ST-Elevation Myocardial Infarction

(STEMI)

Present by:
PH. Reema A. Alamri
Intern - PNU
 Outlines

1. Definitions

2. ACS presentation
3. Type of ACS
4. Diagnoses

5. Treatment

6. References
Acute Coronary Syndromes

A. Definitions
1- Acute coronary syndromes (ACSs) are a spectrum of conditions compatible with acute myocardial
ischemia or infarction due to an abrupt reduction in coronary blood flow.

2- ACS can be divided into ST-segment elevation myocardial infarction (STEMI) and non–ST-segment
elevation acute coronary syndrome (NSTE-ACS).

a. STEMI
- Defined by characteristic symptoms of myocardial ischemia in association with persistent ST elevation
on ECG with positive troponins.

- STEMI is an indication for immediate coronary angiography to determine whether reperfusion can be p
erformed.

- STEMI is a life-threatening, time-sensitive emergency that must be diagnosed and treated promptly via
coronary revascularization, usually by percutaneous coronary intervention (PCI).

b. NSTE-ACS
- During STEMI the 12-lead ECG will show significant ST elevation as the name implies.
Spectrum of ACS Presentations

UA NSTEMI STEMI

Ischemia without Necrosis

Definition Transmural necrosis
necrosis (non-transmural)

Negative Biomarkers Positive biomarkers Positive biomarkers

Diagnosis
ECG ST-segment
No ECG ST-segment elevation
elevation

Treatment Invasive or conservative depending on risk Immediate reperfusion

 The differences between the types of
Acute Coronary Syndromes (ACS)

Unstable Angina Pectoris STEMI NSTEMI

1- Exertional angina of new onset.
• Even if relieved with rest and
requiring a consistent amount
of exertion to procedure
symptoms, when angina first
occurs it is considered
unstable.
1- Anginal symptoms at rest
that result in myocardial
necrosis as identified by
elevated cardiac biomarkers
with ST segment elevation on
the 12-lead
electrocardiogram.
1- Anginal symptoms at rest
that result in myocardial
necrosis as identified by
elevated cardiac enzymes
with no ST segment
elevation on the
12-lead electrocardiogram.

2- Exertional angina that was

previously stable and now occurs
with less physical exertion.

3- Anginal symptoms at rest

without physical exertion.

• In unstable angina, the cardiac

enzymes remain normal or are
only very minimally elevated.
 Diagnosis
• Sign & Symptoms:

1.Chest pain  Chest pain is the cardinal symptom of STEMI.

2.Breathing difficulty  Due to left ventricular dysfunction or dynamic mitral regurgitation.
3.Profuse sweating  Nausea and vomiting may occur due to nervous upset.
4.Syncope (sudden loss of consciousness)  Due to an arrhythmia or severe hypotension.
5.Tachycardia (high pulse rate)  Due to sympathetic nerve activation.
6.Bradycardia (low pulse rate)  Pts w/inferior STEMI may present w/bradycardia due to vagus nerve
activation.
7.Cardiogenic shock  Due to impaired myocardial function.

• Investigations:
1. Electrocardiography (ECG)  Q-wave indicates muscle necrosis & T-wave inversion indicates muscle
ischemia.
2. Cardiac markers  Troponin T, Troponin I, and CK-MB (creatine kinase myocardial band).
3. Full blood count  Elevation of WBC count, Erythrocyte sedimentation rate and C-reactive protein
may elevate.
4. Chest X-ray  For assessing pulmonary edema.
5. Echocardiography  Helpful if the ECG cannot evaluate the diagnosis of STEMI. Wall motion defect
is found in infarct area of the heart. It also can assess ventricular function.
Complications

Early complications Late complications

Heart arrhythmias Post MI syndrome
Acute heart failure Left ventricular aneurysm
Cardiogenic shock Chronic heart failure
Pericarditis
Embolism
Mechanical complications
 Reperfusion Therapy

• Assessment & Initial evaluation:

1. 12-lead ECG should be performed and interpreted within 10 minutes of presentation.
2. Serial cardiac troponins (I or T) should be obtained at presentation and 3–6 hours after sympto
m onset.

