal Core
Fibrous
Thickening Extracellular Cap
Lipid Pool

Foam Cell

Acute Coronary Syndromes: A Companion to Braunwalds Heart Disease, 2nd Ed

 DEFINITION OF ACS

Depends on the specific characteristics of each element of the triad:

Clinical presentation, ECG changes and biochemical cardiac markers.
 DATA

The percentage of STEMI varies in different registries/databases

Registry % of MI which
are STEMI

National Registry of Myocardial

Infarction (NRMI-4) 29%

AHA Get with the Guidelines

32%
Global Registry of Acute Coronary
Events (GRACE) 38%

ACC/AHA 2009 Joint STEMI/PCI Guidelines Focused Update, J. Am. Coll. Cardiol. 2009;54;2205-2241
 ALGORITHM

Admission Typical Chest pain

Working Diagnosis Suspicion of Acute Coronary Syndrome

Normal or ST/T Persistent

ECG Undetermined ECG Abnormalities ST elevation

Troponin: Troponin:
Biochemistry Negative 2x Positive

Risk Stratification Low Risk High Risk

Diagnosis Unstable Angina NSTEMI STEMI

Treatment Non-invasive Invasive Reperfusion

CARDIAC MARKERS

Circulation. 2007;116:e148-304
 CARDIAC MARKERS
Non Coronary Condition with Troponin Elevation
Severe congestive heart failure - acute and chronic
Aortic dissection, aortic valve disease or hyperthropic cardiomyopathy
Cardiac contucion, ablation, pacing, cardioversion, or endomyocardial biopsi
Inflammatory disease, eg. myocarditis, or myocardial extension of endo/pericarditis
Hypertensive crisis
Tachy-brady-arrhythmias
Pulmonary embolism, severe pulmonary hypertension
Hypothyroidism
Apical balloning syndrome
Chronic or acute renal dysfunction
Acute neurological disease, including stroke, or subarachnoid haemorhage
Infiltrative disease, eg. amyloidosis, haemochromatosis, sarcoidosis, scleroderma
Drug toxicity, eg. adriamycin, 5-fluorouracil, herceptin, snake venom
Burns, if affecting > 30% of body surface area
Rhabdomyolysis
Critically illness patient, especially with respiratory failure or sepsis
 INITIAL MANAGEMENT

1. Oxygen
2. Nitrate
3. Analgesia
4. Aspirin
5. Thienopyridine
6. Beta-blocker

MONACo: Morphine O2 Nitrate Aspirin - Clopidogrel

 OXYGEN
Supplemental oxygen should be administered to patients
with arterial oxygen desaturation (i.e., Sao2 < 90%)

But it is reasonable to administer supplemental oxygen

to all patients with uncomplicated STEMI during the
first 6 hours (Class IIa;C).

I IIa IIb III

Circulation. 2010;122;S787-S817
 NITROGLYCERIN
SL nitroglycerin should be given to patients with
ongoing ischemic discomfort, 0.4 mg/5 minutes, total 3
doses
IV nitroglycerin is then indicated for relief of ongoing
ischemic discomfort, control of hypertension, or
management of pulmonary congestion
Nitrates should not be administered to patients with
SBP < 90 mm Hg or SBP 30 mm Hg below baseline,
severe bradycardia (<50 beats/min), tachycardia (>100
beats/min), or suspected right ventricular (RV)
I IIa IIb III
infarction (Class III;C).
2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients With ST-
Elevation Myocardial Infarction
 ANALGESIA

Morphine sulfate (2 to 4 mg IV, with increments of 2 to

8 mg IV repeated at 5- to 15-minute intervals) is the
analgesic of choice for management of pain associated
with STEMI

I IIa IIb III

2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients With ST-
Elevation Myocardial Infarction
 ASPIRIN

Aspirin should be chewed by patients who have not

taken aspirin before presentation with STEMI.

