Outlines
Recognition
Initial management
Reperfusion strategies
Fibrinolytic therapy
Primary percutaneous coronary intervention
Coronary care unit management
CRIB
Oxygen
Continuous monitoring
Watch out for complications of STEMI
Medications
Antiplatelets - dual
Antithrombotics
ACE-i / ARBs
B-Blockers
Statins
Other medications
Nitrates
Aldosterone antagonists
Calcium antagonists
Glycoprotein IIb/IIIa receptor inhibitors
Warfarin
Risk stratifications
Secondary prevention
Cardiac rehabilitation
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1.Recognition
Patient with STEMI may presented with typical presentation of ischemic type chest pain, or atypical presentation which include unexplained nausea vomiting, weakness, dizziness, shortness of breath or non-ischemic type of chest pain. High index of suspicion is very important. Patient with suspected STEMI should be promptly evaluated and managed, in the REDZONE. Diagnosis is confirmed with an ECG, which should be done as soon as possible, and/or elevated cardiac biomarkers.
In some cases especially when patient presents early, the ECG may be normal. In this cases usually 12 lead ECG tracings is repeated at close interval of 15 minutes especially in cases with high index of suspicion. The ECG might show evolving changes indicating STEMI.
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2.Initial management
A quick targeted history is taken and relevant physical examination is done. Vital signs are noted. Patient's haemodynamics is stabilized. Patient is put on continuous cardiac monitoring and vital signs monitoring. Oxygen is given via nasal prong/facemask. 300mg aspirin is given, chewed and swallowed. 300mg clopidogrel also is given.Subligual GTN is given if chest pain persists (unless systolic blood pressure < 90mmHg). 2 large bore intravenous lines is set up and blood taken for cardiac markers, full bood count, coagulation profiles, GSH, renal profiles, glucuse level, and lipid profiles. IV morphine 2 mg is given for pain relief. It can be given every 5 - 15 minutes until pain is relieved, but, evidence of toxicity has to be monitored. IV metoclopramide 10mg is also given. Patient is assessed for reperfusion strategy.
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3.Reperfusion strategies
There are 2 choices of reperfusion strategies : 1)Fibrinolytic therapy 2)Primary percutaneous intervention. Choice of reperfusion strategy is depend upon several factors include: 1)Time from onset of symptoms 2)Time to PCI (door to balloon time) 3)Time to fibrinolysis (door to needle time) 4)Contraindication to fibrinolysis 5)High risk patients
Fibrinolytic therapy
Patient is assessed for contraindication for fibrinolytic therapy.
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| Primary PCI is preferred in these patient as mentioned in above flowchart |
The most widely used fibrinolytic agent is streptokinase. However, other type of fibrinolytic agents may be used in certain special cases, for example when streptokinase is contraindicated.
Patient is continuously monitored during streptokinase administration for progression of the disease and complication of fibrinolysis.
Successful reperfusion can be seen through several indicators.
Meanwhile, failed fibrinolysis is manifested by continuing chest pain, persistent ST segment elevation and hemodynamic instability. These patients are more likely to develop complications.The treatment of choice for this patient is rescue PCI. Second dose of a fibrinolytic agent should not be given.
Primary PCI
There are 4 types of PCI: 1)Primary PCI. 2)Facilitated PCI. 3)Rescue PCI. 4)Delayed PCI.
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4.Coronary care unit
Patient with STEMI should be admitted to coronary care unit. A period of at least 12 hours of complete bed rest is recommended. Bedside commodes and assissted bedside washing is used. Prevention of constipation with stool softeners is encouraged as valsavar maneuver has been shown to precipitate dangerous hemodynamic and electrocardiographic changes. Oxygen is usually given, but, it's used should be limited probably to the first 24 hours in uncomplicated cases. Oxygen via nasal prongs 3 litres/min is usually adequate. The aim is to maintain oxygen saturation above 95%. The general condition, vital signs, pulse oximetry and cardiac monitoring is continuously monitored, looking for complications. Complications of STEMI are shown in the table below.
Compare to uncomplicated cases, complicated cases may need longer period of monitoring in CCU.
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5.Medications
Antiplatelets and antithrombotics/anticoagulants are usually used in management of STEMI. All patients should receive 100-300mg aspirin and 300mg clopidogrel as mentioned aboved. This is followed by a maintenance dose of 75-150mg of aspirin long life and 75mg clopidogrel daily for at least a month. Choices of antithrombotic used commonly in STEMI are unfractionated heparin, low molecular weight heparin or synthetic pentasaccharide (fondaparinux).
Besides that, all patients should be on B-Blockers if there are no specific contraindications. Other medications that have been shown to improve survival if given early in patients with STEMI are ACE-inhibitors (or ARB if ACE-i intolerant) and statins. Some other medications are also been used in certain special cases of STEMI, as there is evidence that it improves the patient outcomes. These medications include nitrates, aldosterone antagonists, calcium antagonists, glycoprotein IIb/IIIa receptor inhibitor and warfarin.
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| Make sure these medications are on, before discharging your patient, unless contraindicated |
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| These medications are not routinely used in STEMI unless there is indication |
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| GP IIb/IIIa inhibitor used for primary PCI |
One should look for any contraindication before prescribing any medications.
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6.Risk stratifications
This step is important in order to determine prognosis and determine further treatment plan for the patient. It starts from admission and is a continuous process. By doing risk stratification we are able to identify: 1)patients with low risk, in whom we can allow to return to former activities early. 2)patients who need early coronary intervention. 3)patients who need CABG surgery. 4)patient who need implantable cardioverter defibrillator.There are indicators that we should seek and investigations we should done. One should have a checklist so that it can be done thoroughly.
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7.Secondary prevention
Secondary prevention is important in order to reduce risk of reinfarction and complications. These measures include:
Smoking cessation
Good dietary habit
Regular exercise
Good control of hypertension
Good glycemic control
Good cholesterol level control
Compliant to medications
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8.Cardiac rehabilitation
All patients’ post STEMI (including those post PCI or CABG surgery) should undergo cardiac rehabilitation. The aim is to improve long-term prognosis and to optimize physical, psychological and social well-being of the patient. It comprises of exercise training and education, counseling, risk factor modification and behavioral interventions. Cardiac rehabilitation should start in the cardiac care unit, and should continue until out-patient setting.
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