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ST segment elevated myocardial infarction (STEMI)

Myocardial infarction with elevation of the electrocardiogram ST segment. Clinical manifestations: - see acute coronary syndrome & myocardial infarction Laboratory: - markers of myocardial infarction positive - serum troponin I elevated - within 6 hours (performance measure) [28] Special laboratory: - electrocardiogram (ECG): a) initial Q waves may predict progression & worse prognosis [7] b) elevation of ST segment* - ST segment elevation in leads II, III & aVF indicate inferior wall MI - all patients with inferior wall MI should have right-sided ECG - ST segment elevation in right-sided lead V4 is the most senstive indicator for right ventricular MI - ST segment elevation in leads V1-V4 indicate anterior wall MI - coronary angiography/PCI for resuscitated out-of-hospital cardiac arrest with ST-segment elevation (performance measure) [28] * ST segment elevation surrogates: - new left bundle-branch block (LBBB) - tall R & ST segment depression in leads V1-V4 (posterior wall MI) [11] Management: 1) also see myocardial infarction 2) initial medical therapy a) aspirin b) oxygen c) nitrates vs IV fluids (see below), morphine d) beta blocker (avoid if acute heart failure, pulmonary edema d) ACE inhibitor e) heparin for 48 hours f) clopidogrel 3) PCI (PTCA) better than thrombolytic therapy a) PCI more effective than thrombolytic therapy [1,11] - intervention of choice for single vessel disease - see CAPITAL AMI study - pretreatment with clopidogrel prior to PCI diminishes mortality (4% vs 6%) [3] - ticagrelor in the ambulance no better than in the cath lab [23] b) cardiac catherization team should be activated while patient is enroute to the hospital c) PCI within 90 minutes of 1st medical contact [11] d) PCI treatment of choice if within 120 minutes of MI [30] - treatment of choice 4 hours after MI (vs thrombolytic therapy) [33] e) each 1-hour delay (from EMS contact) raises risk for CHF by 10% f) all patients within 12 hours of STEMI [15] g) revascularization on non-infarct-related arteries determined by fractional flow reserve associated with diminished need for revascularization (6.1% vs 17.5%) but not all-cause mortality (1.4% vs 1.7%) [27] 4) thrombolytic therapy a) indications 1] PCI unavailable [16] 2] door to balloon time (PCI) exceeds door to needle time (thrombolysis) by > 60 minutes 3] PCI cannot be done within 2 hours [15,30] 4] within 12 hours of myocardial infarction 5] multivessel or distal disease may favor thrombolytic therapy vs PCI b) transfer to PCI-capable hospital should routinely follow thrombolysis [10,11,30] c) thrombolysis prior to PCI worsens outcomes [5] d) thrombolysis -> angiography -> coronary stenting [2] e) rescue PCI better than repeat thrombolysis [4] f) thrombolysis with PCI for persistent symptoms or ST segment elevation equivalent to PCI [8] (see WEST study) 5) antiplatelet agents a) aspirin 160-325 mg PO immediately (chewed, not EC) & QD b) dual antiplatelet therapy (DAPT) - aspirin + prasugrel or ticagrelor for 1 year [30] - 6 months of DAPT reportedly non inferior to 12 months (NEJM not on board) c) clopidrogrel of benefit in addition to aspirin [11] - see COMMIT trial - prasugrel & ticagrelor more potent than clopidogrel with higher risk of bleeding d) in patients with atrial fibrillation - low-dose direct oral anticoagulant + P2Y12 inhibitor - see coronary stent e) use of proton pump inhibitor with aspirin & clopidogrel is an unresolved issue [12] r) aspirin QD should be continued indefinitely after STEMI [15] 6) oxygen: a) 2-4 liters/min by nasal cannula b) do not continue for more than 3 hours unless hypoxia is present c) supplementary oxygen only when SaO2 < 90% [30] 7) nitrates vs IV fluids (see electrocardiogram above) a) right ventricular MI (avoid nitrates) b) posterior wall MI with hypotension 8) morphine for pain relief 9) intravenous beta-blocker: a) metoprolol 3 consecutive 5 mg IV boluses b) esmolol drip c) reduce infarct size d) avoid in patients with pulmonary edema, acute heart failure 10) ACE inhibitor vs ARB a) inhibits post-infarction remodelling b) benefits patients with LVEF < 0.40 function, heart failure, or anterior wall MI [15] c) ARB as beneficial as ACE inhibitor in patients with preserved LV systolic function [24] d) initiate when hemodynamically stable (with 1st 24 hours [11, 15]) 11) LMW heparin vs unfractionated heparin a) unfractionated heparin is preferable to LMW heparin for PCI b) LMW heparin may be preferable to unfractionated heparin for thrombolysis [11] - reduces risk of recurrent MI (9.9% vs 12.0%) at cost of increased major bleeding (2.1% vs 1.4%) [6] 12) direct-acting oral anticoagulant as add-on to antiplatelet therapy - favorable benefit/risk; not so for NSTEMI [29] 13) treat hyperglycemia when serum glucose > 180 mg/dL [12] 14) statin prior to hospital discharge - target serum LDL cholesterol < 70 mg/dL 15) aldosterone antagonist at discharge for eligible patients, spironolactone, eplerenone (quality measure) [28] - aldosterone antagonist with mortality benefit after STEMI with or without heart failure [31] 16) noninvasive stress testing before discharge in medically- treated patients (performance measure) [28] 17) follow-up a) stop smoking b) avoid second hand smoke [15] c) post-MI non-cardiac surgery: delay (if possible) 4-6 weeks (uncomplicated MI) - 4-6 weeks for recipients of bare-metal stents - 6-12 months for recipients of drug-eluting stents [11] 18) cardiac rehabilitation 19) treat depression 20) see myocardial infarction

