STEMI Cases and the ESC STEMI Guidelines Frans Van de Werf, MD, PhD Leuven, Belgium
The Easy Case 2/21/2011
History and Risk Factors 50-year old male patient Past medical history: Teratoma right testis R/resection & chemor/ Arthrosis right knee Mdi Medication: glucosamine, chrondroitinsulfate t Cardio-vascular risk factors: High blood cholesterol +++ Hypertension - Diabetes - Smoking - Heredity -
Current presentation Chest pain ± 2h, irradiating towards both arms Admitted to University Hospital Leuven Blood-pressure: 147/70 mmhg Pulse: 69/ General clinical examination: nil abnormal Urgent ECG: ST-elevation anterior leads Treatment in E.R. : prasugrel 60 mg po, ASA 500 mg iv, heparin 5000 IU iv Immediate transfer to cath-lab
ECG 2/21/2011
Angiogram Pre and dp Post PCI 2/21/2011
First injection 2/21/2011
Final Injection 2/21/2011
ECG 2/21/2011
..more difficult now What would be the strategy if the same patient would have been admitted to a community hospital without a cath lab 80 km away from a PCI center? - transfer? - thromnbolysis? -if transfer which medication during transport? 2/21/2011
Pre-hospital Management *Symptoms compatible with STEMI Pre-hospital diagnosis, triage and care EMS GP/cardiologist Self-decision * 24/7 service Ambulance Private transportation PCI-capable hospital Transfer Non-PCI-capable hospital EMS: Emergency Medical System; STEMI: Acute ST-segment Elevation Myocardial Infarction; GP: General Practitioner; PCI: Percutaneous Coronary Intervention Thick arrows: preferred patient flow; dotted line: to be avoided
Reperfusion Strategies
Rate of Ischemic Events at the Available Follow-up Time from Fibrinolysis to Routine Early PCI (hr) 1.6 2.3 3.7 3.9 16.7 2.7
A very difficult case 2/21/2011
82-year old woman Past medical history: Hysterectomy y History and Risk Factors Diabetes Mellitus II R/ sugar-free diet Biliary stones Atrial fibrillation Medication: bisoprolol bisoprolol 10 mg, amlodipine 5 mg, ramipril 5 mg, fenprocoumon Cardiovascular risk factors: High blood cholesterol - Hypertension ++ Diabetes + Smoking - Heredity -
Current presentation ti Central chest pain ±5h Blood pressure 90/40 mmhg Pulse 65/ Cold extremities, tachypneu Urgent tecg ECG: inferior i ST-elevation Treatment in E.R. : ASA 500 mg iv, clopidogrel copdog 600 mg po, heparin 5000 IU iv Immediate transfer to cath-lab
Coronary angiography Occluded proximal RCA Severe left main stenosis
PCI RCA Residual thrombus After wiring After thrombectomy and balloon dilatation
PCI RCA Aspirated thrombus Repeat thrombectomy Final result RCA
Ongoing hemodynamic instability IABP
First Injection 2/21/2011
Wiring 2/21/2011
After wiring and thrombus aspiration 2/21/2011
Last injection 2/21/2011
IABP 2/21/2011
Ongoing hemodynamic instability despite IABP & Inotropic support Referred for urgent CABG: LIMA > LAD, Venous jump graft > CX > PD Multiple organ failure at ICU 11 days after initial presentation
TIMI Risk Score for STEMI Morrow et al. Circulation 2000
Discussion i Points Time is muscle in the real world 2/21/2011
The Importance of Time to Treatment A Meta-analysis analysis of 50,246 Pts in placebo controlled trials of Lytic Therapy s efitt Patients ute Bene Treated Absolu 1,000 T 80 60 40 20 per 0 0 3 6 9 12 15 18 21 24 Time to Treatment Time to Treatment Boersma E, et al. Lancet. 1996; 348: 771-5 2/21/2011
Relationship Between Myocardial 100 Salvage and Survival 80 Mortality reduction (%) 60 % Modifying factors 40 Collaterals Ischemic preconditioning 20 MVO 2 0 Hours Extent of salvage (% of area at risk) 1 3 6 12 24 Treatment objectives Time to treatment is critical Gersh B. JAMA 2005 Opening the IRA (PCI > lysis)
Recommended Logistics Pre-hospital triage/care: EMS unique telephone number tele-consultation Ambulance 12-ECG recorder/defibrillator ill Networks: staff able to provide basic and advanced life support implementation of a network of hospitals with different levels of technology connected by an efficient ambulance service using the same protocol Targets: < 10 min ECG transmission < 5 min tele-consultation < 120 min to first balloon inflation < 30 min start fibrinolytic therapy
HORIZONS-AMI: Mdi Median Door-to to-balloon Bll Times Blankenship et al Am J Card 2010;106:1527 2/21/2011
Mortality Estimates for 6209 Danish Patients With STEMI Treated With Primary PCI Terkelsen, C. J. et al. JAMA 2010;304:763-771.
STrategic Reperfusion Early After MI Patients presenting with STEMI <3 hrs from onset of symptoms that cannot reliably undergo primary PCI <60 min Group A Group B amb bulance Cath la ab hospital <75 years: TNK Routine ASA Clopidogrel: LD 300 mg + 75 mg QD Enoxaparin: 30 mg IV + 1 mg/kg SC Q12h 75 years: 1/2TNK Routine ASA Clopidogrel: 75 mg QD Enoxaparin: 0.75mg/kg SC Q12h ECG at 90 min: ST resolution 50% YES Diagnostic angiography + PCI / stent, if indicated > 6 hrs / < 24 hrs NO Rescue angiography + PCI / stent immediately ASA, No lytic Antiplatelet and anticoagulation treatment according to local standards Standard angiography + PCI / stent immediately Amb ulance cath lab
Two unusual cases (on movies only) 2/21/2011
An Unusual Case 1 2/21/2011
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Unusual Case 2 2/21/2011
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