STEMI 4.0

“ Pharmacoinvasive era”

Tanyarat Aramsareewong, MD

Cardiovascular Intervention

Association of Thailand

Q1 ผปวยใดตอไปน มโอกาสเปน STEMI

นอยทสด ?

• A. ชาย 45 ป เจบหนาเกน 20 นาท รวมกบอาการเหงอออก • B. หญง 35 ป เจบหนาอกนานเกน 1 เดอน ตอเนองกน • C. หญง 60 ป หนามดหมดสต ( syncope or Cardiac

arrest ) • D. หญง 65 ป เหนอยหายใจไมคลอง นอนราบไมไดมา 1 ชวโมง • E. ชาย 50 ป เปนเบาหวาน จกแนนลนป 1 ชวโมง https://www.facebook.com/perfectheartfoundation/

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Ischemic symptoms

DM , renal insufficiency, dementia : presented with atypical pain

( indigestion , diaphoresis ,non specific dyspnea or syncope )

ผปวยใดตอไปน มโอกาสเปน STEMI

นอยทสด ?

• A. ชาย 45 ป เจบหนาเกน 20 นาท รวมกบอาการเหงอออก • B. หญง 35 ป เจบหนาอกนานเกน 1 เดอน ตอเนองกน • C. หญง 60 ป หนามดหมดสต ( syncope or Cardiac

arrest ) • D. หญง 65 ป เหนอยหายใจไมคลอง นอนราบไมไดมา 1 ชวโมง • E. ชาย 50 ป เปนเบาหวาน จกแนนลนป 1 ชวโมง

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Ischemic heart disease

ISH

Stable Coronary syndrome

Obstructive CAD INOCA

Acute coronary syndrome

STEMI NSTEMI-

ACS/Unstable angina-ACS

MINOCA

INOCA = ischemia and no obstructive coronary disease MINOCA = Myocardial infarction and no obstructive coronary disease

Acute coronary syndrome

• STEMI ( chest pain >20 min)

• NSTEMI -ACS ( NSTE-ACS )

– NSTEMI - ACS ( troponin positive )

– Unstable angina – ACS

1. 2014 ACC/AHA Guidelines for the management patients with non-ST-elevation-ACS

2. 2014 ESC/EACTS Guidelines on myocardial revascularization

3. 2015 ESC/ Guidelines on NSTEMI

4. 2017 ESC/ Management of STEMI

Acute Coronary Syndromes Type I MI

Plaque rupture, ulcer,

erosion, dissection

Stable

angina

Unstable

angina

Non-Q

wave MI

ST elevation ACS Non-ST elevation ACS

ECG

Q wave

MI

NSTEMI STEMI Normal ECG 1-6 %

Non obstructive

coronary for 5-20%

hs Troponin increase 4% (A), 20% ( R )

Q2 Pharmacoinvasive ?

• A. Primary PCI

• B. Rescue PCI

• C. Routine early PCI after fibrinolysis

• D. B and C

• E. Any PCI after fibrinolysis

Pharmacoinvasive ?

• A. Primary PCI

• B. Rescue PCI

• C. Routine early PCI after fibrinolysis

• D. B and C

• E. Any PCI after fibrinolysis

2017 news/revise concept

• Strategy selection and time delays (120

minutes)

• Clear definition of first medical contact ( FMC)

• Definition of “ time 0” to choose reperfusion

strategy ( Clock starts at the time of diagnosis )

• Selection of PCI over fibrinolysis: When “ STEMI

diagnosis “ to wire crossing < 120 minutes )

• Diagnosis STEMI to needle is 10 mins

• DTB eliminate from guideline

2017 news/revise concept

• Time Limits from routine opening of and IRA

– 0-12 ( I )

– 12-48 ( IIa )

– >48 hr ( III )

• ECG at presentation

– LBBB and RBBB consider equal for recommendation urgent

angiography if ischemic symptom

• Time to angiography after fibrinolysis

– 2 to 24 hours

57 years old man presented with chest pain for 4 hours underlying DM

14

From PAMI to 23 RCT trial ( NNT 43 )

Absolute contraindication for Fibrinolytic therapy ( 611)

Relative- contraindication

ยา Fibrinolysis ททานเคยใช ?