• “Early Hospital Care”

1. Goals of therapy are the immediate relief of ischemia and the prevention of MI and death.
2. STEMI
a. Requires urgent revascularization either interventionally or with drug therapy.
b. Primary percutaneous coronary intervention (PCI) is preferred to lytic therapy.
c. Fibrinolytic therapy is indicated for patients with STEMI in whom PCI cannot be performed
within 120 minutes.
Table 1. Applying
Class of
Recommendation
and
Level of Evidence
Primary PCI vs. Fibrinolytic therapy

1- The decision regarding primary PCI vs. Fibrinolytic therapy is important.

2- Many major medical facilities have PCI capabilities since this is the treatment of choice for STEMI.

3- Smaller hospitals or those located in rural areas may not. Those facilities frequently have capabilities
to quickly transfer STEMI patients to a primary PCI facility.

4- When there is no primary PCI available and transfer to a primary PCI facility in a timely fashion
(transfer in less than 60 minutes), Fibrinolytic therapy is indicated.
 Primary PCI

Primary PCI is strongly preferred over thrombolytic therapy, Include:

1. Primary PCI within 36 hours for patients that develop cardiogenic shock and those with Killip
Class III.

2. Fibrinolytic therapy is preferred over primary PCI unless the patient refuses invasive procedures.

3. If symptoms have been present for > 3 hours then primary PCI is preferred.

4. Primary PCI is performed with a door-to-balloon time of < 90 minutes and when symptoms onset
was < or equal 12 hours.

5. Primary PCI is only indicated when symptoms duration is 12 - 24 hours (delayed presentation) if se
vere congestive heart failure, hemodynamic/ electrical instability or continued angina is present.

6. Primary PCI is not recommended when symptom onset is more than 12 hours and the patient is
asymptomatic.
Fibrinolytic therapy

1. Fibrinolytic therapy must be instituted within 24 hours of symptom onset.

2. Fibrinolytic therapy is always given simultaneously with anticoagulation using unfractiona

ted heparin or low molecular weight heparin.

3. When the decision to treat a STEMI patient with fibrinolytic therapy is made (since primar
y PCI is not available in a timely fashion), contraindications to fibrinolytic therapy must b
e considered.

4. Suspected aortic dissection, active bleeding (excluding menses) or a bleeding diathesis are
contraindications to fibrinolytic therapy.

5. In general, if there is high risk of intracranial hemorrhage (ICH) defined as > 4%, then fibr
inolytic therapy is contraindicated as well and primary PCI is preferred.
Contraindications Of Lytic Therapy
Relative contraindications
1. Prior intracranial hemorrhage
2. Ischemic stroke within 3 months
3. Known cerebrovascular abnormality such
as aneurysm or arteriovenous malformation
4. Known malignant intracranial tumor
5. Significant closed head trauma or facial
trauma within 3 months
Absolute contraindications
1. Uncontrolled hypertension (blood pressure
> 180/110) either currently or in the past
2. Intracranial abnormality not listed as
absolute contraindication (i.e. benign
intracranial tumor).
3. Ischemic stroke > 3 months prior
4. Bleeding within 2-4 weeks (excluded
menses)
5. Traumatic or prolonged cardiopulmonary
resuscitation (CPR)
6. Major surgery within 3 weeks
7. Pregnancy
8. Current use of anticoagulants
9. Non-compressible vascular puncture
10. Dementia
 Con…

Coronary artery bypass grafting (CABG) as a means of coronary revascularization duri

ng STEMI is indicated when:

1. PCI fails and there is persistent symptoms or hemodynamic instability.

2. A patient is not a candidates for PCI and has continued symptoms with a significant area o
f myocardium at risk.
3. At the time of ventricular septal defect or mitral valve repair.
4. When left main coronary disease or 3-vessel coronary disease is present with cardiogenic s
hock or ventricular arrhythmias (ventricular tachycardia or fibrillation).