The initial dose should be 162 mg (LOE, A) to 325 mg

(LOE, C). Non-enteric-coated aspirin provides more
rapid buccal absorption.
I IIa IIb III

2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients With ST-
Elevation Myocardial Infarction
 BETA BLOCKERS
Oral beta blocker therapy should be initiated 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
(4) other relative contraindications (e.g., PR interval >
0.24 second, second- or third-degree
atrioventricular (AV) block, or reactive airway
disease) I IIa IIb III

2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients With ST-
Elevation Myocardial Infarction
 THIENOPYRIDINE
Clopidogrel 75 mg per day orally should be added to
aspirin in patients with STEMI regardless of whether
they undergo reperfusion with fibrinolytic therapy or
do not receive reperfusion therapy.

I IIa IIb III

2007 Focused Update in STEMI. Circulation. 2008;117

European Heart Journal (2008)29,29092945
 THIENOPYRIDINE
Clopidogrel 75 mg per day orally should be added to
aspirin regardless of whether they undergo
reperfusion with fibrinolytic therapy or do not
receive reperfusion therapy.
In patients < 75 years of age who receive
fibrinolytic therapy or who do not receive
reperfusion therapy, it is reasonable to administer
an oral loading dose of clopidogrel 300 mg (Class
IIa;C)
I IIa IIb III

2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients With ST-
Elevation Myocardial Infarction
 MEDICAL THERAPY
RAA System
Oral Beta-Blockers
Inhibitor
Should be initiated within 24 1. ACEi administration
hours if not contraindicated: within the first 24 hours
to STEMI with anterior
1. Signs of HF
location, HF, or EF less
2. Evidence of a low output 0.40
state 2. ARB should be given if
intolerant to ACEi
3. Increased risk for
3. Aldosterone antagonist
cardiogenic shock* should be given to who
4. Other contraindications to are already receiving an
ACEi * beta blocker and
use of oral beta-blockers
who have an EF 0.40 and
either symptomatic HF or
diabetes mellitus.
I IIa IIb III I IIa IIb III I IIa IIb III
*Including: age >70 years, systolic BP
<120 mm Hg, sinus tachycardia >110 bpm 2013 ACCF/AHA Guideline
or heart rate <60 bpm, and increased time for the Management of STEMI.
since onset of symptoms of STEMI. JACC. 2013;61(4)
 EVOLUTION OF GUIDELINES FOR ACS

1990 1992 1994 1996 1998 2000 2002 2004 2007 2009 2013

1990 1994
ACC/AHA AHCPR/NHLBI
AMI UA
R. Gunnar E. Braunwald

1996 1999 2004 2007

Rev Upd Rev Upd
ACC/AHA STEMI
ACC/AHA AMI
E. Antman
T. Ryan

2000 2002 2007

Rev Upd Rev
ACC/AHA UA/NSTEMI
E. Braunwald; J. Anderson

2009
Upd
ACC/AHA STEMI/PCI
For the better outcome F. Kushner
 REPERFUSION IN ACS

OR

Pharmacological Mechanical
 STRATEGY ACCORDING TO AHA/ACC 2013

STEMI

PCI-capable Non-PCI-capable
hospital hospital
DIDO 30 mnts

Primary PCI Transfer for Fibrinolytic agent

FMC-device Primary PCI within 30 mnts of
90 mnts FMC-device arrival when
(Class I/ LOE A) 120 mnts anticipated FMC-
(Class I/ LOE B) device >120 mnts
(Class I/ LOE B)

DCA Urgent transfer Transfer for DCA &

for PCI if failed revascularization
(Class IIa/ LOE B) within 3-12 hrs
(Class IIa/ LOE B)
Optimal PCI CABG
Medical *Patients with cardiogenic shock or severe heart failure initially seen at a nonPCI-capable hospital should be transferred for cardiac catheterization
therapy and revascularization as soon as possible, irrespective of time delay from MI onset (Class I, LOE: B). Angiography and revascularization should not be
performed within the first 2 to 3 hours after administration of fibrinolytic therapy.
STRATEGY ACCORDING TO ESC 2012
PRIMARY PCI IN STEMI
 PRIMARY PCI IN STEMI
Type of Stent
I IIa IIb III
BMS or DES is useful in primary PCI for patients
with STEMI.

