STEMI Primer: 101

From Presentation to Cath Lab

Michael S. Blanc, FACC, FSCAI

Community Heart & Vascular Center
San Angelo Community Medical Center
San Angelo, TX

 https://youtu.be/9Wmqq3TfV5w

Vulnerable Plaque and

Stable Plaque

Libby. Circulation. 1995;91:2844-2850.

Most MIs associated with non-flow limiting lesions

SeverityofCoronaryArteryStenosisbeforeAcuteMI

100%
90%
80%
70%
60%
% of Patients
50%
n = 195
40%
30%
20%
10%
0%

<50%

50-70%

>70%

Circulation Vol 93, No12 June 15, 1996

Ambrose, Giroud, Little, Nobuyoshi, et al

Symptoms of Heart
Attack
Chest discomfort
Jaw or arm discomfort
Shortness of breath
Cold sweat
Upset stomach
Fatigue
Over 25% of patients have no chest discomfort
Heart is not heavily innervated and pain is
typically not severe

Acute Phase Risk Stratification:

Pre-infarction characteristics
Age > 70
Prior myocardial
infarction
Female gender
Hypertension
History of CHF
Hyperlipidemia
Diabetes
Race
Clinical Criteria

ECG Criteria
Chest x-raycardiomegaly
Markedly elevated
cardiac enzymes
Elevated BUN
Hemodynamic Criteria
Complications
VSD/PMD-rupture
Myocardial rupture

Continuing Medical Implementation

...bridging the care gap

Acute Phase Risk Stratification:

Physical Examination
Clinical assessment of LV dysfunction
No history of CHF
No CHF with index MI
No LBBB, pacemaker or LVH with ST-Ts
Absence of Q waves-site of MI or outside index
territory
91 % predictive value of EF 40%

Killip classification
Hemodynamic classification
Mechanical complications
Continuing Medical Implementation
...bridging the care gap

Clinical Signs of LV
Dysfunction
Hypotension
Pulsus alternans
Reduced volume
carotid
LV apical
enlargement/displace
ment
Sustained apex - to
S2

Soft S1
Paradoxically split S2
S3 gallop
(not S4 = impaired
LV compliance)
Mitral regurgitation
Pulmonary congestion

rales

Continuing Medical Implementation

...bridging the care gap

Acute Phase Risk Stratification:

Importance of LV dysfunction
Killip Classification

% patients

Mortality (%)

30-50

II Rales, S3, Pulmonary venous hypertension

33

15-20

III Pulmonary edema

15

40

IV Cardiogenic shock

10

80-100

I No CHF

Continuing Medical Implementation

...bridging the care gap

Figure 6

TIMI Risk Score for STEMI

Historical
Age 65-74
75
DM/HTN or angina
Exam
SBP < 100
HR >100
Killip II-IV
Weight < 67 kg

2 points
3 points
1 point
3 points
2 points
2 points
1 point

Presentation
Anterior STE or LBBB
Time to rx > 4 hrs

1 point
1 point

Risk Score = Total

(0 -14)

(FRONT)

Risk Score

0
1
2
3
4
5
6
7
8
>8

Odds of death by 30D*

0.1
0.3
0.4
0.7
1.2
2.2
3.0
4.8
5.8
8.8

(0.1-0.2)
(0.2-0.3)
(0.3-0.5)
(0.6-0.9)
(1.0-1.5)
(1.9-2.6)
(2.5-3.6)
(3.8-6.1)
(4.2-7.8)
(6.3-12)

*referenced to average mortality

(95% confidence intervals)
(BACK)

Complications of Acute Myocardial

Infarction
Arrhythmic Complications
Mechanical Complications
Ischemic Complications
Miscellaneous Complications
[DVT, PE, Pericarditits, TPA complications, Pneumonia]

Mechanical Complications of Acute

Myocardial Infarction
Papillary Muscle Rupture Acute MR
Ventricular Septal Defect
Right Ventricular MI
Free Wall Rupture
Cardiogenic shock
Cardiac Tamponade