• CABG is NOT indicated when there is a small area of myocardium in jeopardy and the pati
ent is stable.
 Basic Treatment
• All patients should receive anti-ischemic and analgesic medications early in care
-Emergency- “MONA” plus β-blocker:
Drugs Doses
M= Morphine  1–5 mg IV every 5–30 minutes CLASS I.
O= Oxygen administration  Sao2 <90%, respiratory distress, or high-risk
features of hypoxemia CLASS I.
N= Anginal pain relief with Nitrates  NTG spray or sublingual tablet (0.3–0.4 mg)
every 5 min for up to 3 doses to relieve acute chest
pain; NTG IV 5–10 mcg/minute; titrate to chest
pain relief or 200 mcg/minute for persistent
ischemia, HF, or HTN CLASS I.
A= Antiplatelet therapy (Aspirin,  Chew and swallow non–enteric coated 162–325
Thienopyridines and Glycoprotein IIb/IIIa mg x 1; Clopidogrel: If aspirin allergy or
inhibitors) gastrointestinal intolerance.
Beta-blockade  Oral β-blocker should be initiated within 24
hours in pts who do not have signs of HF, low-
output state, increased risk for cardiogenic shock
CLASS I.

 Medical therapy upon hospital discharge may include ACE inhibitors, angiotensin receptor
blockers, aldosterone antagonists and HMG CoA reductase inhibitors.
Antiplatelet Management in ACS

Antiplatelet 1- STEMI 2- STEMI +

Primary PCI Fibrinolytic
Aspirin Aspirin Aspirin
P2Y12 Clopidogrel Clopidogrel
Prasugrel
Ticagrelor
GP Iib/IIIa Class I  when given to patients and high-risk features (e.g., elevated
inhibitor troponin) not adequately pretreated with Clopidogrel or Ticagrelor.
 Treatment Regimen

• Patients with STEMI and NSTE-ACS should be treated with antiplatelet and anticoagula
nt therapy:

1. Antiplatelet recommendations:

A. Single Antiplatelet Therapy

Aspirin therapy is given to all patients.
(a) Dosing is 162–325 mg for patients at initial presentation of ACS.
(b) Dosing is 81–325 mg for those who are undergoing PCI, depending on chronic aspirin therapy regi
men.
(c) Aspirin is given indefinitely at a preferred dose of 81 mg after ACS with or without PCI
(class IIa)
 B. Dual Antiplatelet Therapy (DAPT)
Aspirin
Initial ACS therapy
Aspirin 162–325 mg non-enteric orally or chewed x 1
Pre-PCI
Already on aspirin therapy, 81–325 mg
Not on aspirin therapy, aspirin 325 mg before PCI
Post-PCI (ACS indication)
Continue aspirin indefinitely: 81 mg daily
Post-elective PCI (no ACS)
BMS or DES:
• Aspirin 81 mg/day indefinitely
Post-ACS (ischemia-guided strategy with no PCI)
Aspirin 75–162 mg/day continued indefinitely
P2Y12 Receptor Inhibitor
STEMI
CLO 600-mg LD or PRA 60-mg LD or TIC 180-mg
LD for primary PCI
Pre-PCI after fibrin-lytic therapy: 300 CLO 300-mg
LD if within 24 hours of event; CLO 600-mg LD if > 24 hours after event
CLO 600-mg LD as soon as possible before or at time of PCI or PRA 60-mg
LD promptly or no later than
1 hour after coronary anatomy defined or
TIC 180-mg LD as early as possible before or at time of PCI
CLO 75 mg daily or PRA 10 mg daily or TIC 90 mg twice daily for a
minimum of 12 months
BMS:
• CLO 75 mg daily for a minimum of 1 month and ideally up to 12 months
DES:
• CLO 75 mg daily for a minimum of 12 months
CLO 75 mg daily or TIC 90 mg twice daily for up to 12 months
2- Comparison of P2Y12 Receptor Inhibitors
1. Indicated in all STEMI cases unless surgery is needed.
2. Clopidogrel can also be used as an adjunct to fibrinolytic therapy in patients intolerant to aspirin.
3. If coronary artery bypass grafting is required, these agents should not be used.
4. Thienopyridines are preferred to be continued for 12 months.