Interactions

disease interactions

Related

CLOpidogrel & Metoprolol in Myocardial Infarction Trial (COMMIT) Combined Angiolasty & Pharmacologic Intervention versus Thromboylisis ALone in Acute Mycocardial Infarction (CAPITAL AMI) study ECG changes in myocardial ischemia non ST segment elevated myocardial infarction (nonSTEMI, NSTEMI) PTCA/PCI vs thrombolysis for acute MI Which Early ST elevation myocardial infarction Therapy (WEST) study

General

myocardial infarction (MI); heart attack

References

  1. Journal Watch 23(5):42, 2003 Keeley EC et al, Lancet 361:13, 2003 PMID: 12517460
  2. Journal Watch 24(22):166, 2004 Fernandez-Aviles F, Alonso JJ, Castro-Beiras A, Vazquez N, Blanco J, Alonso-Briales J, Lopez-Mesa J, Fernandez-Vazquez F, Calvo I, Martinez-Elbal L, San Roman JA, Ramos B; GRACIA (Grupo de Analisis de la Cardiopatia Isquemica Aguda) Group. Routine invasive strategy within 24 hours of thrombolysis versus ischaemia-guided conservative approach for acute myocardial infarction with ST-segment elevation (GRACIA-1): a randomised controlled trial. Lancet. 2004 Sep 18;364(9439):1045-53. PMID: 15380963
  3. Sabatine MS, Cannon CP, Gibson CM, Lopez-Sendon JL, Montalescot G, Theroux P, Lewis BS, Murphy SA, McCabe CH, Braunwald E; Clopidogrel as Adjunctive Reperfusion Therapy (CLARITY)-Thrombolysis in Myocardial Infarction (TIMI) 28 Investigators. Effect of clopidogrel pretreatment before percutaneous coronary intervention in patients with ST-elevation myocardial infarction treated with fibrinolytics: the PCI-CLARITY study. JAMA. 2005 Sep 14;294(10):1224-32. Epub 2005 Sep 4. PMID: 16143698
  4. Gershlock AH et al, Rescue angioplasty after failed thrombolytic therapy for acute myocardial infarction N Engl J Med 2005, 353:2758 PMID: 16382062
  5. Assessment of the Safety and Efficacy of a New Treatment Strategy with Percutaneous Coronary Intervention (ASSENT-4 PCI) investigators. Primary versus tenecteplase-facilitated percutaneous coronary intervention in patients with ST-segment elevation acute myocardial infarction (ASSENT-4 PCI): randomised trial. Lancet. 2006 Feb 18;367(9510):569-78. PMID: 16488800 - Keeley EC, Boura JA, Grines CL. Comparison of primary and facilitated percutaneous coronary interventions for ST-elevation myocardial infarction: quantitative review of randomised trials. Lancet. 2006 Feb 18;367(9510):579-88. Review. PMID: 16488801 - Stone GW, Gersh BJ. Facilitated angioplasty: paradise lost. Lancet. 2006 Feb 18;367(9510):543-6. No abstract available. PMID: 16488779
  6. Antman EM, Morrow DA, McCabe CH, Murphy SA, Ruda M, Sadowski Z, Budaj A, Lopez-Sendon JL, Guneri S, Jiang F, White HD, Fox KA, Braunwald E; ExTRACT-TIMI 25 Investigators. Enoxaparin versus unfractionated heparin with fibrinolysis for ST-elevation myocardial infarction. N Engl J Med. 2006 Apr 6;354(14):1477-88. Epub 2006 Mar 14. PMID: 16537665 - Gibbons RJ, Fuster V. Therapy for patients with acute coronary syndromes--new opportunities. N Engl J Med. 2006 Apr 6;354(14):1524-7. Epub 2006 Mar 14. No abstract available. PMID: 16537664
  7. Wong CK, Gao W, Raffel OC, French JK, Stewart RA, White HD; HERO-2 Investigators. Initial Q waves accompanying ST-segment elevation at presentation of acute myocardial infarction and 30-day mortality in patients given streptokinase therapy: an analysis from HERO-2. Lancet. 2006 Jun 24;367(9528):2061-7. PMID: 16798389 - Cooper H, Panza JA. Q waves to guide treatment of myocardial infarction. Lancet. 2006 Jun 24;367(9528):2035-7. No abstract available. PMID: 16798367
  8. Armstrong PW et al, A comparison of pharmacologic therapy with/without timely coronary intervention vs. primary percutaneous intervention early after ST-segment myocardial infarction: The WEST (Which Early ST elevation myocardial infarction Therapy) study Eur Heart J 2006, 27:1530 PMID: 16757491
