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STEMI

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Caitlyn Sims

on 25 January 2017

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Transcript of STEMI

SMO 311
Topic : STEMI

Caitlyn Sims 15068082
Brendon Buisman 15091466
Ekta Bramdev 15053548
Krysten Smithers 15036813

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How can the burden of this problem be reduced?
REFERENCES
A STEMI is a ST-elevation myocardial infarction. This definition refers to the electrocardiogram (ECG) with the literal elevation of the ST segment, which is an important indication of serious heart disease. A STEMI injury involves a complete occlusion of a blood vessel resulting in an interruption of blood supply to the myocardium. This ischaemia can lead to necrosis in a portion of the heart eventually resulting in death or serious disability unless treated.
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Figure 1: Illustrating the elevated ST-segment of the ECG
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More than 90% of STEMI’s are attributed to coronary atherosclerotic plaques. The atherosclerotic plaques involved in this particular myocardial infarction is classified as unstable. This refers to the thin fibrous cap, a small cholesterol core and few inflammatory cells. This type of plaque is particularly prone to rupturing, resulting in the initiation of the coagulation cascade. This causes a platelet aggregation which later becomes a blood clot that occupies the entire diameter of the blood vessel.
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Individuals with STEMI’s have:
• Transmural infarction of the myocardium
• Complete block of a coronary artery
• Need treatment with thrombolytics


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How does this problem affect the population?

• Affects: 1-2% of the global population
• Affects: 10% of the global elderly population (males >55, females >65)
• Globally: > 3 000 000 people suffered a ST-elevated myocardial infarction in 2013.
• STEMI’s affect males twice as much as females.
• In the United States of America 810 000 myocardial infarctions occur annually. These include both STEMI’s and Non-STEMI’s.
• In South Africa 47 000 myocardial infarctions occur annually. This is equivalent to 5 MI’s per hour. These include STEMI’s and Non-STEMI’s.

It is evident that the occurrence of this cardiovascular event is critically high, killing millions of people annually. Making it one of the greatest causes of death globally.


STEMI’s are an acute form of heart failure that occur rapidly. Of all those who suffer a STEMI, 25% die within the first few minutes.
Therefore the morbidity during the infarction is short lasted, until either treatment is provided or the person dies.







It is evident that life after an ST-Elevated Myocardial Infarction is a life lived under permanent threat of a following event. The post-event morbidity may limit daily living of most people.

Post Infarction complications:

Patients will have to take chronic medication.
Patients are cautioned not to fly or drive for a few months.
Many patients are reported to have experienced chronic anxiety due to the high risk of a second infarction.
Many patients will be subject to invasive therapy such as open heart surgery.
Symptoms include:
Angina (chest pain)
Dyspnoea
Syncope
Nausea
Other less common symptoms
Post Infarction patients face
a substantial risk of further
events including:
Death
Recurrent MI
Heart failure
Arrhythmias
Angina
Strokes
TREATMENT IN SA
South Africa is an emerging country in the eye of the 1st world healthcare, however it still has many factors that limit the successful treatment of STEMI’s.
A critical form of treatment includes fibrinolytic therapy. Due to poor access to healthcare facilities, understaffed hospitals, a lack of finances and other factors, only 36% of South African STEMI cases receive this fibrinolytic therapy.
Thus the aforementioned factors of the country contribute to the high levels mortality and morbidity due to STEMI’s.



A study performed in South Africa amongst 13 black patients who suffer from myocardial infarctions indicated that 10 of them had complete occlusive atherosclerotic plaques with positive serum results and indicative ECGs of STEMI’s. The remaining 3 who suffer from atherosclerotic plaques do not indicate STEMI patterns but rather coronary spasms, emboli, mitral leaflet syndrome etc.
Many of the risk factors mentioned are preventable. It is therefore critical that primary prevention techniques occur in order to prevent and reduce the burden of this disease. It is imperative that GP’s and health care workers educate the community about these risk factors and screen the population.

