1. STEMI Update 2017 Cardiology Today
11/22/2017 5:39 AM
STEMI Update 2017 Cardiology Today
Michael C Fraizer, MD
Iowa Heart Center
Feb 4, 2017
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2. Disclosures AstraZeneca Mount Sinai Heart St. Jude Medical
Yale University School of Medicine
Employee-Iowa Heart Center/Mercy-Des Moines

3. Vascular Biology

4. Natural History of CAD : A story of remodeling

5. ACC2014 NSTE slide set

7. Spectrum of ACS Presentations
UA NSTEMI STEMI
Definition
Ischemia without necrosis
Necrosis (nontransmural)
Transmural necrosis
Diagnosis
Negative Biomarkers
Positive biomarkers Positive biomarkers
No ECG ST-segment elevation
ECG ST-segment elevation
Treatment
Invasive or conservative depending on risk
Immediate reperfusion
Roger VL, Go AS, Lloyd-Jones DM, et al.. Circulation. 2011;123:e18-e209. 7

8. Cardiac-specific troponins are optimum biomarkers (Level IC)
Timing of Release of Various Biomarkers After Acute Myocardial Infarction
Cardiac-specific troponins are optimum biomarkers (Level IC)
For STEMI, reperfusion therapy should be initiated as soon as possible and is not contingent on a biomarker assay (Level IC)
Shapiro BP, Jaffe AS. Cardiac biomarkers. In: Murphy JG, Lloyd MA, editors. Mayo Clinic Cardiology: Concise Textbook. 3rd ed. Rochester, MN: Mayo Clinic Scientific Press and New York: Informa Healthcare USA, 2007:773–80.
Anderson JL, et al. J Am Coll Cardiol 2007;50:e1–e157, Figure 5.

9. STEMI: scope of problem

10. STEMI: Definitions and Diagnosis
ST elevation
Men >=2.0mm in V2-V3 and/or >=1.0 mm in limb leads (2 contiguous leads)
Women >=1.5mm in V2-V3 and/or >=1.0 mm in limb leads (2 contiguous leads)

11. STEMI: Definitions and Diagnosis
ST elevation
Men >=2.0mm in V2-V3 and/or >=1.0 mm in limb leads (2 contiguous leads)
Women >=1.5mm in V2-V3 and/or >=1.0 mm in limb leads (2 contiguous leads)
(New LBBB or significant ST depression in V1-V4 may signify true posterior MI)

12. STEMI: Definitions and Diagnosis
ST elevation
Men >=2.0mm in V2-V3 and/or >=1.0 mm in limb leads (2 contiguous leads)
Women >=1.5mm in V2-V3 and/or >=1.0 mm in limb leads (2 contiguous leads)
(New LBBB or significant ST depression in V1-V4 may signify true posterior MI)
Signs/symptoms consistent with MI (lasting >15min and <12 hours)

13. STEMI: Definitions and Diagnosis
ST elevation
Men >=2.0mm in V2-V3 and/or >=1.0 mm in limb leads (2 contiguous leads)
Women >=1.5mm in V2-V3 and/or >=1.0 mm in limb leads (2 contiguous leads)
(New LBBB or significant ST depression in V1-V4 may signify true posterior MI)
Signs/symptoms consistent with MI (lasting >15min and <12 hours)
**Goal ECG within 10 minutes of patient arrival

14. Key Features of an ECG
Marieb EN, Hoehn K. Human Anatomy and Physiology. 8th ed. San Francisco, CA: Pearson Benjamin Cummings; 2010.

15. Normal 12-lead ECG LATERAL ANTERIOR LATERAL INFERIOR
Accessed Aug

16. Where is the STEMI?

17. Where is the STEMI?
Anterior and lateral- large vascular territory!

18. Where is the STEMI?

19. Where is the STEMI?
Inferior (with RV involvement)

20. Where is the STEMI?

21. Where is the STEMI?
Everywhere? No, pericarditis…

22. Thygesen, K. et al. Circulation 2007;116:2634-2653

23. Thygesen, K. et al. Circulation 2007;116:2634-2653

24. Differential Dx for ACS Chest Pain Syndromes (beyond STEMI, NSTEMI, UA)
Aortic dissection
Pulmonary embolus
Perforating ulcer
Pericarditis
GERD (Gastroesophageal reflux disease)
Heart failure, Pneumonia, Pneumothorax

25. Differential Dx for ACS Chest Pain Syndromes (beyond STEMI, NSTEMI, UA)
Aortic dissection
Pulmonary embolus
Perforating ulcer
Pericarditis
GERD (Gastroesophageal reflux disease)
Heart failure, Pneumonia, Pneumothorax

