STEMI

Oddy Litanto, MD
introduction
Definition of STEMI
• A clinical syndrome defined by characteristic
symptoms of myocardial ischemia in association
with
• persistent electrocardiographic (ECG) ST elevation
• subsequent release of biomarkers of myocardial
necrosis
The J point is the the junction between
the termination of the QRS complex
and the beginning of the ST segment
Ecg evolution of STEMI
ECG in STEMI
• The ECG diagnosis may
be more difficult in
some cases
5 point 2 point 3 point

> 3 points
STEMI diagnosis and Treatment
Plan Strategy
Relief of
Initial diagnosis hypoxaemia and
symptoms

Management
Selection of
during
reperfusion
hospitalization and
strategies
at discharge
 Initial diagnosis: History taking
• Evaluation of the patient’s complaints should focus on
• chest discomfort: graded on a scale of 1 to 10
• often described as a crushing, vice-like constriction, a feeling
equivalent to an “elephant sitting on the chest,” or heartburn.
• radiate to areas such as the neck, jaw, interscapular area, upper
extremities, and epigastrium
• typically lasts longer than 20 minutes
• associated symptoms→ nausea, vomitus, cold sweat,
syncope, dyspneu
• History→ prior episodes of MI, such as stable or
unstable angina, MI, coronary bypass surgery, or PCI.
• Comorbid: DM, HT.
 Initial diagnosis: Physical Exam
• A physical examination should be performed to aid in
the diagnosis and assessment of the extent, location,
and presence of complications of STEMI. (Level of
Evidence: C)
• → AHA 2004
When to do an posterior and RV
ECG?
• VI-V4 ST depression
• Inferior STEMI
• Typical chest pain but no ECG changes in
conventional ECG
How to do posterior ECG?
How to do RV ECG?

Sandapan V1, V2, V3→ V3R, V4R, V5R

Sandapan V4, V5, V6→ V7, V8, V9
 STEMI Equivalent
• Not all coronary occlusions meet STEMI criteria.
• Not all ECGs meeting STEMI criteria suggest coronary
occlusion.
 De Winter’s T Waves
• Precordial ST depression with a tall, symmetric T wave
Early management of
STEMI
 Relief of pain, breathlessness, and
anxiety
• Relief pain →
• Comfort reasons
• Pain → > symphatetic activation → vasoconstriction &
increases myocardial workload
• Oxygen is indicated in hypoxic patients with arterial
oxygen saturation (SaO2) < 90%
• hyperoxia may be harmful in patients with
uncomplicated MI,
Failed fibrinolytic Criteria
• ST-segment resolution < 50% within 60–90 min of
fibrinolytic administration
• haemodynamic or electrical instability
• worsening ischaemia
• persistent chest pain

RESCUE PCI ASAP !!!

Successful fibrinolytic Criteria
• ST-segment resolution > 50% at 60–90 min
• typical reperfusion arrhythmia
• disappearance of chest pain

• Succesfull lytic → routine early angiography is still

recommended if there are no contraindications
Primary PCI >12 hrs
• ECG evidence of ongoing ischaemia
• ongoing or recurrent pain and dynamic ECG
changes
• ongoing or recurrent pain, symptoms
• signs of heart failure, shock, or malignant
arrhythmia
Periprocedural
pharmacotherapy
Platelet inhibition
• STEMI patients:
• DAPT a combination of aspirin and a P2Y12 inhibitor
• a parenteral anticoagulant
• The preferred P2Y12 inhibitors for primary PCI are
• prasugrel [60 mg loading dose and 10 mg maintenance
dose once daily per os (p.o.)
• ticagrelor (180 mg p.o. loading dose and 90 mg
maintenance dose twice daily)
• more rapid onset of action, greater potency, and
superior to clopidogrel in clinical outcomes
Platelet inhibition
• neither of these agents is available (or if they are
contraindicated), clopidogrel 600 mg p.o. should
be given instead (CURRENT-OASIS 7)→ PCI
• No PCI→ clopidogrel 300mg po
Anticoagulation
• Anticoagulant options for primary PCI include
• UFH (heparin)
• Enoxaparin
• Bivalirudin
• Use of fondaparinux in the context of primary PCI
was associated with potential harm (OASIS 6) Trial
Fibrinolysis and
pharmacoinvasive strategy
• Fibrinolytic therapy is an important reperfusion
strategy in settings where primary PCI cannot be
offered in a timely manner
• recommended within 12 h of symptom onset if
primary PCI cannot be performed within 120 min
• Make sure no contraindications
Anticoagulation
• Preferable anticoagulant for STEMI undergoing
fibrinolytic:
• UFH
• Enoxaparin
• Fondaparinux

• Parenteral anticoagulation should preferably be

given until revascularization (if performed).
• Otherwise, it should be given for at least 48 h or for
the duration of hospital stay, up to 8 days.
Management during
hospitalization and at
discharge
Thank You