RISK FACTORS
PREVALENCE
MORBIDITY
Introduction

DRUG THERAPY
1) Anti-platelet drugs or anti-coagulants:
Aspirin

Clopidogrel

Warfarin
3) Weight Control
1) Blood Pressure Control
Secondary Prevention
2) RAAS Blockers
ACE-I

ARBs

Aldosterone Blockade
3) Beta Blockers
4) Influenza Vaccination
LIFESTYLE CHANGES
1) Cessation of Smoking
A plan of action must be developed in order to successfully aid the patient in fully quitting smoking. If necessary, the patient must be provided with additional support in the form of counseling, pharmacological therapy and advice from their medical practitioner. The patient must be questioned about their progress at each consultation and the patient’s family should be advised to collectively quit tobacco use.
2) Physical Activity
An appropriate and patient-specific exercise program must be adopted by the patient. The program must be supervised by medical professionals and should involve 30 to 60 minutes daily of aerobic activity, supplemented with resistance training twice in a weekly cycle.
A plan of action is initiated to aid in the reduction or maintenance of the patient’s body weight. The weight loss/maintenance program should target a combination of physical exercise, diet and behavioural issues of the patient. During each consultation, the patient’s BMI and waist circumference should be assessed in order to monitor their progress. The initial objective is a 10% decrease in the patient’s current mass. A goal BMI of 18,5 – 44,9 kg/m should then be reached.
162 mg – 325 mg aspirin is administered to all post-PCI STEMI patients who have received a stent implantation, provided that they are neither allergic nor resistant to aspirin, or have abnormal tendency to bleed. Aspirin is administered once daily for a minimum duration of one month, after which a dose of 75 mg – 162 mg is continued indefinitely. Patients who have increased bleeding tendencies should be given 75 mg – 162 mg aspirin in the initial period after a stent implantation.
75 mg Clopidogrel must be administered to post-PCI STEMI patients following stent implantation for a duration of 12 months, provided that the patient does not have any abnormal bleeding tendencies. STEMI patients who have not received a stent implant are administered Clopidogrel for 14 days. Longstanding treatment with Clopidogrel, 75 mg once daily, is continued for all STEMI patients.


Warfarin is indicated for post-STEMI patients with other cardiac pathologies such as dysrhythmias etc. However, when used in combination with aspirin and Clopidogrel, interactions result in an increased risk of abnormal bleeding tendencies in patients. If combination therapy is required, aspirin is administered in a low dose of 75 mg – 81 mg along with a 75 mg dose of Clopidogrel.
ACE-I should be administered to all post-STEMI patients indefinitely, especially in cases where the left ventricular ejection fraction of the patient is less than 40%, the patient suffers from diabetes, hypertension or CKD and in all patients with high cardiovascular risk, unless contraindicated. In patients who have a low cardiovascular risk administration of ACE-I is sensible.
ARBs are administered to patients who are intolerant to ACE-I.
Indication is for all post-STEMI patients with either diabetes or heart failure that are being treated with ACE-I and beta blockers and have a left ventricular ejection fraction of less than 40%. Aldosterone blockers are contraindicated in patients with hypokalaemia and renal dysfunction.
Unless contraindicated, beta-blockers are administered indefinitely to all post-STEMI patients.
An annual influenza vaccination is recommended to all patients suffering with CVD.
MANAGEMENT OF RISK FACTORS
It is imperative for all post-STEMI patients to implement strategies to reduce their blood pressure to a reading below 140/90 mmHg (or 130/80 mmHg for all diabetic and CKD patients). These strategies involve a combination of drug therapy (administration of beta blockers and/or ACE-I with a diuretic e.g. thiazides), physical activity, dietary modifications (reduction in alcohol, fatty foods and salt consumption and introduction of more fruits and vegetables into diet) and weight control.
2) Lipid Management
All post-STEMI patients should aim to reduce their LDL-C levels to less than 100 mg/dL and non-HDL-C levels to less than 130 mg/dL. This can be achieved through decreasing the trans fatty acid, saturated fat and cholesterol content in the patient’s diet and increasing their intake of omega-3 fatty acids and dietary fibre. The implementation of a physical exercise and weight management program should be initiated to supplement the dietary modifications. Drug therapy is also utilized to lower non-HDL-C levels (e.g. administration of statins, fibrates or niacin). The lipid profile of the patient must be assessed at each consultation.
3) Diabetes Management
It is imperative that all post-STEMI patients suffering from diabetes undertake methods to control their disease and aim to maintain an optimal HbA1c level. This can be achieved through drug therapy, dietary modifications, physical exercise and weight, blood pressure and cholesterol management.
Most cases of STEMI’s occur do to atherosclerotic plaque (90%). The risk factors leading to this include:

