STEMI ST ELEVATION MYOCARDIAL INFARCTION CARL L. TOMMASO, MD DIRECTOR, CARDIAC CATHETERIZATION SKOKIE HOSPITAL, NSUHS

I HAVE NO DISCLOSURES THIS IS THE FIRST TIME I HAVE PRESENTED AT THE FALL FELLOWS COURSE

BUT THIS AIN’T MY FIRST RODEO

Clinical Syndrome Defined By: STEMI DEFINITION Clinical Syndrome Defined By: Characteristic Symptoms Of Myocardial Ischemia Persistent (ECG) ST Elevation And Subsequent Release Of Biomarkers Of Myocardial Necrosis

DIAGNOSTIC ST ELEVATION ESC/ACCF/AHA/WHF Task Force New ST Elevation At The J Point In At Least 2 Contiguous Leads Of ≥2 mm In Men Or ≥1.5 mm In Women In Leads V2–V3 And/Or Of ≥1 mm In Other Contiguous Chest Leads Or The Limb Leads In The Absence Of Left Ventricular (LV) Hypertrophy Or Left Bundle-branch Block (LBBB)

New Or Presumably New LBBB Should Not Be Considered Diagnostic Of Acute Myocardial Infarction (MI) In Isolation . ST Depression In ≥2 Precordial Leads (V1–V4) May Indicate Transmural Posterior Injury; Multilead ST Depression With Coexistent ST Elevation In Lead AVR Has Been Described In Patients With Left Main Or Proximal Left Anterior Descending Artery Occlusion

Yeh, R et al. N Engl J Med 2010; 362:2155-2165 Age- and Sex-Adjusted Incidence Rates of Acute Myocardial Infarction, 1999 to 2008. 64% Yeh, R et al. N Engl J Med 2010; 362:2155-2165

DOOR (FMC) TO BALLOON (DEVICE) TIME Initially < 120 Minutes Considered Appropriate Dropped To < 90 Min When Everyone Proved They Could Make 120 Min Attempt To Change Standard To Median Time Of 60 Min (As Many < 60 Min As >60 Min) To Be BCBS Center Of Excellence, Satisfy Leapfrog And Other Rating Services

Menees DS et al. N Engl J Med 2013;369:901-909.

24/7

Need to have plan in place concerning management

Even a 100% committed PCI Hospital needs Capability of thrombolytic administration: Weather Committed Lab Personnel Issues Holiday Party

Checklist. Improving Door-to-Device Times 1. Prehospital ECG to activate the PCI team 2. Emergency physicians activate the PCI team. 3. A single call to a central page operator activates the PCI team. 4. Goal is set for the PCI team to arrive in the catheterization laboratory within 20 minutes after being paged. 5. Timely data feedback and analysis are provided to members of the STEMI care team.

MECHANICAL THROMBECTOMY 3.2 Class IIa Manual aspiration thrombectomy is reasonable for patients undergoing primary PCI (Level of Evidence: B) RHEOLYTIC THROMBECTOMY (ANGIOJET)-Only indicated for large vessels (SVBG/RCA) with large amts of thrombus

EXPIRA Sardella et al JACC 2009;53:309

EXPIRA MICROVASCULAR DAMAGE NO MCV DAMAGE Sardella e al JACC 2009;53:309 NO MCV DAMAGE Sardella et al JACC 2009;53:309

TASTE Figure 2 Kaplan–Meier Curves for Death from Any Cause and Hospitalization Due to Reinfarction. Kaplan–Meier curves are shown for the cumulative probability of death from any cause (Panel A) and of hospitalization due to reinfarction (Panel B) up to 30 days after PCI only (PCI) or after PCI with thrombus aspiration (PCI+TA). The insets show the same data on an enlarged y axis. Kaplan–Meier Curves for Death from Any Cause and Hospitalization Due to Reinfarction. Fröbert O et al. N Engl J Med 2013;369:1587-1597

Hazard Ratios for the Primary End Point in Subgroups of Patients. Figure 3 Hazard Ratios for the Primary End Point in Subgroups of Patients. Hazard ratios are shown for the primary end point of mortality within 30 days after PCI. All the subgroups were prespecified except those defined by status with respect to bivalirudin therapy and glycoprotein IIb/IIIa blocker therapy, which were analyzed post hoc. ECG denotes electrocardiography, and TIMI Thrombolysis in Myocardial Infarction. Hazard Ratios for the Primary End Point in Subgroups of Patients. Fröbert O et al. N Engl J Med 2013;369:1587-1597

ASPIRATION THROMBECTOMY Class IIa indication May reduce microvascular damage May not effect mortality or rehospitalization May be useful to “let you know where you are” Use as infusion catheter (contrast or meds) Figure 3 Hazard Ratios for the Primary End Point in Subgroups of Patients. Hazard ratios are shown for the primary end point of mortality within 30 days after PCI. All the subgroups were prespecified except those defined by status with respect to bivalirudin therapy and glycoprotein IIb/IIIa blocker therapy, which were analyzed post hoc. ECG denotes electrocardiography, and TIMI Thrombolysis in Myocardial Infarction.

