Management of STEMIs

Alistair Watson

The next 6mins 20secs

Diagnosing an acute coronary syndrome
Acute Management of STEMI
Coronary Angiography and PCI
Fibrinolysis
Secondary Prevention

Diagnosing an Acute
Coronary Syndrome
Need at least 2 out of 3 of;
Symptoms of ischaemia (i.e. chest pain)
ECG changes consistent with ischaemia or
necrosis
Elevation of cardiac markers

ECG Changes and Cardiac

Markers
ECG Changes

Q wave is pathological if >25% height of R wave. Generally permanent.

Cardiac Markers
Troponin (I or T) >99th centile
rise or fall of >20% on the second sample
Peak level of elevation is 12-24hrs after onset of symptoms

Acute Management
I would adopt an ABCDE approach
All ACS patients-MONA
M Morphine (+ Metoclopramide IV for anti-emetic)
O Oxygen*
N - Nitrates
A Aspirin 300mg orally
*only if sats <94% or <88% if known COPD

If High Risk NSTEMIor STEMI MONAC (C Clopidogrel)

If unstable angina or NSTEMI- MONAF (F
Fondaparinux)

Coronary Angiography and

Primary PCI
Coronary angiography-x-rays of coronary
arteries

PCI-widening of the coronary artery, using a

balloon catheter. A metallic stent is usually
placed in the artery after dilatation.

Indications for PCI

Presentation within 12 hours of onset of
symptoms
AND
can be delivered within 120 minutes of time
when fibrinolysis could have been given.

Exception

presenting more than 12 hours after onset of symptoms if evidence of

continuing myocardial ischaemia

Fibrinolysis
alteplase, reteplase, streptokinase or
tenecteplase
Choice depends on hospital protocol

Indications for Fibrinloysis

presenting within 12 hours of onset of
symptoms
AND
primary PCI cannot be delivered within 120
minutes of the time when fibrinolysis could
have been given.

After Fibrinolysis
ECG 60-90mins after fibrinolysis
ST-segment elevation suggests failed reperfusion

If failed,
coronary angiography with follow on PCI if
indicated.

DO NOT REPEAT FIBRINOLYTIC THERAPY

Everyone ok?

Secondary Prevention
A Antiplatelets and ACE-I
B

Beta blockers and Blood Pressure

C Cholesterol and Cigarettes

D Diet and Diabetes
E

Education and Exercise

Risk Factors
Modifiable:
Hypertension
Smoking
Diabetes
Hyperlipidaemia
Obesity

Conservative
Education, Education, Education
Diet
Exercise
Weight management
Smoking cessation
Alcohol consumption

Cardiac Rehabilitation
Programme
Biopsychosocial approach
Bio-improve cardiovascular fitness
Pyscho-address exercise related anxiety and
mood
Social-support from MDT and other patients

MDT
GP
GP nurse practitioner
Smoking cessation counselor
Physiotherapist
Occupational therapist
MI Specialist nurse
Psychologist
Dietician
Consultant Diabetologist
Consultant cardiologist

Medical
ACE inhibitor
dual antiplatelet therapy (aspirin + clopidogrel)
Aspirin for life. Clopidogrel for 1 year

beta-blocker
For life if left-ventricular systolic dysfunction.
1 year if not

Statin
80mg atorvastatin

Surgical
PCI with coronary artery stents
CABG

Summary 1
Diagnosing an ACS
Acute management of a STEMI
Indications for coronary angioplasty and PCI

Summary 2
Indications for thrombolysis
Secondary Prevention-2As, 2Bs, 2Cs, 2Ds, 2Es