Parameter Clopidogrel Prasugrel Ticagrelor

FDA ACS managed medic-ally ACS with PCI ACS managed medically or with PCI
or with PCI
“Dose in ACS”
Loading: 600 mg 60 mg 180 mg
Maintenance: 75 mg daily 10 mg daily 90 mg BID
Pro-drug Yes Yes No
Half-life 6 hours (Parent drug); 7 hours; 7 hours;
30min (Active metabolite) (range 2-15 hr) 9 hrs (Active metabolite)
Stop before surgery 5 days 7 days 5 days
Drug-Disease - Increased bleeding with - More bleeding Asthma, bradycardia: More bleeding with
Interactions NSAIDs with NSAIDs NSAIDs, OACs
- Prior history of Strong 3A4 inhibitors ­↑ ticagrelor
stroke or TIA concentrations; strong 3A4 inducers ↓ ticagrelor
concentrations;
do not exceed 40 mg of simvastatin or lovastatin
Limit aspirin to < 100mg Monitor digoxin
levels
STEMI + Fibrinolytic

Antiplatelet 1- STEMI 2- STEMI +

Primary PCI Fibrinolytic
Aspirin Aspirin Aspirin
P2Y12 Clopidogrel Clopidogrel
Prasugrel
Ticagrelor
GP Iib/IIIa Class I when given to patients and high-risk features (e.g., elevated
inhibitor troponin) not adequately pretreated with Clopidogrel or Ticagrelor.
3- Fibrinolytic Therapy

Drugs Dosing
Alteplase ≤ 67 kg: 15 mg IVP over 1–2 minutes, then 0.75 mg/kg IV over 30
(t-PA, Activase) minutes (maximum 50 mg), then 0.5 mg/kg (maximum 35 mg) over 60
minutes;
>67 kg: 15 mg IVP over 1–2 minutes, then 50 mg over 30 minutes; then
35 mg over 1 hour (maximum total dose 100 mg)
Reteplase 10 units IV; repeat 10 units IV in 30 minutes
(r-PA, Retavase)
Tenecteplase <60 kg: 30 mg IV;
(TNK-t-PA, TNKase) 60–69 kg: 35 mg IV;
70–79 kg: 40 mg IV;
80–89 kg: 45 mg IV;
>90 kg: 50 mg IV (about 0.5 mg/kg)
4- Glycoprotein IIb/IIIa inhibitors
1.They very strongly inhibit platelet function by blocking the binding of fibrinogen to the a
ctivated glycoprotein IIb/IIIa receptor complex.
2.Any of these agents may be used in addition to aspirin, a thienopyridine and anticoagulati
on (except with bivalirudin) at the time of PCI in high risk patients with STEMI.

Drugs Not Pretreated with P2Y12 Renal Adjustments

Abciximab PCI: 0.25-mg/kg IV bolus, then 0.125 Not necessary
(ReoPro) mcg/kg/minute (max 10 mcg/kg) for 12 hours
ACS without PCI: Not recommended
Eptifibatide PCI: 180-mcg/kg IV bolus × 2 If CrCl < 50 mL/minute/ 1.73 m2,
(Integrilin) (10 minutes apart); 2 mcg/kg/minute initiated after reduce infusion 50%; avoid in
first bolus for 18–24 hoursc patients on hemodialysis; not
ACS without PCI: Of uncertain benefit in patients studied in patients with SCr >4
adequately pretreated with a P2Y12 receptor mg/dL
inhibitor; single bolus used as above
Tirofiban PCI: 25-mcg/kg IV bolus over 3 minutes, then 0.15 If CrCl < 30 mL/minute/ 1.73 m2,
(Aggrastat) mcg/kg/minute for 18–24 hours reduce infusion 50%
ACS without PCId: 0.4 mcg/kg/minute for 30
minutes (LD infusion), then 0.1 mcg/kg/minute for
18–72 hours
5- Anticoagulation

