STEMI STUDY GUIDE

1. STEMI characteristics a. +/- Chest pain b. ECG Changes: ST elevation c. Biomarkers: Elevated cardiac enzymes 2. Cardiac Biomarkers a. Peak sensitivity at 8-12 hours b. Elevation may persist for 5-7 days c. Troponin I level i. <0.01 = Normal ii. 0.01-0.12 Troponin “leak” iii. >0.12 = Positive for MI 3. Diagnosis a. ST segment elevation on EKG b. Positive biomarkers of necrosis c. Symptoms same as UA/NSTEMI i. Only way to differentiate NSTEMI and STEMI is look at EKG for ST elevation 4. Reperfusion Therapy a. Goals i. Minimize ischemic time to <120 minutes (ideally <60 minutes) ii. PCI capable hospital: <90 minutes from 1st medical contact to balloon iii. Non-PCI capable hospital: 1. Transfer to PCI hospital and PCI <90 minutes from EMS to balloon 2. fibrinolytics administered <30 minutes from EMS contact iv. If a PCI cannot be performed in <90 minutes from 1st medical contact, administer fibrinolytic therapy <30 minutes from EMS contact b. Fibrinolytics i. Timing 1. <12 hrs (Class I evidence) (Max benefit <3 hrs) 2. 12-24 hrs (Class IIa evidence) 3. >24 hrs DO NOT GIVE! (Class III) ii. Agents 1. Alteplase a. 15 mg IV bolus, infuse 0.75mg/kg x 30 min (max 50mg), then 0.5mg/kg x 60 min (max 35mg) (total max 100mg in 90 min) 2. Tenecteplase a. IV Bolus over 5 seconds, 30mg if <60kg, 35mg if 60-69kg, 40 mg if 70-79kg, 45mg if 80-89kg, 50mg if >90kg iii. Contraindications 1. Absolute a. Previous intracranial hemorrhage

Relative a. Improvement in hemodynamic parameters c. the higher the risk of bleeding iv. Killip class III or IV 4. Onset >3 hrs 2. Internal bleeding within 2-4 weeks g. Efficacy a. Delay to invasive strategy c. When preferred 1. Severe. Monitoring 1. Presentation with uncontrolled SBP > 180 mmHg or DPB > 110 mmHg c. Significant closed head trauma within 3 months 2. Safety a. Active bleeding or bleeding diathesis f. Known intracranial lesion/neoplasm c. Traumatic or prolonged CPR (>10 min) e. If not. rescue PCI 2. Bleeding i. chronic hypertension b. Active peptic ulcer j. Noncompressible vascular punctures h.b. PCI i. High Risk STEMI a. poorly controlled. Pregnancy i. Aortic dissection e. Ischemic stroke within 3 months unless within past 3 hours d. Reduction of ST elevation >50% within 90 minutes after reperfusion 1. Interventional strategy not available 2. Current anticoagulation i. Early presentation (<3 hrs) and delay in PCI (door to balloon >90 min) 3. Contraindications to fibrinolysis 3. Improvement in electrical rhythm i. When preferred 1. “Washout” of cardiac biomarkers d. Major surgery within 3 weeks f. History of prior ischemic stroke or other intracranial pathology d. The higher the INR. Relief of symptoms b. Dx of STEMI in doubt . Cardiogenic shock b. Intracranial hemorrhage v.

75mg/kg IV 2. Aspirin 162-325 mg chewed b.5-0.5. 30mg IV bolus b. Give if LVEF <40% and either HF or diabetes who are receiving and ACEI ii. If no UFH/LMWH initiated – 0. MONA i. Dosing a. Nitroglycerin SL x 3. Eplerenone 25mg qday initially then 50mg qday f. Enoxaparin 1. reevaluate for secondary prevention iii. Anticoagulants i. 1mg/kg sc q 24h d. Evidence of low output state 3. SBP < 120 mm Hg. STEMI Treatment a. Intensive glucose control i. Aldosterone Antagonists i. Start IV if pt hypertensive on presentation d. increased time since onset of symptoms of UA/NSTEMI 4. IV if needed iv. Age > 70.3mg/kg IV iii. Use ARB if ACEI intolerant and pt has HF with LVEF <40% e.6 – 1. Clinical signs of HF 2.0U/ml (not required in most cases) . ACE Inhibitors i. Spironolactone 12. PCI only i. if Sa02>90% (Class I) 2. Monitoring a. Do not give if renal dysfunction or hyperkalemia iii. Increased risk for cardiogenic shock a. Start ORAL within first 24 hrs unless: 1. Maintain BG <180mg/dl while avoiding hypoglycemia c. PR interval > 0. If CrCl <30ml/min.5mg qday initially then 25-50 qday max iv. Beta blockers i. If early contraindications. If >8hrs from last dose – 0. Prescribe at discharge if no contraindications ii. Active asthma or reactive airway disease ii.24 ms 5. Morphine 2-4 mg IV in 2 mg increments up to 8mg q 5-15 min ii. sinus tachycardia > 110 or HR < 60. Anti-Xa = 0. 1mg/kg SC q 12h maintenance c. All patients during initial 6 hours (Class IIa) iii. 2nd/3rd degree AV block without pacemaker 6. If <8 hrs from last dose – none needed ii. Oxygen 1.

2. Monitoring a. then 75 mg PO qday ii. UFH g.b. Physical activity vii. PCI only – Add UFH 50-60 units/kg IV bolus 2. Weight management vi. Bleeding iii.5mg SQ q day b. BUN. Dosing a. Smoking cessation ii. Duration 1. >1 year (Class IIa) h. 300mg PO x 1 (no data if non-PCI and age>75 hrs). PCI – 1 yr 2. >14 days (Class I) b. Secondary Prevention i. Hct. SCr. ALL STEMI PTS 1. <70mg/dl (Class IIa) ii. Lipid management iv. Avoid for CrCl < 30ml/min c. Fondaparinux 1. LDL Goal <100mg/dl (Class I). Hg. Clopidogrel i. Annual influenza vaccine . Blood pressure control iii. Statins i. No PCI a. Diabetes management v. All pts should receive be discharged with statin unless they have a contraindications i. Timing: If significant change in clinical status or 4 hrs after dose ii.

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