26. STEMI: First things first
Titrate oxygen (starting at 2L/min) to maintain SpO2 between 90%-94%
Cardiac Monitor & attach hands-free defibrillator pads
NTG 0.4mg SL every 5 min or Nitropaste PRN for chest pain (hold for SBP < 90)
Analgesia (Morphine sulfate or Fentanyl) IV PRN for pain
Establish IV, basic labs

27. STEMI: Critical decision time How to achieve reperfusion?
PRIMARY PCI Pathway – FMC to PCI less than
120 minutes – ACTIVATE CATH LAB
Goal: Door-in to Door-out in < 30 minutes

28. STEMI: Critical decision time How to achieve reperfusion?
PRIMARY PCI Pathway – FMC to PCI less than
120 minutes – ACTIVATE CATH LAB
Goal: Door-in to Door-out in < 30 minutes
2. FIBRINOLYSIS Pathway - FMC to PCI anticipated to be > 120 min (continued)
Goal: Door to Needle < 30 minutes

29. Importance of Rapid Reperfusion in STEMI
30-minute delay = 8% increase in 1-year mortality
Rathore SS, Curtis JP, Chen J, et al. BMJ. 2009;338:b1807.
Antman E. ST-segment elevation myocardial infarction: Management. In: Bonow RO, Mann DL, Zipes P, et al, eds. Braunwald's Heart Disease. 9th ed. Philadelphia, PA: Elsevier Saunders; 2011a: 29

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

31. Initiate Medical therapy
Aspirin 324 mg PO chewable
IV heparin (70units/kg, max 4000 units)
Antiplatelet: Ticagrelor 180mg once
May also consider clopidogrel or prasugrel
Consider metoprolol if patient hypertensive
DO NOT give BBs to patients with CHF or low output (shock) states

32. STEMI Outcomes in patients with STEMI and planned PCI
Ticagrelor compared with clopidogrel in patients with acute coronary syndromes the PLATelet Inhibition and patient Outcomes trial
Outcomes in patients with STEMI and planned PCI
Ph.Gabriel Steg*, Stefan James, Robert A Harrington, Diego Ardissino, Richard C. Becker, Christopher P. Cannon, Håkan Emanuelsson, Ariel Finkelstein, Steen Husted, Hugo Katus, Jan Kilhamn, Sylvia Olofsson, Robert F. Storey, Douglas Weaver, Lars Wallentin, for the PLATO study group
*Unité INSERM U-698
Hôpital Bichat – Claude Bernard
Université Paris VII – Denis Diderot
The PLATO trial was funded by AstraZeneca 32

33. Primary endpoint: CV death, MI or stroke12 11 10 9 8 7 6 5 4 3 2 1
Clopidogrel
11.0
9.3
Ticagrelor
K-M estimated rate (% per year)
HR: 0.85 (95% CI = 0.74–0.97), p=0.02
Months
No. at risk
Ticagrelor
4,201
3,887
3,834
3,732
3,011
2,297
1,891
Clopidogrel
4,229
3,892
3,823
3,730
3,022
2,333
1,868 33

34. Conclusions
Reversible, more intense P2Y12 receptor inhibition for one year with ticagrelor in comparison with clopidogrel in patients with STEMI intended for reperfusion with primary PCI provides
Reduction in composite of CV death, MI or stroke
Reduction in MI and stent thrombosis
Reduction in total mortality
No increase in the risk of major bleeding
The NNT (number needed to treat) to avoid one primary endpoint (CV death, MI or stroke) is 59
The mortality reduction is afforded on top of modern care
Ticagrelor may become a new standard of care for the management of patients with STEMI intended for primary PCI 34

35. Fibrinolytic therapy
Pharmacological “clot buster

36. 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%

37. Table 6. Contraindications and Cautions for Fibrinolytic
● Any prior ICH
● Known structural cerebral vascular lesion (e.g., AVM)
● Known malignant intracranial neoplasm (primary or metastatic)
● Ischemic stroke within 3 mo
● EXCEPT acute ischemic stroke within 4.5 h
● Suspected aortic dissection
● Active bleeding or bleeding diathesis (excluding menses)
● Significant closed-head or facial trauma within 3 mo
● Intracranial or intraspinal surgery within 2 mo
● Severe uncontrolled HTN hypertension (
JACC Vol. 61, No. 4, 2013

38. The Primary Coronary Angioplasty Trialists
The PCAT Collaboration
The Primary Coronary Angioplasty Trialists
11 prospective, randomized trials of
thrombolytic therapy vs. primary PTCA
2,725 patients randomized
streptokinase trials, 699 rand. pts
3 t-PA trials with 3-4º dosing, 588 rand. pts
3 accelerated t-PA trials, 1437 rand. pts
All study data pooled for true meta-analysis

