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NSTEMI/STEMI - diagnosis and treatment

According to ESC 2012 and 2015 guidelines, slightly modified ;).
by

J K

on 11 January 2016

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Transcript of NSTEMI/STEMI - diagnosis and treatment

SYMPTOMS
Chest pain:
1. Substernal pain, usually described as a sensation of tightness, pressure, or squeezing; can radiate to the left arm, lower jaw, neck, right arm, back, upper abdomen.
2. Often not connected to prior physical exercise or stress.
3. Lasts longer than 5-20 min, isn't relieved after taking nitrates.
R.E.S.T. - Radiation, Exertion pain, Sweating (diaphoresis), Throwing up
Stable angina
1. Chest discomfort - typical location, sometimes radiates.
2. Primed by physical exercise or stress.
3. Symptoms abate shortly after interruption of the activity or after taking sublingual nitrates (usually after 1-3 min).
Angina equivalent symptoms
10-30% of myocardial infarctions are silent, sometimes asymptomatic, especially in elders, women and patients with diabetes.
Symptoms may include:
sweating
abdominal pain
nausea and vomiting
dyspnea
syncope
generalized weakness
UA/NSTEMI pain classification
Recent destabilization of previously stable angina with at least CCS Class III angina characteristics (crescendo angina)
Prolonged (20 min) anginal pain at rest
New onset (de novo) angina (CCS class II or III)
Post-MI angina.
DIAGNOSIS
ECG
BIOMARKERS
INITIAL TREATMENT
STEMI
NSTEMI
Typical changes in 2 or more leads.
Often more than 1 ECG study is needed.
depression (less often transient elevation) of ST segment; diagnostically significant are flat or descending depressions by 0,05 mEv or more

negative T waves (more than 0,1 mEv), sometimes inversion of previously negative T waves

no ECG changes in 30-50% of patients
1. Typical Pardee wave evolution:
new ST elevation at the J-point in two contiguous leads with the cut-off points: ≥0.2 mV in men or ≥ 0.15 mV in women in leads V2–V3 and/or ≥ 0.1 mV in other leads
emergence of pathological Q waves
return of ST segment to isoelectric position
reduction of R wave amplitude, deepening of Q wave, inversion of T wave
2. Newly formed left bundle branch block (LBBB)
We have plenty of biomarkers to choose from:
cardiac troponin (cTnT, cTnI)
CK-MB
myoglobin
FABPc
Yet the most useful is cTnT and cTnI, especially HS TnT. Other biomarkers aren't routinely used.
Elevated level of a biomarker in a single test is not enough - dynamic changes in concentration are diagnostically important. Make another test after several hours (for HS TnT the interval between first and second test is 3 hours).
1. Symptoms
2. ECG
3. Biomarkers
Regardless of the MI type (STE and NSTE):
nitrates - sublingual form (patient should take it at the onset of pain; if it doesn't relieve it after 5 min - he should call emergency)
oxygen - for every patient with SaO2 <95%
morphine - i.v. 5mg if the pain is severe
ASA - 150-500mg (300mg if PCI is planned)
(m.o.n.a)
Antiplatelet drugs (ASA and ...):
prasugrel (loading dose 60mg, then 10mg 1x per day)
or
ticagrelor (loading dose 180mg, then 90mg 2x per day)
if unavailable:
clopidogrel (loading dose 300mg (or 600mg if PCI is planned), then 75mg 1x per day)
Anticoagulants:
NSTEMI: strategy dependent:
immediate invasive strategy (<2h) - UFH or bivalirudin
early invasive strategy (<24h) - fondaparinux (I choice) or enoxaparin (II choice)
early conservative strategy - fondaparinux, enoxaparin or other LMWH
STEMI: either LMWH or UFH (UFH prefered if CABG is planned <24h),
fondaparinux is contraindicated
PCI center
EMS or non-PCI center
PCI possible
<120min
?
PCI
FIBRINOLYSIS
Primary PCI
is indicated:
in all patients with symptoms of <12h duration and persistent ST-segment elevation or (presumed) new LBBB.
for patients with severe acute heart failure or cardiogenic shock, or with contraindications to fibrinolysis regardless of time that passed since first symptoms of MI.
if there is evidence of ongoing ischaemia, even if symptoms may have started >12h beforehand or if pain and ECG changes have been stuttering.
Rescue PCI
(after unsuccessful fibrinolysis) - as soon as possible, preferaby <60min after initiation of fibrinolysis
PCI after successful fibrinolysis
- in all patients 3-24h after fibrinolysis
INDICATIONS FOR CABG
PCI can't be performed in patients with vessel anatomy unsuitable for PCI

