STEMI

Diagnosis STEMI is diagnosed when there is:

 Rise and/or fall in cardiac troponins, with at least
one value above the 99th percentile of the URL,
and accompanied with at least one;
 Clinical history consistent with chest pain of
ischaemic origin of > 30 minutes.
 ECG changes of ischaemia/ infarction and/or the
development of pathological Q waves.
 Imaging evidence of new loss of viable
myocardium or new regional wall motion
abnormality
 Identification of an intracoronary (IC) thrombus by
angiography or autopsy

ECG
• ST elevation of > 1 mm in 2 contiguous leads or
• a new onset LBBB in the resting ECG
• in a patient with ischaemic type chest pains of > 30
minutes and
• accompanied by a rise and fall in cardiac biomarkers

‘Reinfarction’ is used for MI that occurs within 28 days

of the incident event (incident MI) while recurrent MI
occurs after 28 days
History  Chest pain begins abruptly and lasts for >30
minutes
 Centre of the chest and may radiate to the jaw or
down the left arm
 may occur at rest or with activity
 tightness or heaviness in the chest, but usually
described as a pressure, squeezing or a severe
crushing pain with a sense of impending doom,
and is associated with sweating, nausea, vomiting
and shortness of breath
 burning quality and localised to the epigastria or
interscapular region

Other important points to note in the history are the

presence of:
• Previous history of ischaemic heart disease, PCI or
CABG.
• Risk factors for atherosclerosis.
• Symptoms suggestive of previous transient ischaemic
attack (TIA) or other forms of vascular disease
ECG The cut-off points for new or presumed new ST segment
elevation at the J point (in the absence of Left
Ventricular Hypertrophy (LVH) and LBBB) is:
• the presence of ≥ 0.1 mV ST segment elevation in
all leads except leads V2-V3
• a cut-off point of ≥ 0.25 mV (in males < 40 years), ≥
0.2 mV (in males ≥ 40 years) and ≥ 0.15 mV in females
is used in leads V2-V3

Patients with ischaemic type chest pain > 30 minutes

and new presumed new RBBB accompanied with:
• ST segment elevation ≥ 1 mm - should be managed
as STEMI
• ST-segment depression or T wave abnormalities
(excluding those in leads V1–V4) – should be managed
as NSTEMI. If pain persists, they should be considered
for an early PCI strategy

In those with ST segment depression in leads V1-

V3, it is advisable to have an ECG recording of the
posterior chest wall (V7-V9) to identify a true infero-
basal (formerly known as infero-posterior) STEMI
Serum cardiac 1. Cardiac Troponin T (cTnT) and Cardiac Troponin I
biomarkers (cTnI).
2. Creatine Kinase-Myocardial Band (CK-MB).
3. Creatine Kinase (CK).
4. Myoglobulin -This appears rapidly after myocardial
necrosis but has not achieved widespread use in
cardiac practice

Pre-hospital  General public - chew 300mg aspirin immediately

management  For patients with known coronary heart disease
(CHD) - take one dose of sublingual glyceryl
trinitrate (GTN) by tablet or spray

If the ECG shows changes of STEMI:

 1. PHC providers should administer initial therapy:
 Soluble or chewable aspirin (300mg)38,39
and
 Clopidogrel- Loading dose of 300mg, if > 75
years of age- the loading dose is 75mg.40-
42
 *Fibrinolysis when applicable.44-47 -
Fibrinolysis treatment initiated by PHC
providers resulted in shorter DNT,
translating into greater health and cost
benefits

STEMI The objective of a STEMI network is to link non PCI-

network capable centres to PCIcapable centres with the aim of
providing PCI services in a timely manner for patients:
• With STEMI
• Who have been given fibrinolytic therapy and:
- have failed reperfusion or,
- as part of a pharmaco-invasive strategy or,
- have high risk features requiring early intervention.
• The optimal treatment of these patients should be
based on the implementation of networks between
hospitals (‘hub’ and ‘spoke’) with various levels of
technology, linked by an efficient ambulance service.
In hospital 1. Pain should be relieved with titrated IV morphine
management at 2-5 mg by slow bolus injection every 5-15
minutes as necessary. Watch for adverse events –
hypotension and respiratory depression
2. Antiemetic (IV metoclopramide 10 mg or
promethazine 25 mg) should be given with
morphine and 8-hourly as necessary
3. Venous access established and blood taken for
cardiac biomarkers (CKMB), full blood count, renal
profile, glucose and lipid profile. A baseline lipid
profile can help guide the dose of high dose statin
to be administered. Preferably two IV lines should
be set up
4. Intramuscular injections and NSAIDs should
be avoided.
5. The patient’s suitability for reperfusion by either
fibrinolytic therapy or primary PCI should be
quickly assessed.
6. In ED – Flowchart 1