I IIa IIb III BMS* should be used in patients with high bleeding risk,
inability to comply with 1 year of DAPT, or anticipated
invasive or surgical procedures in the next year.
*Balloon angioplasty without stent placement may be used in selected patients.

I IIa IIb III

DES should not be used in primary PCI
for patients with STEMI who are unable
to tolerate or comply with a prolonged
Harm course of DAPT because of the increased
risk of stent thrombosis with premature
discontinuation of one or both agents.
2013 ACCF/AHA Guideline for the Management of STEMI. JACC. 2013;61(4)
 PRIMARY PCI IN STEMI
Antithrombotic
I IIa IIb III
Aspirin 162 to 325 mg should be given before
primary PCI.

I IIa IIb III A loading dose of a P2Y12 receptor inhibitor should be given
as early as possible or at time of primary PCI to patients with
STEMI. Options include:
Clopidogrel 600 mg; or
Prasugrel 60 mg; or
Ticagrelor 180 mg

I IIa IIb III P2Y12 inhibitor therapy should be given for 1

year to patients with STEMI who receive a
stent (BMS or DES) during primary PCI using
the following maintenance doses:
Clopidogrel 75 mg; or
Prasugrel 10 mg; or
Ticagrelor 90 mg
2013 ACCF/AHA Guideline for the Management of STEMI. JACC. 2013;61(4)
 PRIMARY PCI IN STEMI
Anticoagulant
I IIa IIb III UFH, with additional boluses administered as needed
to maintain therapeutic activated clotting time levels,
taking into account whether a GP IIb/IIIa receptor
antagonist has been administered; or

I IIa IIb III

Bivalirudin with or without prior treatment with UFH.

I IIa IIb III In patients with STEMI undergoing PCI who are at
high risk of bleeding, it is reasonable to use
bivalirudin monotherapy in preference to the
combination of UFH and a GP IIb/IIIa receptor
antagonist.
I IIa IIb III
Fondaparinux should not be used as the
sole anticoagulant to support primary PCI
because of the risk of catheter thrombosis.
Harm
2013 ACCF/AHA Guideline for the Management of STEMI. JACC. 2013;61(4)
 FIBRINOLYSIS IN STEMI

In the absence of contraindications, fibrinolytic therapy should be given

within the previous 12 hours when it is anticipated that primary PCI cannot
be performed within 120 minutes of FMC.
 FIBRINOLYSIS IN STEMI

Absolute Contraindications Relative Contraindications

Any prior intracranial History of chronic, severe, poorly controlled
hemorrhage hypertension
Known structural cerebral Severe uncontrolled hypertension on presentation
vascular lesion (eg, AVM) (SBP >180 mm Hg or DBP >110 mm Hg)
Known malignant intracranial History of prior ischemic stroke 3 months,
neoplasm (primary or dementia, or known intracranial pathology not
metastatic) covered in contraindications
Ischemic stroke within 3 Traumatic or prolonged (10 minutes) CPR or major
months EXCEPT acute ischemic surgery ( 3 weeks)
stroke within 3hours Recent (within 2 to 4 weeks) internal bleeding
Suspected aortic dissection Non-compressible vascular punctures
Active bleeding or bleeding For streptokinase/anistreplase: prior exposure ( 5
diathesis (excluding menses) days ago) or prior allergic reaction to these agents
Significant closed head trauma Pregnancy
or facial trauma within 3 Active peptic ulcer
months Current use of anticoagulants: the higher the INR,
the higher the risk of bleeding
 FIBRINOLYSIS IN STEMI

Drugs Initial Treatment Contraindication

Streptokinase (SK) 1.5 million units over 30-60 mnt iv Prior SK

15 mg iv bolus
0.75 mg/kg over 30 mnts then
Alteplase (t-PA) 0.5 mg/kg over 60 mnts iv
Total dosage not to exceed 100
mg