PCI was unsuccessful

sudden occlusion of a vessel during PCI

cardiogenic shock in patient with significant stenosis of left main coronary artery or 2-3 coronary arteris

mechanical complications of MI

chest pain resolves
ST elevation resolves by 50%
development of Q waves
reperfusion arrythmia
CK washout
Criteria for successful reperfusion
Fibrinolysis is indicated where primary PCI cannot be offered to STEMI patients
within the recommended timelines.
Absolute:
Previous intracranial haemorrhage or stroke of unknown origin at any time
Ischaemic stroke in the preceding 6 months
Central nervous system damage or neoplasms or atrioventricular malformation
Recent major trauma/surgery/head injury (within the preceding 3 weeks)
Gastrointestinal bleeding within the past month
Known bleeding disorder (excluding menses)
Aortic dissection
Non-compressible punctures in the past 24 h (e.g. liver biopsy, lumbar puncture)
Relative:
Transient ischaemic attack in the preceding 6 months
Oral anticoagulant therapy
Pregnancy or within 1 week postpartum
Refractory hypertension (systolic blood pressure >180 mmHg and/or diastolic blood pressure >110 mmHg)
Advanced liver disease
Infective endocarditis
Active peptic ulcer
Prolonged or traumatic resuscitation
CONTRAINDICATIONS
SHIPBLAST:

S
urgery history within 3 months
H
ead trauma within 3 months
I
ntracranial hemorrhage
P
latelets < 100000/mm3, PT > 15s
B
P > 180/110mmHg
L
evel of glucose <50 or >400 mg/dl
A
nticoagulation use
S
urgery recently

further categorization:
any head trauma, bleeding or surgery
factors that increase bleeding (platelets, PT/aPTT, BP, anticoaulants)
other: glucose
start fibrinolysis within 30min after admission
prefer fibrin-specific drugs (alteplase, tenecteplase)
never use streptokinase in patients previously treated with streptokinase or anistreplase
concomitantly use antiplatelet drugs
Immediate transfer
Preferably
≤90min
FMC
10min
<60min
≤30min
3-24h
Coronary angiography
<60min
Successful fibrinolysis?
Immediate transfer
Yes
No
Yes
No
Patient-dependent time
MYOCARDIAL INFARCTION
DIAGNOSIS AND MANAGEMENT
DIAGNOSIS
ECG
BIOMARKERS
INITIAL TREATMENT
STEMI
NSTEMI
Typical changes in 2 or more leads.
Often more than 1 ECG study is needed.
depression (less often transient elevation) of ST segment; diagnostically significant are flat or descending depressions by 0,05 mEv or more

negative T waves (more than 0,1 mEv), sometimes inversion of previously negative T waves

no ECG changes in 30-50% of patients
1. Typical Pardee wave evolution:
new ST elevation at the J-point in two contiguous leads with the cut-off points: ≥0.2 mV in men or ≥ 0.15 mV in women in leads V2–V3 and/or ≥ 0.1 mV in other leads
emergence of pathological Q waves
return of ST segment to isoelectric position
reduction of R wave amplitude, deepening of Q wave, inversion of T wave
2. Newly formed left bundle branch block (LBBB)
We have plenty of biomarkers to choose from:
cardiac troponin (cTnT, cTnI)
CK-MB
myoglobin
FABPc
Yet the most useful is cTnT and cTnI, especially HS TnT. Other biomarkers aren't routinely used.
Elevated level of a biomarker in a single test is not enough - dynamic changes in concentration are diagnostically important. Make another test after several hours (for HS TnT the interval between first and second test is 3 hours).
1. Symptoms
2. ECG
3. Biomarkers
Regardless of the MI type (STE and NSTE):
nitrates - sublingual form (patient should take it at the onset of pain; if it doesn't relieve it after 5 min - he should call emergency)
oxygen - for every patient with SaO2 <95%
morphine - i.v. 5mg if the pain is severe
ASA - 150-500mg (300mg if PCI is planned)
(m.o.n.a)
Antiplatelet drugs (ASA and ...):
prasugrel (loading dose 60mg, then 10mg 1x per day)
or
ticagrelor (loading dose 180mg, then 90mg 2x per day)
if unavailable:
clopidogrel (loading dose 300mg (or 600mg if PCI is planned), then 75mg 1x per day)
Anticoagulants:
NSTEMI: strategy dependent:
immediate invasive strategy (<2h) - UFH or bivalirudin
early invasive strategy (<24h) - fondaparinux (I choice) or enoxaparin (II choice)
early conservative strategy - fondaparinux, enoxaparin or other LMWH
STEMI: either LMWH or UFH (UFH prefered if CABG is planned <24h),
fondaparinux is contraindicated
PCI center
EMS or non-PCI center
Risk stratification
Therapeutic
strategy

Very high
Very high
High
High
Intermediate
Intermediate
Low
Low
immediate
invasive
<2h
early
invasive
<24h
invasive
<72h
non-invasive
testing
if possible
immediate transfer
same-day transfer
transfer
transfer optional
FMC
Risk assessment
i.e. GRACE scale or...
There's an app for that:
www.outcomes.org/grace
STEMI
NSTEMI
Thank You for Your









time.
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