39. 30 Day Mortality with Reperfusion Therapy in AMI
Meta-Analysis Comparison
17%; p<0.0001
34%; p=0.02
Death, %
Placebo
Lytic
PTCA
11 PTCA-lytic trials
(n=2,606) - PCAT
9 placebo controlled
lytic trials (n=58,800)
FTT: 39

40. PCAT: Stroke % Hemorrhagic stroke All stroke 2.5 P=0.02 P=0.002 1.88 2
1.45
1.5
P=0.02
1.09 % 1
0.80
0.66
0.5
0.22
0.07
0.07
In-hospital
30 days
In-hospital
30 days
Hemorrhagic stroke
All stroke

41. PCI vs Fibrinolysis for STEMI:
Short-Term Clinical Outcomes
PCI
N=7739
Fibrinolysis
P<.0001
Frequency (%)
P<.0001
P=.0002
P=.0003
P<.0001
P=.032
Metaanalysis of 23 trials, which together randomly assigned 7739 thrombolytic-eligible patients with ST-segment elevation AMI to primary PTCA (n=3872) or thrombolytic therapy (n=3867). Streptokinase was used in eight trials (n=1837), and fibrin-specific agents in 15 (n=5902). Most patients who received thrombolytic therapy (76%, n=2939) received a fibrin-specific agent.
P=.0004
P<.0001
Death
Death, no shock data
ReMI
Rec. Ischemia
Total Stroke
Hem. Stroke
Major Bleed
Death MI CVA
Keeley E, et al. Lancet ;361:13-20
Keeley E, et al. Lancet ;361:13-20.

42. The Goal
Patient point-of-entry (POE) protocols should be developed with the understanding that a patient may call and be in an EMS zone that transports to a STEMI-referral or STEMI-receiving hospital. Also, patients may directly present to a non-PCI center and be in need of inter-hospital transfer or present to a primary PCI center.
The ACC/AHA guidelines encourage EMS on scene be equipped with 12-Lead ECG technology. Advanced systems may consider pre-hospital fibrinolysis, but the majority in the U.S. EMS should have a destination protocol in place.
[Note to Presenter: Following text from the 2004 Full Text STEMI ACC/AHA Guidelines caption (pg 19).]
Patient transported by EMS after calling
1: Reperfusion in patients with STEMI can be accomplished by the pharmacologic (fibrinolysis) or catheter-based (primary PCI) approaches. Implementation of these strategies varies based on the mode of transportation of the patient and capabilities at the receiving hospital. Transport time to the hospital is variable from case to case, but the goal is to keep total ischemic time within 120 minutes. There are three possibilities:
a) If EMS has fibrinolytic capability and the patient qualifies for therapy, pre-hospital fibrinolysis should be started within 30 minutes of EMS arrival on scene;
b) If EMS is not capable of administering pre-hospital fibrinolysis and the patient is transported to a non-PCI-capable hospital, the hospital door-to-needle time should be within 30 minutes for patients in whom fibrinolysis is indicated;
c) If EMS is not capable of administering pre-hospital fibrinolysis and the patient is transported to a PCI-capable hospital, the hospital door-to-balloon time should be within 90 minutes.
Inter-hospital transfer:
It is also appropriate to consider emergency inter-hospital transfer of the patient to a PCI-capable hospital for mechanical revascularization if:
1: There is a contraindication to fibrinolysis;
2: PCI can be initiated promptly (within 90 minutes after the patient presented to the initial receiving hospital or within 60 minutes compared to when fibrinolysis with a fibrin-specific agent could be initiated at the initial receiving hospital); fibrinolysis is administered and is unsuccessful (i.e.,"rescue PCI").
Secondary non-emergency inter-hospital transfer can be considered for recurrent ischemia.
Patient self transport:
Patient self-transportation is discouraged. If the patient arrives at a non-PCI capable hospital, the door-to-needle time should within 30 minutes. If the patient arrives at a PCI-capable hospital, the door-to-balloon time should be within 90 minutes. The treatment options and time recommended after first hospital arrival are the same.

44. 2015 ACC/AHA/SCAI Focused Update on Primary PCI for Patients with STEMI: An Update of the 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention and the ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction
Developed in Collaboration with the American College of Emergency Physicians
© American College of Cardiology Foundation, American Heart Association, and Society for Cardiovascular Angiography and Interventions

45. 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction
Developed in Collaboration with American College of Emergency Physicians and Society for Cardiovascular Angiography and Interventions
© American College of Cardiology Foundation and American Heart Association, Inc.

46. Citation
This slide set is adapted from the 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction (Journal of the American College of Cardiology). Published on December 17, 2012,
The full-text guidelines are also available on the following Web sites:
ACC ( and AHA (my.americanheart.org)