ASPIRATION TROMBECTOMY Figure 3 Hazard Ratios for the Primary End Point in Subgroups of Patients. Hazard ratios are shown for the primary end point of mortality within 30 days after PCI. All the subgroups were prespecified except those defined by status with respect to bivalirudin therapy and glycoprotein IIb/IIIa blocker therapy, which were analyzed post hoc. ECG denotes electrocardiography, and TIMI Thrombolysis in Myocardial Infarction.

ASPIRATION TROMBECTOMY

ASPIRATION TROMBECTOMY

USE OF STENTS IN STEMI CLASS I 1. Placement of a stent (bare-metal stent [BMS] or drug-eluting stent [DES]) is useful in primary PCI for patients with STEMI 2. BMS should be used in patients with high bleeding risk, inability to comply with 1 year of dual antiplatelet therapy (DAPT), or anticipated invasive or surgical procedures in the next year. CLASS III: HARM 1. DES should not be used in primary PCI for patients with STEMI who are unable to tolerate or comply with a prolonged course of DAPT because of the increased risk of stent thrombosis with premature discontinuation Figure 3 Hazard Ratios for the Primary End Point in Subgroups of Patients. Hazard ratios are shown for the primary end point of mortality within 30 days after PCI. All the subgroups were prespecified except those defined by status with respect to bivalirudin therapy and glycoprotein IIb/IIIa blocker therapy, which were analyzed post hoc. ECG denotes electrocardiography, and TIMI Thrombolysis in Myocardial Infarction.

USE OF STENTS IN STEMI BMS v DES Reintervention Figure 3 Hazard Ratios for the Primary End Point in Subgroups of Patients. Hazard ratios are shown for the primary end point of mortality within 30 days after PCI. All the subgroups were prespecified except those defined by status with respect to bivalirudin therapy and glycoprotein IIb/IIIa blocker therapy, which were analyzed post hoc. ECG denotes electrocardiography, and TIMI Thrombolysis in Myocardial Infarction. Kastrati et al. Eur H J 2007;28:2706

USE OF STENTS IN STEMI BMS v DES Reintervention Figure 3 Hazard Ratios for the Primary End Point in Subgroups of Patients. Hazard ratios are shown for the primary end point of mortality within 30 days after PCI. All the subgroups were prespecified except those defined by status with respect to bivalirudin therapy and glycoprotein IIb/IIIa blocker therapy, which were analyzed post hoc. ECG denotes electrocardiography, and TIMI Thrombolysis in Myocardial Infarction. Kastrati et al. Eur H J 2007;28:2706 Kastrati et al. Eur H J 2007;28:2706

USE OF STENTS IN STEMI BMS v DES Kastrati et al. Eur H J 2007;28:2706 Reintervention Figure 3 Hazard Ratios for the Primary End Point in Subgroups of Patients. Hazard ratios are shown for the primary end point of mortality within 30 days after PCI. All the subgroups were prespecified except those defined by status with respect to bivalirudin therapy and glycoprotein IIb/IIIa blocker therapy, which were analyzed post hoc. ECG denotes electrocardiography, and TIMI Thrombolysis in Myocardial Infarction.

USE OF STENTS IN STEMI BMS v DES Kastrati et al. Eur H J 2007;28:2706 Reintervention Figure 3 Hazard Ratios for the Primary End Point in Subgroups of Patients. Hazard ratios are shown for the primary end point of mortality within 30 days after PCI. All the subgroups were prespecified except those defined by status with respect to bivalirudin therapy and glycoprotein IIb/IIIa blocker therapy, which were analyzed post hoc. ECG denotes electrocardiography, and TIMI Thrombolysis in Myocardial Infarction. Kastrati et al. Eur H J 2007;28:2706 Kastrati et al. Eur H J 2007;28:2706

PCI OF NON-INFARCT VESSEL Class III: Harm PCI should not be performed in a noninfarct artery at the time of primary PCI in patients with STEMI who are hemodynamically stable (Level of Evidence: B)

PRAMI-PReventive angioplasty in AMI Wald DS et al. N Engl J Med 2013;369:1115-1123

PRAMI Wald DS et al. N Engl J Med 2013;369:1115-1123

PRAMI Wald DS et al. N Engl J Med 2013;369:1115-1123

CONCLUSIONS INCIDENCE OF STEMI DECREASING

CONCLUSIONS INCIDENCE OF STEMI DECREASING D2B < 90 MIN DOESN’T IMPROVE OUTCOMES

CONCLUSIONS INCIDENCE OF STEMI DECREASING D2B < 90 MIN DOESN’T IMPROVE OUTCOMES MECHANICAL THROMBECTOMY MAY NOT IMPROVE OUTCOMES, BUT MAY BE USEFUL PROCEDURE

CONCLUSIONS INCIDENCE OF STEMI DECREASING D2B < 90 MIN DOESN’T IMPROVE OUTCOMES MECHANICAL THROMBECTOMY MAY NOT IMPROVE OUTCOMES, BUT MAY BE USELFUL PROCEDURE DES BETTER THAN BMS

CONCLUSIONS INCIDENCE OF STEMI DECREASING D2B < 90 MIN DOESN’T IMPROVE OUTCOMES MECHANICAL THROMBECTOMY MAY NOT IMPROVE OUTCOMES, BUT MAY BE USELFUL PROCEDURE DES BETTER THAN BMS PCI OF NON-INFARCT VESSEL MAY BE USEFUL