Reteplase (r-PA) 10 U + 10 U iv given 30 mnts apart

Single iv bolus
30 mg if < 60 kg
Tenecteplase (TNK- 35 mg if < 70 kg
tPA) 40 mg if < 80 kg
45 mg if < 90 kg
50 mg if 90 kg
 FIBRINOLYSIS IN STEMI
Antithrombotic
I IIa IIb III Aspirin (162- to 325-mg loading dose) and clopidogrel (300-mg
loading dose for patients 75 years of age, 75-mg dose for patients
>75 years of age) should be administered to patients with STEMI
who receive fibrinolytic therapy.
I IIa IIb III
Aspirin should be continued
indefinitely and

I IIa IIb III

Clopidogrel (75 mg daily) for
I IIa IIb III at least 14 days

Up to 1 year

2013 ACCF/AHA Guideline for the Management of STEMI. JACC. 2013;61(4)

 FIBRINOLYSIS IN STEMI
Anticoagulant
I IIa IIb III Patients with STEMI undergoing reperfusion with fibrinolytic therapy should
receive anticoagulant therapy for a minimum of 48 hours, and preferably for
the duration of the index hospitalization, up to 8 days or until
revascularization if performed. Recommended regimens include:

I IIa IIb III a. UFH administered as a weight-adjusted intravenous bolus and

infusion to obtain an activated partial thromboplastin time of
1.5 to 2.0 times control, for 48 hours or until revascularization;
b. Enoxaparin administered according to age, weight, and
I IIa IIb III
creatinine clearance, given as an intravenous bolus, followed in
15 minutes by subcutaneous injection for the duration of the
index hospitalization, up to 8 days or until revascularization; or

I IIa IIb III c. Fondaparinux administered with initial intravenous dose,

followed in 24 hours by daily subcutaneous injections if the
estimated creatinine clearance is greater than 30 mL/min, for
the duration of the index hospitalization, up to 8 days or until
revascularization.
2013 ACCF/AHA Guideline for the Management of STEMI. JACC. 2013;61(4)
 ANTICOAGULANT
Class; LOE
Agent Dose
ACC/AHA ESC
Fondaparinux 2.5 mg i.v. bolus followed by an s.c. dose of 2.5 mg once daily up IIa;B I;B
to 8 days or hospital discharge if creatinine 3 mg/mL or 265
mmol/L
Enoxaparin < 75 years and creatinine levels 2.5 mg/mL or 21mmol/L (men) IIa;C I;B
or 2 mg/mL or 177mmol/L (women): i.v. bolus of 30 mg followed
15 min later by s.c. dose of 1 mg/kg every 12 h until hospital
discharge for a maximum of 8 days. The first two s.c. doses should
not exceed 100 mg.
> 75 years: no i.v. bolus; start with first s.c. dose of 0.75 mg/kg
with a maximum of 75 mg for the first two s.c. doses.
In patients with creatinine clearance of < 30 mL/min, regardless
of age, the s.c. 1.0 mg per kg every 24 hours
Heparin I.v. bolus of 60 U/kg with a maximum of 4000 U followed by an i.v. III IIb;C
infusion of 12 U/kg with a maximum of 1000 U/h for 2448h.
Target aPTT: 50 70 s to be monitored at 3, 6, 12, and 24 h

2007 Focused Update in STEMI. Circulation. 2008;117

European Heart Journal (2008)29,29092945
 PRIMARY PCI vs FIBRINOLYSIS
Thrombolysis +++ ++ +/- -
PPCI ++++ +++ +++ +++

100
90
Salvage Index (%of initial area at

80
70 Time dependency of myocardial salvage
60
50
40
30 Time-
dependent Moderately Time-dependent Less or no Time-dependent Myocardial
20 Myocardial Myocardial salvage salvage
salvage
risk

10
0
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
15 min 40 min 2 h 6h 12 h > 12 h
Efficacy of reperfusion is expressed : ++++very effective; +++effective; ++moderately effective; +/- uncertainly effective; - not effective