Acute Mortality
Reduction

Early Recognition of Symptoms

Pre -Hospital Resuscitation of Sudden Death
Fast-Track Protocol for Thrombolytic Therapy
Code STEMI Direct PCI protocols
Optimal Use of Adjunctive Therapy
Monitoring for Complications
Evidence Based Risk Stratification
Appropriate Revascularization for NSTEMI
Continuing Medical Implementation
...bridging the care gap

Prognosis Post MI
Mortality in the first year post MI
averages 10%
Subsequently mortality 5% per year
85% of deaths due to CAD
50%

of these sudden
50% within first 3 months
33% within the first three weeks
Continuing Medical Implementation
...bridging the care gap

Early Mortality After

AMI
Mortality at 25 - 30 Days

Pre-CCU

CCU

-Block

GISSI-1 ISIS-2 GUSTO GUSTO-3 ASSENT-2

SK
SK+ASA
tPA
tPA &
tPA &
rPA
TNK

Continuing Medical Implementation

...bridging the care gap

Medications

ASA 325 mg po chewed

Ticagrelor (Brilinta) 180 mg
Alternative-Clopidogrel

(Plavix) 600 mg
Alternative-Prasugrel (Effient) 60 mg

Heparin 5000 unit IV

Atorvastatin 80 mg

Primary endpoint: CV death, MI or stroke

12

Clopidogrel

K-M estimated rate (% per year)

11

11.0

10

9.3

Ticagrelor

8
7
6
5
4
3
2

HR: 0.85 (95% CI = 0.740.97), p=0.02

1
0

No. at risk
Ticagrelor 4,201
Clopidogrel 4,229

2
3,887
3,892

4
3,834
3,823

6
Months
3,732
3,730

8
3,011
3,022

10
2,297
2,333

11

12
1,891
1,868

Beta-Blockers

COMMIT: Study design

INCLUSION:

>45,000 patients with suspected acute

MI (ST change or LBBB) within 24 h of
symptom onset

TREATMENT:

Metoprolol 15 mg iv over 15 mins, then

200 mg oral daily vs matching placebo

EXCLUSION:

Shock, systolic BP <100 mmHg, heart

rate <50/min or II/III AV block

1 OUTCOMES: Death & death, re-MI or VF/arrest up to

4 weeks in hospital (or prior discharge)
Mean treatment and follow-up: 16 days

Effects of Metoprolol
COMMIT (N = 45,852)

Totality of Evidence (N = 5

Death
13%
P=0.0006

30% relative
increase in
*cardiogenic
shock

ReMI
22%
P=0.0002
VF
15%
P=0.002

*Risk factors for cardiogenic shock :heart failure, age > 70 , systolic blood
pressure < 120, sinus tachycardia > 110 or heart rate < 60, increased time
since onset of STEMI symptoms

Lancet. 2005;366:1622.

Beta-Blockers
Recommendations - Class Ia
(B)

ORAL beta-blocker therapy SHOULD BE initiated

in the first 24 hours 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, or
4) relative contraindications to beta blockade
1AVB > 0.24 sec,
2nd- or 3rd-degree heart block
reactive airway disease

**

There is no study evaluating oral beta blockers

*Risk factors
for cardiogenic shock :heart failure, age > 70 , systolic blood pressure < 120,
alone
sinus tachycardia > 110 or heart rate < 60, increased time since onset of STEMI symptoms

Beta-Blockers
Recommendations - Class IIa
(B)

It is reasonable to administer an IV BETA

BLOCKER at the time of presentation to STEMI
patients who are HYPERTENSIVE and 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, or
4) relative contraindications to beta blockade
1AVB > 0.24 sec,
2nd- or 3rd-degree heart block
reactive
*Risk factors for cardiogenic
shock :heart
failure, age
> 70 , systolic blood pressure < 120, sinus
airway
disease
tachycardia > 110 or heart rate < 60, increased time since onset of STEMI symptoms

Beta-Blockers
Recommendations - Class III
(A)
IV beta blockers SHOULD NOT be administered

to STEMI patients who have any of the following:

1) signs of heart failure
2) evidence of a low output state
3) increased risk* for cardiogenic shock
4) relative contraindications to beta blockade
1AVB > 0.24 sec,
2nd- or 3rd-degree heart block
reactive airway disease