• “Time is muscle” - Every patient with STEMI should

have the occluded artery reopened (reperfusion
therapy) as soon as possible after the onset of
symptoms.
• Reperfusion therapy is indicated in all patients with
 symptoms of ischaemia of
Reperfusion Time from onset of symptoms to STEMI diagnosis
strategies 1. In early presentation (within 3 hrs of symptom
(Primary PCI is onset) – primary PCI more preferred than
superior to fibrinolytic when:
fibrinolytic  Fibrinolytic therapy is contraindicated.
therapy as a (memorise 10!!!)
reperfusion  In high-risk patients.
strategy)  PCI time delay is more than 60 minutes
2. Late presentation (3 to 12 hours of symptom
onset)
 Primary PCI is preferred
 If the time delay to primary PCI is longer
than > 120minutes, the best option is to
give fibrinolytic therapy and make
arrangements to transfer the patient to a
PCI-capable centre
3. Very late presentation (> 12 hours)
 Both primary PCI and fibrinolytic therapy are
not routinely recommended in patients who
are asymptomatic and haemodynamically
stable.
 However, reperfusion therapy would still be
beneficial in patients with persistent
ischaemic symptoms, hemodynamic or
electrical instability. In this subgroup,
primary PCI is the preferred strategy

Contraindications to fibrinolytic therapy

High-risk patients
 Large infarcts.
 Anterior infarcts.
 Hypotension and cardiogenic shock
 Significant arrhythmias.
 Elderly patients.
 Post-revascularization (post-CABG and post-PCI).
 Post-infarct angina

Fibrinolytic 1. golden hour – 2 hours from time of onset

therapy 2. should only be given to patients with STEMI
3. streptokinase – most widely used, not fibrin
specific, 1.5 mega units in 100 ml normal saline or
5% dextrose over 1 hour
4. Tenecteplase – fibrin specific agent, more rapid
reperfusion, in a single bolus
 5. Hypotensive patient (due to relative
hypovolaemia/ RV infarction/ acute LV failure)
 Given IV fluids as necessary.
 Started on inotropes, preferably
noradrenaline
 Fibrin specific agent
6. Indicators of successful reperfusion
 Resolution of chest pain (may be
confounded by the use of narcotic
analgesics).
 Early return of ST segment elevation to
isoelectric line or a decrease in the height of
the ST elevation by 50% (in the lead that
records the highest ST elevation) within 60-
90 minutes of initiation of fibrinolytic
therapy
 Early peaking of CK and CK-MB levels
 Restoration and/or maintenance of
haemodynamic and/or electrical stability
Percutaneous 1. preferred reperfusion strategy in patients with
Coronary ischaemic symptoms < 12 hours
Intervention 2. Failed fibrinolytic therapy
(PCI)  Ongoing chest pains.
 Persistent hyper-acute ECG changes (< 50%
resolution of ST elevation in the lead
showing the greatest degree of ST elevation
at presentation)
 Haemodynamic and electrical instability
 Rescue PCI is initiated very early (1 to
2 hours) after failed fibrinolytic
therapy
Technical 1. Antiplatelet therapy
considerations  Oral aspirin 300 mg should be given before
and primary PCI
pharmacother  Clopidogrel 300-600 mg loading dose to be
apy during given as early as possible or,
primary PCI  Prasugrel 60 mg loading dose to be given
after the coronary angiogram has been
performed or
 Ticagrelor 180 mg loading dose to be given
as early as possible
 GP IIb/IIIa inhibitors may be considered in
selected patients with IC thrombus –
abciximab, tirofiban
2. Antithrombotic therapy
 IV unfractionated heparin (UFH) with
additional bolus to maintain activated
clotting time (ACT) above 275 secs.
 IV low molecular weight heparin (LMWH) –
enoxaparin
 IV fondaparinux is not recommended
because of the risk of catheter thrombosis.
 Bivalirudin infusion
3. Access site
 • Radial access is recommended over
femoral access – reduce bleeding
complications
Cardiac care Monitoring
unit 1. General condition
2. Vital signs
3. Pulse oximetry
4. Cardiac rhythm
5. SBP >90mmHg prior to ACE-I or B-blockers
6. Oxygen, via nasal prongs, at 2-4 litres/minute
7. DAPT
 Duration post-fibrinolysis – 1 month to 1
year
 Post PCI – 1-year or 6 months if high
bleeding risk
 Aspirin and ticagrelor 60 mg twice a day for
>12 months may be considered for up to 3
years, in high risk patients who have
tolerated DAPT without a bleeding
complication
8. P2Y12 inhibitor
9. Antithrombotic therapy - patients who received
fibrinolytic therapy and did not undergo PCI
10. Oral anticoagulants – DOACS, warfarin
 For AFib & LV thrombus
11. ß-blockers
 in patients with heart failure and/or LV
systolic dysfunction
12. ACE-Is and ARBs
 within the first 24 hours of STEMI
 Contraindications - SBP < 100 mmHg,
Established contraindications e.g. bilateral
renal artery stenosis
13. Mineralocorticoid receptor antagonists –
eplerenone
14. Statins
15. Nitrates
 In patients with continuing chest pain and /
or ischaemia, HF, Hypertension
 Contraindications: SBP <90mmHg, RV
infarction, hx of phospho-diesterase 5
inhibitor ingestion

