HOW TO DIAGNOSE & TREAT

ST SEGMENT ELEVATION
MYOCARDIAL INFARCTION

Kurnia Mebrillianttari
 PREVALENCE

Worldwide, ischaemic heart disease is the single most common cause of death and its
frequency is increasing

Indonesia in 2013, Pusdatin Kemenkes RI:

Doctor diagnosed 883.447 cases(0.5%)
West Java (160.812)………….North Maluku (1.436)

Doctor diagnosed/symptom 2.650.340 cases (1.5%)

East Java (375.127)…………. West Papua(6.690)
 STEMI Diagnosis
Symptoms

Consistent with myocardial

ischaemia

Typical:persistent chest pain radiating

to the neck, lower jaw, or left arm

Atypical:
shortness of breath
nausea/vomiting
fatigue
palpitations
or syncope
 STEMI Diagnosis
Signs
12 Lead ECG

Hyperacute Evolution Old infarct

phase
Specific ST Q pathologic
Nonspecific ST elevation ST segment
elevation T inverted isoelectric
T taller & wider Q pathologic T normal/ inverted
In some cases
patients may
have

coronary artery
occlusion/global
ischaemia

in the absence of
characteristic ST
elevation
Reperfusion strategy time in patients presenting

via EMS / non-PCI centre

Fibrinolytic Therapy
Fibrinolytic Therapy Contraindication
Fibrinolytic Therapy Contraindication
 What to do

Oxygen

Indicated in patient with pulmonary edema with SaO2 <90% to maintain

saturation >95%

CPAP in patient with respiratory distress

Intubated if indicated
 Primary PCI

DAPT
Aspirin loading dose 150-300 mg chewing, maintenance 75-100 mg
+
Ticagrelor loading dose 180 mg, maintenace 2x 90 mg
/ Prasugrel 60 mg, maintenance 1x10mg
/ Clopidogrel 600 mg, maintenance 1x75 mg

IV Anticoagulant
UFH 70-100 IU/kg iv bolus without GP IIb/IIIa inhibitor or 50-70 IU/kg iv with
GP IIb/IIIa

/ Enoxaparin 0.5mg/kg iv bolus

/ Bivalirudin 0.75mg/kg iv bolus, maintenance 1.75 mg/kg/hr to 4 hour post PCI
Patient not receiving Reperfusion Therapy

DAPT
Aspirin loading dose 150-300 mg chewing, maintenance 75-100 mg
+
Clopidogrel 300 mg, maintenance 1x75 mg

IV Anticoagulant
UFH 60 IU/kg iv bolus (max 4000IU) maintenance 12IU/kg/hr 24-48 hr

/ Enoxaparin
Age < 75 30mg iv bolus, next 15 minute 1 mg/kg sc every 12 hour
Age >75 no iv bolus, start 0.75 mg/kg sc
eGFR <30mL/min/1.73 m2 every 24 hour

/ Fondaparinux 2.5 mg iv bolus, kemudian 2.5 mg sc

 Management During Hospitalization

CCU/ICCU
Provide all aspects of care for STEMI patients,
Treatment of ischaemia, severe heart failure, arrhythmias, and common
comorbidities.

Monitoring
All STEMI patients have ECG monitoring for a minimum of 24 h

Length of stay
A minimum of 24 h in CCU/ICCU whenever possible, after which they may be
moved to a step-down monitored bed for an additional 24–48 h.
 Long Term Therapies for STEMI

Lifestyle interventions and risk factor control

Smoking cessation
Diet, alcohol, and weight control
Exercise-based cardiac rehabilitation
Resumption of activities
Blood pressure control
Adherence to treatment

Antithrombotic therapy
DAPT, combining aspirin and a P2Y inhibitor (prasugrel, ticagrelor, or
1

clopidogrel) for patients with STEMI undergoing primary PCI (for up to

12 months)
 Long Term Therapies for STEMI

Beta-blockers

Early i.v. beta-blocker treatment reduces the incidence of acute

malignant ventricular arrhythmia

Lipid Lowering Therapy

Target LDL-C < 1.8 mmol/L (<70 mg/dL) or at least 50% reduction . in
LDL-C if the baseline LDL-C level is 1.8–3.5mmol/L
Lower-intensity statin therapy for. patients at risk of side effects from
statins
 Long Term Therapies for STEMI

Nitrates
Routine use of nitrates in STEMI was of no benefit
Intravenous nitrates may be useful during the acute phase in patients
with hypertension or heart failure

Calcium antagonists

Routine use of calcium antagonists in the acute phase is not

indicated
Chronic phase, Verapamil reduces risk of mortality and reinfarction
 Long Term Therapies for STEMI

Ace-i & ARB

Recommended in patients w/ impaired LVEF (< 40%) or experiencing

heart failure in the early phase

Mineralocorticoid /aldosterone receptor antagonists

MRA, Eplerenone, is recommended in patients with LV dysfunction

(LVEF <40%) & heart failure after STEMI
Thank You