• A.ไมเคยเลยสกตว

• B. Streptokinase

• C. tPA ( alteplase )

• D. TNK ( Metalyse )

• E. rPA ( reteplase )

Immediate ED general treatment

• O2 at 4 L/min; if O2 sat < 90%

• Aspirin 160 mg to 325 mg ( gr V chewable )

• NTG SL , spray ( not more than 3 dose, interval 3-5

minutes ) or IV ( BP > 90 mmHg and no-more 30 mmHg

below baseline, HR 50- 100 bpm)

• Alteplase ( rt-PA )

– 15 mg IV bolus

– 0.75 mg/kg IV over 30 min ( up t 50 mg)

– 0.5 mg/lg IV over 60 min ( up to 35 mg )

• P2Y12 inhibitor for fibrinolysis

•Clopidogrel 300 mg load ( 4 tables ) No loading if age > 75 years

Fibrinolysis

• Actilyze

– 50 mg/vial power x 2

– Cost 20,865 baths x 2 = 41,730 baths

– Reimbursement 50,000 baths ( Heparin intravenous (IV): 5,000 units IV bolus as soon as possible, followed by 1,000 units per hour

continuous IV infusion for at least 48 hours; GUSTO 1 regimen )

• SK 1.5 million unit over 30-60 minutes

– Cost 8,110 บาท – Reimbursement 10,000 baths

• Metalyze

– 40 mg vial ( < 80 kgs)

– Cost 39,804 ( ราคาราชวถ ) -- 22,000 ( NLEM 25 April 2560 )

– Reimbursement 50,000

Tenecteplase ( TNK )

F. Van de Werf, ACC 2013

62

Sx onset

61

1 Hour 2 Hours

29 9

Rx TNK

31 86

Sx onset

Rx PPCI

100 min

178 min

MEDIAN TIMES TO TREATMENT (min)

36% Rescue PCI at 2.2h

n=1892

64% non-urgent cath at 17h

1st Medical

contact Randomize IVRS

1st Medical

contact Randomize IVRS

F. Van de Werf, ACC 2013

SINGLE ENDPOINTS UP TO 30 DAYS

Pharmaco-invasive

(N=944)

PPCI

(N=948)

P-value

All cause death

Cardiac death

(43/939) 4.6%

(31/939) 3.3%

(42/946) 4.4%

(32/946) 3.4%

0.88

0.92

Congestive heart

failure

(57/939) 6.1% (72/943) 7.6% 0.18

Cardiogenic shock (41/939) 4.4% (56/944) 5.9% 0.13

Reinfarction (23/938) 2.5% (21/944) 2.2% 0.74

Dose of fibrinolytic agents

Q3 Which finding classified as Fail fibrinolysis

• A. Disappearance of chest pain

• B. ST segment resolution > 50% at 60-90

minutes

• C. Sustained VT ( with hypotension )

• D. AIVR ( arrhythmia )

• E. C and D

After fibrinolysis chest pain 8/10

• ST segment resolution > 50% at 60-90

minutes X

• Typical reperfusion arrthythmia X

– No ( AIVR)

• Disappearance of chest pain X

• Early peak of cardiac marker X

Which finding classified as Fail fibrinolysis

• A. Disappearance of chest pain

• B. ST segment resolution > 50% at 60-90

minutes

• C. Sustained VT ( with hypotension )

• D. AIVR ( arrhythmia )

• E. C and D

31

PMK Cardiology Review PMK Cardiology Review

Rescue PCI

Culprit lesion ( IRA ) in mid LAD

31

Case-2

• A 77 year olds male presented with severe central

chest pain started from 3.00 am ( 3 hrs before arrived

hospital ) .

• Underlying disease : Hypertension on medications ,

Exsmoker for 10 years.