Late myocardial salvage: time to recognize its reality in the reperfusion therapy of acute myocardial infarction. Eur H J (2006)27,19007
 PRIMARY PCI vs FIBRINOLYSIS

20 60
Myocadial Salvage (% of LV)

50
15

Salvage Index (%)

40
10
30

5 20

10
0
1-2 H 2-6 H 6-12 H 12-48 H
0
PCI Thrombolysis 1-2 h 2-6 h 6-12 h 12-48 h

Schmig A, et al. Late myocardial salvage: time to recognize its reality in the reperfusion therapy of acute myocardial
infarction. Eur Heart J 2006;27:19007
PRIMARY PCI vs FIBRINOLYSIS

Meta Analysis of 23 Trials (n=7739)

Lancet 2003;361:9351
 CORONARY ARTERY BYPASS GRAFT SURGERY
Indication
Urgent CABG is indicated in patients with
I IIa IIb III
STEMI and coronary anatomy not amenable
to PCI who have ongoing or recurrent
ischemia, cardiogenic shock, severe HF, or
other high-risk features.

I IIa IIb III

CABG is recommended in patients with
STEMI at time of operative repair of
mechanical defects.

Emergency CABG within 6 hours of symptom

I IIa IIb III
onset may be considered in patients with
STEMI who do not have cardiogenic shock
and are not candidates for PCI or fibrinolytic
therapy.

2013 ACCF/AHA Guideline for the Management of STEMI. JACC. 2013;61(4)

 CORONARY ARTERY BYPASS GRAFT SURGERY
Discontinuing Antithrombotic / Anticoagulant
I IIa IIb III
Aspirin should not be withheld before urgent
CABG.
I IIa IIb III
Clopidogrel or ticagrelor should be discontinued
at least 24 hours before urgent on-pump CABG, if
possible.
I IIa IIb III Short-acting intravenous GP IIb/IIIa receptor
antagonists (eptifibatide, tirofiban) should be
discontinued at least 2 to 4 hours before urgent
CABG.
I IIa IIb III
Abciximab should be discontinued at least 12
hours before urgent CABG.
I IIa IIb III Urgent CABG within 5 days of clopidogrel or
ticagrelor administration or within 7 days of prasugrel
administration might be considered, especially if the
benefits of prompt revascularization outweigh the risks of bleeding.
2013 ACCF/AHA Guideline for the Management of STEMI. JACC. 2013;61(4)
 SPONTANEOUS REPERFUSION
ECG
OR
Defined as 70% resolution of
the cumulative ST-segment
elevation compared with the
initial electrocardiogram AND
70% reduction in pain
Angiography
Angiographic TIMI flow grade
3 in the culprit vessel before
PCI (first contrast injection)
Am J Cardiol 2009;103:14953
Heart 2009;16:13316
Am Heart J 2008;156:248-55
 SPONTANEOUS REPERFUSION

30-DAY CLINICAL OUTCOME

Spontaneous Reperfusion vs Spontaneous Reperfusion vs
Reperfusion Therapy Primary PCI
25
35 31 25
30 19
20
25
Patient (%)

19
20 15
15 10 5.8
10 6.3
5 0.6 5 0.6
0 0
Mortality CHF, Recurrent Mortality CHF, Recurrent
ACS and/or ACS and/or
death death

Spontaneous Reperfusion No Spontaneous Reperfusion

Relation of Clinically Dened Spontaneous Reperfusion to Outcome in STEMI. Am J Cardiol 2009;103:149 153
 SUMMARY

1. STEMI is a spectrum of ACS that has a highest rate in

morbidity and mortality

2. The fast-accurate assessment and management of STEMI

greatly affect the outcome

3. The selection of revascularization strategy in STEMI is a

vital point

4. The general practitioner has a pivotal role in the early

phase of management of STEMI
THANK YOU
Workshop:
The Management of STEMI
Surabaya Cardiology Update
Bambang Herwanto
2013