STEMI resident survival guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Alejandro Lemor, M.D. [2]

Definition

ST elevation myocardial infarction (STEMI) is a syndrome defined by symptoms of myocardial ischemia (sudden chest pain and pressure, shortness of breath) associated with persistent ECG ST elevation and subsequent release of cardiac enzymes.

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated. STEMI is a life-threatening condition and must be treated as such irrespective of the causes.

Common Causes

• Rupture of high-risk plaque in the coronary arteries
• Occlusive Thrombus

Management

Diagnostic Approach

Shown below is an algorithm summarizing the diagnostic approach to STEMI based on the 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction

Characterize the symptoms: ❑ Chest pain ❑ Sudden onset ❑ Described as a sensation of tightness, pressure, or squeezing ❑ Radiation to the jaw or left arm ❑ No relief with medications or rest ❑ Worse with time ❑ Shortness of breath (Dyspnea) ❑ Diaphoresis ❑ Light-headedness ❑ Nausea and/or vomiting

Obtain a detailed history: ❑ Age ❑ Previous MI ❑ Previous PCI or CABG ❑ Cardiac risk factors: ❑ Hypertension ❑ Diabetes ❑ Hypercholesterolemia ❑ Smoking ❑ Obesity

Examine the patient: ❑ Measure the blood pressure ❑ Measure the heart rate ❑ Auscultate the heart searching for murmurs ❑ Search for signs of CHF ❑ Decreased air entry in the lungs ❑ Edema in the extremities

Rule out life threatening alternative diagnoses: ❑ Aortic dissection ❑ Pulmonary embolism ❑ Cardiac tamponade ❑ Tension pneumothorax ❑ Esophageal rupture

Order labs and tests:

Order EKG ❑ New ST elevation at the J point in at least 2 contiguous leads of 2 mm (0.2 mV) in men or 1.5 mm (0.15 mV) in women in leads V2–V3 and/or of 1 mm (0.1 mV) in other contiguous chest leads or the limb leads ❑ For EKG examples click here

Order Cardiac Enzymes ❑ Troponin I ❑ CK-MB

Other labs: ❑ Creatinine ❑ Glucose ❑ Hemoglobin

❑ Symptoms + increase in Troponin + EKG ST elevation

Start treatment for STEMI

Therapeutic Apporach

Shown below is an algorithm depicting the therapeutic approach to STEMI based on the 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction.

Initial Treatment ❑ Administer 300 mg aspirin ❑ Administer oxygen in patients with saturation <90% ❑ Administer sublingual nitroglycerine, (0.4-0.8 mg) ❑ Administer morphine IV (initial dose 2-4 mg with increments of 2-8 mg every 5 to 15 minutes) ❑ Administer beta-blockers (unless contraindicated) ❑ Administer statins (atorvastatin, 80 mg) ❑ Administer antithrombotic treatment ❑ Fondaparinux, or ❑ UFH in case of renal failure

Is PCI available?

Yes

No

❑ Send to cath lab for primary PCI

Evaluate for ❑ The time from onset of symptoms ❑ The risk of complications related to STEMI ❑ The risk of bleeding with fibrinolysis ❑ The presence of shock or severe HF ❑ The time required for transfer to a PCI-capable hospital

Adjunctive Antithrombotic Therapy to Support Reperfusion With Primary PCI

❑ Transfer for primary PCI ❑ FMC to device time as soon as possible and ≤ 120 min.

❑ Administer fibrinolytic agent within 30 min of arrival

Antiplatelet Therapy ❑ P2Y12 receptor inhibitors ❑ Clopidogrel (600 mg), or ❑ Ticagrelor (180 mg), or ❑ IV GP IIb/IIIa inhibitors ❑ Abciximab ❑ Loading dose 0.25 mg/kg IV bolus ❑ Maintenance dose 0.125 mg/kg/min, or ❑ Eptifibatide ❑ Loading dose 180 mcg/kg IV bolus followed by another bolus after 10 minutes ❑ Maintenance dose 2 mcg/kg/min, or ❑ Tirofiban ❑ Loading dose 25 mcg/kg ❑ Maintenance dose 0.15 mcg/kg/min

Anticoagulant Therapy ❑ UFH ❑ With GP IIb/IIIa receptor antagonist planned: 50- to 70-U/kg IV bolus to achieve therapeutic ACT of 200-250 s. ❑ With no GP IIb/IIIa receptor antagonist planned: 70- to 100-U/kg bolus to achieve therapeutic ACT of 250-300 s. ❑ Bivalirudin: 0.75-mg/kg IV bolus, then 1.75–mg/kg/h infusion with or without prior treatment with UFH. An additional bolus of 0.3 mg/kg may be given if needed.

UFH: Unfractionated Heparin; ACT: Activated clothing time

References

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