  9. Swor R et al, Prehospital 12-lead ECG: Efficacy of effectiveness? Prehosp Emerg Care 2006 10:374 PMID: 16801283
  10. Cantor WJ et al Routine Early Angioplasty after Fibrinolysis for Acute Myocardial Infarction N Engl J Med 2009, 360:2705-2718 PMID: 19553646 http://content.nejm.org/cgi/content/short/360/26/2705
  11. Medical Knowledge Self Assessment Program (MKSAP) 15, 16, 17, 18, 19. American College of Physicians, Philadelphia 2009, 2012, 2015, 2018, 2022. - Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022
  12. Kushner FG et al 2009 Focused Updates: ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction (Updating the 2004 Guideline and 2007 Focused Update) and ACC/AHA/SCAI Guidelines on Percutaneous Coronary Intervention (Updating the 2005 Guideline and 2007 Focused Update) Am Coll Cardiol (Published online 18 November 2009) PMID: 19942100 doi:10.1016/j.jacc.2009.10.015 http://content.onlinejacc.org/cgi/content/full/j.jacc.2009.10.015v1
  13. Terkelsen CJ et al. Health care system delay and heart failure in patients with ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention: Follow-up of population-based medical registry data. Ann Intern Med 2011 Sep 20; 155:361. PMID: 21930853
  14. Geriatrics at your Fingertips, 13th edition, 2011 Reuben DB et al (eds) American Geriatric Society
  15. O'Gara PT et al 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction: Excutive Summary: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2012 Dec 19; 127:e362 PMID: 23247303 http://circ.ahajournals.org/content/early/2012/12/17/CIR.0b013e3182742c84.full.pdf+html
  16. Armstrong PW et al. Fibrinolysis or primary PCI in ST-segment elevation myocardial infarction. N Engl J Med 2013 Mar 10 PMID: 23473396 http://www.nejm.org/doi/full/10.1056/NEJMoa1301092 - Bhatt DL. Timely PCI for STEMI - Still the treatment of choice. N Engl J Med 2013 Mar 10; PMID: 23473397 http://www.nejm.org/doi/full/10.1056/NEJMe1302670
  17. Boden WE, Eagle K, Granger CB. Reperfusion strategies in acute ST-segment elevation myocardial infarction: a comprehensive review of contemporary management options. J Am Coll Cardiol. 2007 Sep 4;50(10):917-29. Epub 2007 Aug 21. PMID: 17765117
  18. Armstrong PW, Westerhout CM, Welsh RC. Duration of symptoms is the key modulator of the choice of reperfusion for ST-elevation myocardial infarction. Circulation. 2009 Mar 10;119(9):1293-303 PMID: 19273730
  19. Di Mario C, Dudek D, Piscione F et al Immediate angioplasty versus standard therapy with rescue angioplasty after thrombolysis in the Combined Abciximab REteplase Stent Study in Acute Myocardial Infarction (CARESS-in-AMI): an open, prospective, randomised, multicentre trial. Lancet. 2008 Feb 16;371(9612):559-68 PMID: 18280326
  20. Kushner FG, Hand M, Smith SC Jr et al 2009 Focused Updates: ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction (updating the 2004 Guideline and 2007 Focused Update) and ACC/AHA/SCAI Guidelines on Percutaneous Coronary Intervention (updating the 2005 Guideline and 2007 Focused Update): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2009 Dec 1;120(22):2271-306 PMID: 19923169
  21. Gershlick AH et al Reperfusion therapy for STEMI: is there still a role for thrombolysis in the era of primary percutaneous coronary intervention? Lancet. August 17, 2013 PMID: 23953386 - Curzen N et al What is the optimum adjunctive reperfusion strategy for primary percutaneous coronary intervention? Lancet. August 17, 2013 PMID: 23953387 - Windecker S et al Future treatment strategies in ST-segment elevation myocardial infarction. Lancet. August 17, 2013 PMID: 23953388 - James SK anf Spertus JA Evidence-based treatments for STEMI: are we doing enough? Lancet. August 17, 2013 PMID: 23953374
