1. Management of AMI in patients presenting with STEMI
2017 ECS Guidelines
Management of AMI in patients presenting with STEMI

2. 2017 ESC Guidelines
Introduction

3. 2017 ESC guidelines
Introduction
STEMI: patients with persistent chest discomfort or other symptoms suggestive of ischemia and STE in at least 2 contiguous leads.
Ischemic Heart Disease is the single most common cause of death
incidences of STEMI is decreasing, NSTEMI is increasing
Mortality - influenced by age, time delay to Tx, history of MI, DM, renal failure, number of diseased arteries, LVEF, presence of EMS based STEMI network
IHD develops 7-10 years later in women, still a leading cause of death, present atypically and later. majority of pts >75 = women.

4. 2017 ESC guidelines
Whats New

5. 2017 ESC Guidelines
EMergency Care
Reduction in CP after nitroglycerin administration can be misleading and is not recommended as a diagnostic maneuver
response to nitro is neither sensitive nor specific in diagnosing ACS
If clinical suspicion of ACS - if EKG is equivocal or does not show evidence of MI, EKGs should be repeated and compared with previous EKGs
STEMI does not just mean >1mm elevation in 2 contiguous leads.
criteria for V2 and V3 is different depending on age and gender.

6. 2017 ESC guidelines Emergency Care V2, V3 STE > 2.5mm in men <40
STE >2.0 in men >40
STE >1.5 in women
Inferior MI -> get R precordial leads to identify concomitant RV infarction
ST depression in V1-V3, with positive T wave suggests posterior MI -> get posterior leads (V7-V9)
The Presence of Q waves should not change reperfusion strategy

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Emergency Care

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Emergency care

9. 2017 ESC guidelines Bundle Branch Block
Emergency Care
Bundle Branch Block
presence of concordant STE appears to be one of the best indicators of AMI with occluded infarct artery
presence of new LBBB does not predict MI
Patients with RBBB and MI have a poor prognosis
difficult to detect ischemia
PCI should be considered with persistent ischemic symptoms in presence of RBBB

10. 2017 ESC guidelines Ventricular paced rhythms
Emergency Care
Ventricular paced rhythms
Scarbossas criteria can be used on paced EKGs, not as specific
Isolated Posterior MI
Isolated ST depression in V1-V3 (>0.5mm) and STE (>0.5mm) in V7-V9
Left main coronary obstruction
presence of ST depression >1mm in 8 or more leads coupled with STE in aVR and/or V1 suggests multivessel ischemia or L main disease

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atypical EKGs that should prompt primary PCI in patients with ongoing symptoms suggestive of myocardial ischemia

12. 2017 esc guidelines Non diagnostic EKGs
emergency care
Non diagnostic EKGs
sometimes they present very early (look for hyperacute T waves), some just may not have STEs
repeat the EKG for dynamic changes
as many as 20% of STEMIs are diagnosed on subsequent EKG
Suspicion of ongoing myocardial ischemia is an indication for primary PCI even without STE.

13. 2017 esc guidelines emergency care
Pain should be managed; pain means increased sympathetic activation -> vasoconstriction -> increased cardiac workload

14. 2017 esc guidelines emergency care Cardiac arrest
In patients following cardiac arrest and STE on EKG - primary PCI is indicated
Urgent angiography (2hours) should be considered after cardiac arrest when there is a high index of suspicion of ongoing infarction
chest pain before arrest, known CAD, abnormal EKG, shockable arrest…
unfavorable conditions should be taken into consideration against PCI
Cooling should not delay primary PCI

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16. 2017 esc guidelines STEMI should be diagnosed <10 minutes after FMC
Pre hospital care
STEMI should be diagnosed <10 minutes after FMC
when STEMI is diagnosed by EMS - bypass ED to PCI
pre-hospital fibrinolysis is indicated in patients presenting early when STEMI diagnosis to PCI mediated reperfusion time is >120 min.