1. Full anticoagulation should be started in all STEMI patients unless a CIs exists.
2. Either unfractionated heparin, low molecular weight heparin or Bivalirudin can b
e used.
3. Unfractionated heparin for 48 hours total, and
4. Low molecular weight heparin for 8 days or until hospital discharge.
Con..
Classes PCI STEMI ± Primary Dose adjustment &
PCI CIs
UFH ____ Target ACT Target ACT Avoid if history of HIT
If GP IIb/IIIa, UFH 50 to 70unit/kg IVB If GP IIb/IIIa, UFH 50 to
If no GP IIb/IIIa, UFH 70 to 100unit/kg IVB 70 unit/kg IVB
If no GP IIb/IIIa, UFH
70to 100 unit/kg IVB
Enoxaparin LMWH If last dose <8 hours, no add 30 mg IVB, followed If CrCl < 30 mL/
(Lovenox) If last dose >8 hours, 0.3 mg/kg IVB immediately by 1 mg/ kg minute/1.73 m2, 1 mg/kg
If last dose 8–12 hours before or fewer than SC twice daily; SC/d
two therapeutic doses received before PCI do not exceed 100 mg on Avoid if history of HIT
first two doses
If >75 years, omit bolus;
0.75 mg/kg
SC bid; do not exceed 75
mg on first two doses
Fondaparinux Factor Xa If last dose < 8 hours, no add 2.5 mg IVB; then 2.5 mg CIs if CrCl < 30 mL/
(Arixtra) inhibitor If last dose > 8 hours, 0.3 mg/kg IVB SC daily minute/1.73 m2
If last dose 8–12 hours before or fewer than
two therapeutic doses received before PCI
Bivalirudin Direct 0.75 mg/kg IVB, 1.75 mg/kg/hr IV 0.75 mg/kg IVB, 1.75 Adjust infusion dose in
(Angiomax) thrombin Discontinue at end of PCI, or continue for up mg/kg/hr IV severe renal dysfunction
inhibitor to 4 hrs after procedure if needed If CrCl < 30 mL/
Hold UFH 30 min before admin. minute/1.73 m2, reduce
infusion to 1 mg/kg/
hour; if on hemodialysis,
reduce infusion to 0.25
mg/kg/hour
 6- Other drugs can be use

Drugs Notes
ACE inhibitors/ARB - Indication: left ventricular systolic dysfunction or
Inhibitors pts diabetic.
- Avoid: hypotension, can worsen myocardial ischemia, hyperkalemia,
and RF.
- Usually: ARBs are only given if ACE inhibitors are
tolerate due to cough.
HMG-CoA reductase - Indication: High intensity (LDL reduction > 50%)  age < 75,
Inhibitors and
Moderate intensity (30-50% reduction of LDL)  age > 75 yrs old.
- Atorvastatin 80 mg PO daily.
- Lifetime after ACS unless CIs exists, or baseline LDL is < 70
CCB - Diltiazem and Verapamil  used when CIs to beta-blockers (such as
asthma)
- There is no heart failure or significant left ventricular systolic
dysfunction present
References

1. ACCP Updates in Therapeutics® 2015: The Pharmacotherapy Preparatory Rev

iew and Recertification Course.

2. 2015, ACC/AHA/SCAI Focused Update on Primary PCI for Patients with STE
MI.

3. Joseph T. DiPiro, Robert L. Talbert, Gary C. Yee, Gary R. Matzke, Barbara G.

Wells, L. Michael Posey, Copyright © 2014 by McGraw-Hill Education, Pharm
acotherapy: A Pathophysiologic Approach, 9th Edition