  22. Alexander KP, Newby LK, Armstrong PW et al Acute coronary care in the elderly, part II: ST-segment-elevation myocardial infarction: a scientific statement for healthcare professionals from the American Heart Association Council on Clinical Cardiology: in collaboration with the Society of Geriatric Cardiology. Circulation. 2007 May 15;115(19):2570-89. PMID: 17502591
  23. Montalescot G et al. Prehospital ticagrelor in ST-segment elevation myocardial infarction. N Engl J Med 2014 Sep 1 PMID: 25175921 http://www.nejm.org/doi/full/10.1056/NEJMoa1407024
  24. Yang JH et al Angiotensin receptor blocker in patients with ST segment elevation myocardial infarction with preserved left ventricular systolic function: prospective cohort study. BMJ 2014;349:g6650 PMID: 25398372 http://www.bmj.com/content/349/bmj.g6650
  25. O'Gara PT, Kushner FG, Ascheim DD et al 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2013 Jan 29;127(4):e362-425 PMID: 23247304
  26. Van de Werf F, Bax J, Betriu A, Blomstrom-Lundqvist C et al Management of acute myocardial infarction in patients presenting with persistent ST-segment elevation: the Task Force on the Management of ST-Segment Elevation Acute Myocardial Infarction of the European Society of Cardiology. Eur Heart J. 2008 Dec;29(23):2909-45 PMID: 19004841
  27. Smits PC, Abdel-Wahab M, Neumann FJ et al for the Compare- Acute Investigators. Fractional flow reserve-guided multivessel angioplasty in myocardial infarction. N Engl J Med 2017 Mar 18; PMID: 28317428 Free full text http://www.nejm.org/doi/10.1056/NEJMoa1701067 - Kober L. Complete revascularization in ST-elevation myocardial infarction? N Engl J Med 2017 Mar 18; PMID: 28317460 Free Article http://www.nejm.org/doi/10.1056/NEJMe1702825
  28. Writing Committee Members, Jneid H, Addison D, Bhatt DL et al 2017 AHA/ACC Clinical Performance and Quality Measures for Adults With ST-Elevation and Non-ST-Elevation Myocardial Infarction. J Am Coll Cardiol. September 2017 PMID: 28943066 http://www.onlinejacc.org/content/early/2017/09/14/j.jacc.2017.06.032
  29. Chiarito M, Cao D, Cannata F et al Direct Oral Anticoagulants in Addition to Antiplatelet Therapy for Secondary Prevention After Acute Coronary Syndromes. A Systematic Review and Meta-analysis. JAMA Cardiol. Published online February 7, 2018 PMID: 29417147 https://jamanetwork.com/journals/jamacardiology/article-abstract/2672050
  30. Ibanez B, James S. 'Ten Commandments' of the 2017 ESC STEMI Guidelines Eur Heart J. 2018;39(2):83 Not indexed in PubMed Medscape early release March 2018 https://www.medscape.com/viewarticle/891454 - Kedhi E, Fabris E, van der Ent M et al Six months versus 12 months dual antiplatelet therapy after drug-eluting stent implantation in ST-elevation myocardial infarction (DAPT-STEMI): randomised, multicentre, non-inferiority trial. BMJ. 2018 Oct 2;363:k3793. PMID: 30279197 Free Article https://www.bmj.com/content/363/bmj.k3793
  31. Dahal K, Hendrani A, Sharma SP et al Aldosterone Antagonist Therapy and Mortality in Patients With ST-Segment Elevation Myocardial Infarction Without Heart Failure. A Systematic Review and Meta-analysis. JAMA Intern Med. Published online May 21, 2018 PMID: 29799995 https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2681656 - Pitt B, Zannad F. Mineralocorticoid Receptor Antagonists in ST-Segment Elevation Myocardial Infarction JAMA Intern Med. Published online May 21, 2018 PMID: 29799990 https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2681651
  32. Yu D, Blair JEA A STEMI Mimic. N Engl J Med 2019; 380:e41 PMID: 31141637 https://www.nejm.org/doi/full/10.1056/NEJMicm1810236
  33. Geriatric Review Syllabus, 10th edition (GRS10) Harper GM, Lyons WL, Potter JF (eds) American Geriatrics Society, 2019