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Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc. Chapter 53 Management of ST-Elevation Myocardial Infarction

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Page 1: Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc. Chapter 53 Management of ST-Elevation Myocardial Infarction

Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc.

Chapter 53

Management of

ST-Elevation Myocardial Infarction

Page 2: Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc. Chapter 53 Management of ST-Elevation Myocardial Infarction

2Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc.

ST-Elevation Myocardial Infarction (STEMI)

Myocardial infarction (MI): necrosis of the myocardium resulting from ischemia

STEMI: acute MI caused by complete interruption of regional myocardial blood flow Causes elevation of the ST segment on the

electrocardiogram (ECG) Managed differently than non–ST-elevation MI

(partial blood flow blockage)

Page 3: Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc. Chapter 53 Management of ST-Elevation Myocardial Infarction

3Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc.

Pathophysiology of STEMI

Blood flow to a region of myocardium is stopped (platelet plugging and thrombus formation)

Hydrogen ions accumulate Local metabolic changes occur Myocardial injury triggers ventricular

remodeling Degree of residual cardiac impairment

depends on amount/location of damage

Page 4: Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc. Chapter 53 Management of ST-Elevation Myocardial Infarction

4Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc.

Diagnosis of STEMI

Chest pain Severe substernal, crushing/constricting, down

arm and jaw Characteristic ECG changes Sweating, weakness, sense of impending

doom 20% of patients with STEMI experience no

symptoms Biochemical markers for MI

Page 5: Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc. Chapter 53 Management of ST-Elevation Myocardial Infarction

5Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc.

Management of STEMI

Routine drug therapy Oxygen Aspirin (not NSAIDs) Morphine Beta blockers Nitroglycerin

Page 6: Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc. Chapter 53 Management of ST-Elevation Myocardial Infarction

6Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc.

Management of STEMI

Reperfusion therapy Primary percutaneous coronary intervention Fibrinolytic (thrombolytic) therapy Action: to dissolve clots; converts plasminogen to

plasmin

Page 7: Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc. Chapter 53 Management of ST-Elevation Myocardial Infarction

7Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc.

Management of STEMI

Adjuncts to reperfusion therapy Heparin Antiplatelet drugs

Page 8: Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc. Chapter 53 Management of ST-Elevation Myocardial Infarction

8Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc.

Management of STEMI

Thrombolytic drugs Alteplase, a tissue plasminogen activator Reteplase Streptokinase Tenecteplase Urokinase

Percutaneous coronary intervention (PCI)

Page 9: Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc. Chapter 53 Management of ST-Elevation Myocardial Infarction

9Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc.

Primary Percutaneous Coronary Intervention

Primary refers to the use of angioplasty rather than fibrinolytic therapy

Stents may be placed Goal: primary PCI within 90 minutes of patient

contact Success rate with PCI somewhat higher than

with thrombolytics

Page 10: Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc. Chapter 53 Management of ST-Elevation Myocardial Infarction

10Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc.

Fibrinolytic (Thrombolytic) Therapy

Dissolves clots Converts plasminogen to plasmin (proteolytic

enzyme)1. Alteplase, a tissue plasminogen activator2. Reteplase3. Streptokinase4. Tenecteplase5. Urokinase

Page 11: Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc. Chapter 53 Management of ST-Elevation Myocardial Infarction

11Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc.

Fibrinolytic (Thrombolytic) Therapy

Most effective when patient presents early; not given if pain has been present longer than 12 hours (best if given during first 4–6 hours)

Goal: to improve ventricular function, limit size of infarct, and reduce mortality

Timely administration = Opening of occluded artery in 80% of patients

Guidelines suggest 30-minute target time Best for patients younger than 75 years

Page 12: Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc. Chapter 53 Management of ST-Elevation Myocardial Infarction

12Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc.

Adjuncts to Reperfusion Therapy:

Management of STEMI Unfractionated heparin used for treatment lasting less

than 48 hours Low-molecular-weight (LMW) heparin used for

treatment lasting longer than 48 hours Antiplatelet drugs

Clopidogrel (Plavix) Glycoprotein (GP) IIb/IIIa inhibitors

Low-dose aspirin May use concurrently with clopidogrel Should take indefinitely Higher dose for PCI patients

Page 13: Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc. Chapter 53 Management of ST-Elevation Myocardial Infarction

13Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc.

Adjuncts to Reperfusion Therapy:

Management of STEMI Angiotensin-converting enzyme (ACE)

inhibitors and angiotensin II receptor blockers (ARBs) Decrease short-term mortality in all patients Start treatment within 24 hours ACE inhibitors studied more extensively than

ARBs Calcium channel blockers

Antianginal, vasodilation, and antihypertensive actions

Page 14: Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc. Chapter 53 Management of ST-Elevation Myocardial Infarction

14Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc.

Complications of STEMI

Ventricular dysrhythmias Develop frequently and are major cause of death

after MI Prophylactic antidysrhythmics not successful

Cardiogenic shock Results from tissue perfusion reduction 7%–15% of post-MI patients develop shock in first

few days

Page 15: Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc. Chapter 53 Management of ST-Elevation Myocardial Infarction

15Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc.

Complications of STEMI

Ventricular dysrhythmias Cardiogenic shock Heart failure Cardiac rupture

Page 16: Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc. Chapter 53 Management of ST-Elevation Myocardial Infarction

16Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc.

Secondary Prevention of STEMI

Discharge 6–10 days after event 5%–5% of patients have another infarct

in first year Outcome improved with risk factor reduction

Cholesterol control, smoking cessation, exercise, blood pressure (BP) control, diabetes control

All post-MI patients should take: Beta blocker ACE inhibitor Antiplatelet drug or anticoagulant