• BP 140/80 mmHg HR = 86 bpm BW = 57 kgs, Height =

168 cm

• Lung : clear

• Heart : regular , No murmur

First EKG at 6.34 am

SK 1.5 mu was given at 7.40 am

clexane 0.3 IV then 0.6 sc q 12 hrs ( Crcl = 44 )

34

Intracranial haemorrhage and mortality of available

thrombolytic agents ( save 30 in 1000 in 6 hours)

0.93

6.17

0.94

6.15

0.72

6.3

0.54

7.4

0.37

9.53

0.91

7.47

0.77

9.02

0

2

4

6

8

10

12

Intracranial haemorrhage Mortality

Perc

enta

ge

TNK in ASSENT-2

rt-PA in ASSENT-2

rt-PA in GUSTO I

SK in GUSTO I

SK in INJECT

rPA in GUSTO III

rPA in INJECT

EKG after SK ( 8.22 am )

with persistent chest pain 5/10

Clopidogrel 300 mg plus aspirin 325 mg

EKG at second hospital 14.44 pm pain

score 3/10 ( 6 hrs after SK, 11 hrs after onset )

16.00 pm star procedure, heparin 4,000 unit was given ( 8

hrs after last dose of enoxaprarin

Left dominant with ostial LAD lesion

Long lesion in proximal to mid LAD

37

PMK Cardiology Review PMK Cardiology Review

37

Double bolus dose of integrillin

Before stent After DES stent

38

PMK Cardiology Review PMK Cardiology Review

38

17.01 pm transfer patient to CCU with out any

complications : ACT = 427 sec

Sheath removal with TR band 14 cc ,

No bleeding, No hematoma

Finally 3 TR bands , bleeding stop

after 24 hours of SK

Q4 What dosage of medications incorrect in this case

• A. SK 1.5 million unit over 60 minutes

• B. Aspirin 325 mg loading dose then 81

mg od

• C. Clopidogrel 300 mg loading dose then

75 mg od

• D. Enoxaparin 0.3 mg IV then 0.6 sc q 12

hours

• E. Heparin 4000 unit IV before PCI ( after enoxaprin 8 hours )

• Aspirin 325 mg loading dose ( I )

• 81-325 mg daily maintenance dose ( I )

• 81 mg maintenance dose ( IIa )

• P2Y12 receptor inhibitor ( I )

Clopidogrel

• Age < 75 y : 300 mg loading followed by 75 mg for

at least 14 days

• Age > 75 y : No loading dose followed by 75 mg/day for 14 days

Antiplatelete with fibrinolysis

Fibrinolysis therapy ( prevent 30 early death in 1000 )

6% in UK, 7% in Poland, 8% in France

Mortality rate STEMI in Europe = 3%

Fibrinolytic therapy

STEMI < 6 h Lytic eligible

Lytic choice by MD

(TNK, tPA, rPA, SK 20%)

ENOX

< 75 y: 30 mg IV bolus

SC 1.0 mg / kg q 12 h (Hosp

DC)

≥ 75 y: No bolus

SC 0.75 mg / kg q 12 h (Hosp DC)

CrCl < 30: 1.0 mg / kg q 24 h

Double-blind, double-dummy

ASA

Day 30

1° Efficacy Endpoint: Death or Nonfatal MI

1° Safety Endpoint: TIMI Major Hemorrhage

Extract TIMI 25

UFH

60 U / kg bolus (4000 U)

Inf 12 U / kg / h (1000 U / h)

Duration: at least 48 h

Cont’d at MD discretion

What dosage of medications incorrect in this case

• A. SK 1.5 million unit over 60 minutes

• B. Aspirin 325 mg loading dose then 81

mg od

• C. Clopidogrel 300 mg loading dose then

75 mg od

• D. Enoxaparin 0.3 mg IV then 0.6 sc q 12

hours

• E. Heparin 4000 unit IV before PCI ( after enoxaprin 8 hours )

Selected routine medical RX

Generic Start Max dose

Beta-blocker

Heart failure and LV

dysfuction

COMMIT , CAPRICORN

Metoprolol

Carvidilol

tartate (25-50 mg )q 12

6.25 mg q 12

200 /day

25 mg q 12

ACEI ( anterior wall, LV <

40 , DM)