16. CCB
17. Trimetazidine
Complications 1. Arrhythmias.
of STEMI 2. LV dysfunction and shock.
3. Mechanical complications.
 Free wall rupture
 Ventricular septal rupture
 MR
4. RV infarction - ST elevation in the right praecordial
leads (V4R)
5. Others e.g. pericarditis
 Reinfarction
 Post-infarct angina
 LV thrombus and arterial embolism
 Deep venous thrombosis (DVT)
Contraindications to fibrinolytic therapy (MEMORISE!!!)
Absolute contraindications Relative contraindications
1. Risk of intracranial 1. Risk of intracranial
haemorrhage haemorrhage
 History of intracranial  Severe uncontrolled
bleed. hypertension on
 History of ischaemic presentation (blood
stroke within 3 months. pressure (BP) >
 Known structural 180/110 mmHg)
cerebral vascular  Ischaemic stroke more
lesion (e.g. than 3 months.
arteriovenous  History of chronic,
malformation). severe uncontrolled
 Known intracranial hypertension
neoplasm 2. Risk of bleeding
2. Risk of bleeding  Current use of
  Active bleeding or anticoagulant in
bleeding diathesis therapeutic doses
(excluding menses). [International
 Significant head Normalised Ratio (INR)
trauma within 3 > 2] or direct oral
months. anticoagulant (DOAC).
 Suspected aortic  Recent major surgery
dissection < 3 weeks.
 Traumatic or prolonged
CPR > 10 minutes.
 Recent internal
bleeding (e.g.
gastrointestinal or
urinary tract
haemorrhage) within 4
weeks.
 Non-compressible
vascular puncture.
 Active peptic ulcer
3. Others
 Pregnancy.
 Prior exposure (> 5
days and within 12
months of first usage)
to streptokinase (if
planning to use same
agent)

#in STEMI, primary PCU is the preferred strategy IF can be performed

within timeframe; 90 minutes from FMC in PCI-capable center, OR 120
minutes if transfer from non-PCI capable.
# Fibrinolysis is considered when PCI cannot be performed within the
recommended timeframes
#If fibrinolysis is successful (evidenced by symptom resolution and ST-
segment resolution), a pharmacoinvasive strategy is often pursued,
where the patient is transferred for PCI within 3–24 hours to optimize
outcomes
Cardiogenic shock diagnosis
1. SBP <90 mmHg for 30 minutes or MAP <65 mmHg for 30 minutes or
vasopressors required to achieve a systolic blood pressure ≥ 90
mmHg;
2. Pulmonary congestion or elevated left-ventricular filling pressures
3. Signs of impaired organ perfusion with at least one of the following
criteria:
 altered mental status.
 cold, clammy skin.
 Oliguria
 increased serum lactate