17. 2017 ESC guidelines prehospital care Non PCI Center
If fibrinolysis is contraindicated - transfer to PCI regardless of time

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reperfusion therapy

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reperfusion therapy
Primary PCI is preferred reperfusion strategy in patients with STEMI w/in 12 hours of symptom onset
PCI is performed faster and results in lower mortality in high volume centers
Lack of data to set the time limit to choose PCI over fibrinolysis
time from STEMI Dx to PCI mediated reperfusion < 120min
If fibrinolysis is indicated - bolus < 10 min from diagnosis

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reperfusion therapy
Fibrinolysis should be administered in prehospital setting if possible
Patients should be transferred to PCI facility as soon as possible after bolus of lytics
Rescue PCI is indicated if:
failed fibrinolysis (STE resolution <50% w/in 60-90min)
hemodynamic or electrical instability
persistent chest pain or worsening ischemia
Routine, early PCI (2-24hrs) is indicated after successful fibrinolysis

22. 2017 ESC guidelines reperfusion therapy
Primary PCI indicated for patients with symptoms >12 hours in presence of:
EKG evidence of ongoing ischemia
ongoing or recurrent CP and dynamic EKG changes
ongoing or recurrent pain, signs/symptoms suggestive of heart failure, shock, arrhythmias
No consensus on PCI after 12 hours of symptoms in absence of signs of ongoing ischemia - debatable
Routine PCI of occluded IRA in asymptomatic patients >48hours after symptoms onset is NOT indicated.

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reperfusion therapy

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reperfusion therapy

26. 2017 ESC guidelines pharmacotherapy
Patients undergoing primary PCI should receive DAPT (ASA plus P2Y12 inhibitor) plus parenteral anticoagulation
limited evidence as to when the P2Y12 inhibitor should be given
early administration may be preferable for early efficacy
Prasugrel and Ticagrelor are superior to clopidogrel
should be avoided in patients with previous hemorrhagic stroke, patients on oral AC and pts with mod/severe liver Dz.
prasugrel is not recommended in patients with h/o CVA or >75
all should be used with caution in pts at risk of bleeding or significant anemia

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reperfusion therapy

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anticoagulation
Options for primary PCI including UFH, enoxaparin, bivalirudin
no evidence of increased bleeding with enoxaparin
enoxaparin a/w significant reduction of death compared to UFH
Enoxaparin should be considered in STEMI
Bivalirudin should be considered in patients w/ high bleeding risk
Bivalirudin is recommended for patients with HIT

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ANticoagulation

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Fibrinolysis
Largest benefit when given <2 hrs after symptom onset
Recommended within 12 hours of of symptoms onset if primary PCI cannot be performed within 120 min and no contraindications
The later the patient presents, the more consideration should be given to transfer for PCI
Pre-hospital fibrinolysis reduced early mortality by 17% compared with in hospital, particularly when administered in first 2 hours.
Goal - Bolus within 10 min of STEMI Dx

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Fibrinolysis

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Fibrinolysis
Following initiation of lytic therapy, it is recommended to transfer ALL patient to PCI center
In cases of failed fibrinolysis, or if evidence of re- occlusion/reinfarction, rescue PCI is indicated
re-administration of fibrinolysis is not indicated
If Successful PCI (>50% reduction of STE at 60-90min, reperfusion arrhythmia, resolution of CP), routine early angio and PCI still recommended (2-24 hours)
reduces rates of reinfarction and recurrent ischemia

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FIbrinolysis

35. 2017 ESc guidelines fibrinolysis Adjunctive therapies in fibrinolysis
Clopidogrel added to ASA reduces risk of cardiovascular events and overall mortality in patients treated with lytics
Anticoagulation should be given until revascularization
Enoxaparin a/w reduction in the risk of death and reinfarction at 30 days when compared with UFH, at the cost of increased non cerebral bleeding complications
Net clinics benefit favored enoxaparin
Cocktail - Weight adjusted tenecteplase, ASA, clopidogrel and enoxaparin IV followed by sc until PCI

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fibrinolysis

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Fibrinolysis

38. 2017 ESC guidelines Hazards of lytics
Fibrinolysis
Hazards of lytics
small but significant excess of strokes, hemorrhagic
advanced age, lower weight, females, previous cerebrovascular disease and HTN on admission and predictors of hemorrhage
approx 1%
half dose tenecteplase by 50% if >75 years

39. fibrinolysis - contraindications
2017 ESD guidelines
fibrinolysis - contraindications