SAVE, AIR, TRACE

Captopril

Ramipril

Enalapril

6.25 mg q 8

2.5 mg q 12

2.5 mg q 12

50 mg q 8

5 mg q 12

10 mg q 12

ARB ( VALIANT) Valsartan 20 mg q 12 160 mg q 12

Aldosterone

LVEF < 40 , DM

EPHESUS

Aldactone 25 mg od 25 -50 od

Statin

PROVE- IT

MIRACL

Atorvastatin 80 mg Avoid fibrate, CYP3A4

Check list before discharge

48

Anterior wall MI, DM, HT , HF

IIa in every case with out contraindication

Discontinue antithrombotic drugs

before PCI

Drug Haft life D/C before PCI

Heparin 1.5 3-4 hours

LMWH 6-8 12 hours

Fondaparinux 17 24 hours

Continue all antiplatelet to PCI

Length of stay

• Monitor ECG 24 hours

• Low risk 2-3 days after PCI

• Low risk ( PAMI criteria )

– Age < 70 years

– LVEF > 45 %

– One or two vessel disease

– Successful PCI

– No persistent arrhythmia

Q5 : What is the most powerful factors to decreased mortality after MI ?

• A . Stop smoking

• B. Weight reduction

• C. Increase physical activity

• D. Limit sexual activity

• E. Psychosocial factor ( CBT )

Long term therapy for STEMI

• Stop smoking ( decreased mortality 36% )

– Buproprione and varenicline , Nicotine replacement

– electrical cigarettes with nicotine ?

• Diet and weight control

– BMI > 20 , < 25 kg/m2 , Waist Circumferential > 102 cm in male,

88 cm in women

• Physical activity ( 22% Decreased Vascular death ) 8-24 weeks

• Psychosocial factor intervention (CBT 45% MI )

• Resumption of activities

– Sexual activity can be resumed early if adjusted to physical

ability

– Long distance air travel in low risk ( LVEF >40%, No HF, no

residual ischemia and arrhythmia

Diet , Alcohol

• Mediterranean diet

• < 10% situated fat , Polysatuated fat avoid trans

fat

• Salt intake < 5 g/day

• 30-45 g fiber/day

• > 200 g fruit and > 200 g vegetable

• Fish 2 times a week , 30 g unsalt nut

• Alcohol 20 g/day men, 10 g/day women

• Discouraging sugar-sweetened drinks

What is the most powerful factors to decreased mortality after MI ?

• A . Stop smoking

• B. Weight reduction

• C. Increase physical activity

• D. Limit sexual activity

• E. Psychosocial factor ( CBT )

Medications and interventions for

improved survival

• AAA

– Antiplatelet ( aspirin + P2Y12 inhibitor)

– ACEI/ARB

– Aldosterone blocker

• B – Beta-blocker

• C – Cessation of Smoking

• D – Diet ( DM controlled HbA1C < 7 )

• E - Exercise ( 5 times/week ) ( 120 minutes /week moderate

intensity)

• F – Influenza vaccine

• G – Good mood ( avoid stress )

• H – ( High intensity statin, keep LDL < 70 mg/dl )

Antiplatelet after PCI in ACS

Summary

• 1. Early diagnosis and initial management

• 2. Early reperfusion strategy ( 120 minutes)

• 3. Proper antithrombotic regimen

• 4. Early hospital care

• 5. Long term therapies and secondary prevention

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Patient with an indication for OAC Undergoing PCI

Hyperglycemia

MINOCA diagnosis criteria

• Universal AMI criteria

• Non-obstructive coronary arteries on

angiography, No coronary artery stenosis

> 50% in any IRA

• No clinical specific cause of acute presentation

MINOCA Incidence 1-14% , Mortality rate 3.5% for 1 year

• 1. Atherosclerotic plaque rupture,

ulceration, fissuring erosion or coronary

dissection

• 2. Imbalance Oxygen demand and supply

( coronary spasm and coronary emboli )

• 3. Coronary endothelial dysfunction

• 4. Secondary to myocardial dysfunction

with out involvement of coronaries artery ( myocarditis or Takotsubo syndrome )

Early transfer STEMI after lysis

P2Y12 after fibrinolysis

66

Secondary PCI

GUSTO 1