Hypertension
High cholesterol
Poor diet
Poor exercise
Central obesity
Alcohol
Smoking
Age
Positive family history
Gender
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Primary Prevention
Assess For Risk Factors
• Using the Framinghams assessment
• Test the risk assessment every 3-5 years

Risk Factors For General Cardiovascular Diseases
Smoking
Diabetes mellitus
Low grade inflammatory diseases such as SLE
Depression
Positive family history
Hypertension
Hypercholesterolaemia
Kidney disease

In patients with more than two risk factors, it is recommended to have a 10-year coronary artery disease risk score assessment. This can be achieved through history taking within a dialogue with the patient and making lifestyle changes. Primary prevention can best be achieved by tackling the risk factors that can be controlled, such as hypertension and diabetes mellitus by controlling the disease with adherence with medication and regular monitoring - as well as cessation of smoking.


In a primary prevention study done in England, two groups of people were selected. One which received pravastatin which reduces serum LDL cholesterol and another received a placebo. In a 10-year follow-up study, the group which received the pravastatinhad a 8,6% death rate related to transmural myocardial infarctions , where as the placebo group had a mortality of 10,3%. This indicates how lifestyle changes such as diet, or increased physical activity can improve the chances of not acquiring a cardiovascular disease.
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2. Pasotti M, Prati F, Arbustini E. The pathology of myocardial infarction in the pre-and post-interventional era. Heart. 2006 Nov 1;92(11):1552-6.
3. uchigagomed. stemi and nstemiecg illustration [Internet]. 2017 [cited 9 January 2017]. Available from: https://uchicagomed.files.wordpress.com/2012/06/stemi-and-nstemi-ecg-illustration-pu.jpg?w=600&h=482

4. White HD, Chew DP. Acute myocardial infarction. The Lancet. 2008 Aug 22;372(9638):570-84.
5. MEDPAGE TODAY [Internet]. Epidemiology of Acute Coronary Syndrome: Current Patterns, Causes, and Effects. [published 2014 February 24; cited 2017 January 16]. Available from: http://www.medpagetoday.com/resource-center/moving-forward-after-ACS/epidemiology/a/44449
6. Delport R. STEMI South Africa – current situation and future plans, inspired by SFL [Internet]. Available at:http://www.sasci.co.za/uploads/files/SFL_SA_Report_2016_04_R_Delport.pdf
7. Wilson P [Internet]. Prognosis after myocardial infarction. UpToDate; [Updated 2014 July 1; Cited 2017 January 16]. Available from: http://www.uptodate.com/contents/prognosis-after-myocardial-infarction
8. Chesler E, Mitha AS, Weir EK, Matisonn RE, Hitchcock PJ. Myocardial infarction in the black population of South Africa: coronary arteriographic findings. American heart journal. 1978 Jun 30;95(6):691-6.

9. Campbell-Scherer DL, Green LA. ACC/AHA guideline update for the management of ST-segment elevation myocardial infarction. American family physician. 2009 Jun 15;79(12).
10. Domanski MJ. Primary prevention of coronary artery disease. New England Journal of Medicine. 2007 Oct 11;357(15):1543.

11. Antman EM, Armstrong PW, Green LA, Halasyamani LK, Hochman JS, Krumholz HM, Lamas GA, Smith SC, Hand M, Bates ER, Mullany CJ. 2007 focused update of the ACC/AHA 2004 guidelines for the management of patients with ST-elevation myocardial infarction. Journal of the American College of Cardiology. 2008 Jan 15;51(2):210-47.
12. McManus DD, Gore J, Yarzebski J, Spencer F, Lessard D, Goldberg RJ. Recent trends in the incidence, treatment, and outcomes of patients with STEMI and NSTEMI. The American journal of medicine. 2011 Jan 31;124(1):40-7.

ACRONYMS
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