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

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

3. BUT THIS AIN’T MY FIRST RODEO

4. 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

5. 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)

6. 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

7. 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:

8. 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

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

10. 24/7

11. Need to have
plan in place
concerning management

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

13. 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.

14. 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

15. EXPIRA
Sardella et al JACC 2009;53:309

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

17. 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:

18. 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:

19. 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.

20. 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.

21. ASPIRATION TROMBECTOMY

22. ASPIRATION TROMBECTOMY

23. 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.

24. 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

25. 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

26. 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.

27. 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

28. 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)

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

30. PRAMI
Wald DS et al. N Engl J Med 2013;369:

31. PRAMI
Wald DS et al. N Engl J Med 2013;369:

32. CONCLUSIONS
INCIDENCE OF STEMI DECREASING

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

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

35. 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

36. 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