*Risk factors for cardiogenic shock :heart failure, age > 70 , systolic blood
pressure < 120, sinus tachycardia > 110 or heart rate < 60, increased time
since onset of STEMI symptoms

Statin Evidence: MIRACL Study

Primary Efficacy Measure

Placebo
Cumulative Incidence (%)

15

17.4%
14.8%

Atorvastatin
10
Time to first occurrence of:
Death (any cause)
Nonfatal MI
Resuscitated cardiac arrest
Worsening angina with new
objective evidence and urgent
rehospitalization

Relative risk = 0.84

P = .048
95% CI 0.701-0.999

0
0

12

Time Since Randomization (weeks)

Schwartz GG, et al. JAMA. 2001;285:1711-1718.

16

Reperfusion

Time is Muscle

Brief Review of
Thrombolytic Trials
GISSI-1: Streptokinase 18% reduction in mortality at 21 d
GUSTO-1: tPA. 15% reduction in 30-day mortality compared
to Streptokinase
GUSTO-3: Reteplase had no benefit over tPA but is easier to
use (double bolus)
ASSENT: TNKase is similar to tPA but with less non-cerebral
bleeding and better mortality with symptoms>4 hrs: Single
bolus, fibrin selective, resistance to PAI-1
*Overall risk of ICH is 0.7%; Strokes occurred in 1.4%

Anticoagulants
Patients undergoing reperfusion with

fibrinolytics should receive anticoagulant

therapy for a minimum of 48 hours
(unfractionated heparin) or up to 8 days
Anticoagulant regimens with established

efficacy include:
UFH (LOE: C)
Enoxaparin (LOE:A)
Fondaparinux (LOE:B)

PCI vs Fibrinolysis for STEMI:

Short-Term Clinical Outcomes
Frequency (%)

PCI

N=7739

Fibrinolysis

P<.0001

P<.0001
P=.0002
P=.0003

P<.0001

P=.032
P=.0004

Death

Death,
no shock
data

ReMI

Rec.
Total
Ischemia Stroke

P<.0001

Hem.
Stroke

Major
Bleed

Death
MI
CVA

Keeley E, et al. Lancet . 2003;361:13-20.

Reperfusion Therapy fr Patients with STEMI

*Patients with cardiogenic shock or severe heart failure initially seen at a nonPCI-capable hospital should be transferred for cardiac
catheterization and revascularization as soon as possible, irrespective of time delay from MI onsetClass I, LOE: B). Angiography and
revascularization should not be performed within the first 2 to 3 hours after administration of fibrinolytic therapy.

Reperfusion at a NonPCI-Capable
Hospital

Transfer of Patients
With STEMI to a PCICapable Hospital for
Coronary Angiography
After Fibrinolytic
Therapy

Rescue PCI
If evidence of

cardiogenic shock,
severe heart failure
hemodynamically compromising
ventricular arrhythmias.

If fibriolysis has failed

Evaluate 90 minutes for a <50% ST

resolution in lead with greatest elevation

SACMC Standards
EMS SENDS EKG TO ER MD FROM
FIELD
Scene

time 15 min for STEMI.

ER MD MAKES DX and ACTIVATES

CATH LAB TEAM
One

phone call activation

ER PRESENTATION-EKG < 5 MIN

ER MED BOX
DIRECT ADMIT TO CATH LAB

SACMC
SACMC average DBT 54 min
Five years of DBT < 90 min

Helicopter
Transfer

Local EMS should generally be used if available and 30 minute

time to destination hospital
Whenever possible, helipad adjacent to ED

Ground/Air Transfer:
Enhance First
Responders
transportation
Early activation of Air

Onsite Helipad:
Availability of Transport

Helicopter capable of transporting patients on 10 minute notice 24/7.

available alternate transport options identified.

When Helicopter Not

Available:
When Identify
not Plan B: Who is
next

Immediately activate helicopter transport during initial communication between

referring hospital ED and receiving hospital regarding need for reperfusion
Referral team activates:
Establish a system whereby all patient transfers of any type can be specified as
time critical within one hour versus diversion possible