ST-Segment Elevation Myocardial Infarction (STEMI)

- It is a type of myocardial infarction in which coronary blood flow decreases abruptly due to a
thrombotic occlusion of a coronary artery secondary to atherosclerosis resulting to death of
heart muscle tissues. This injury usually produced by cigarette smoking, hypertension and lipid
accumulations. In some cases, STEMI may be due to coronary artery occlusion caused by
coronary emboli, congenital abnormalities, coronary spasm and inflammatory diseases.
Patient with STEMI primarily complains of pain describes as heavy, squeezing, and crushing,
diaphoresis and weakness. Typically, patient with STEMI experienced pain on the central portion
of the chest and or in the epigastric area and radiates at the arms, some radiates at abdomen,
back or lower jaw and neck. However, in Elderly patient they present sudden onset of difficulty
of breathing, which ay progress to pulmonary edema.
STEMI has 3 temporal stages: (1) acute stage is from few hours to 7 days (2) healing, 7 days to
28 days and (3) healed stage, 29 days or more than.

Killip Scoring for prognostication

Class Description Risk of mortality

Class I  No rales or signs of pulmonary or venous congestion 0-5%
 Normal BP
Class II  Moderate heart failure 10-20%
 With bibasal rales
 Normal BP
 S3 Gallop
 Tachypnea or signs of right-sided CHF (venous and
hepatic congestion

Class III  Severe heart failure 35-45%

 With mid-basal rales and pulmonary edema
 Presence of S3 and S4
 Normal BP

Class IV  Shock with SBP <90mmHg and evidence of peripheral 85-95%

vasoconstriction
 Peripheral cyanosis
 Mental confusion and oliguria

Diagnostics:
1. 12 lead Electrocardiogram
- ECG must be done and interpreted within 10 minutes of patient arrival. ECG results
were ST-segment elevation and mostly ultimately evolve to Q wave it is due to total
occlusion of an epicardial coronary. The diagnosis of STEMI requires the typical ST-
segment elevation in at least 2 continuous leads or new onset of LBBB.
2. Cardiac Biomarkers
- Troponin T and Toponin I is increases after STEMI to levels may times higher than the
upper reference limit. Creatinine phosphokinase (CK) rises within 4 to 8 hours.
3. Cardiac imaging
- 2 D Echo shows abnormalities of a wall motion. Radionuclide techinques such as MPI
with Setamibi or thallium is less often used due to lack of specificity and sensitivity. And
Cardiac MRI

TIMI SCORE
- It is a tool used to predict the chances of having or dying from a heart condition such as
myocardial infarction.

TIMI SCORE

Risk score = 0-14

High risk => 5 points (12%
mortality)

Treatment for STEMI

Goal:
- control cardiac discomfort or chest pain
- identify patient who are candidates for urgent reperfusion therapy
- Hospital management.

Initial management in Emergency Room

 Aspirin
 - Is essential in the management of patient with suspected STEMI and entire acute
coronary syndromes.
 PCI ( such as clopidogrel)
- Given within 120 minutes of first medical contact.
 Oxygen support
- If hypoxemia is present adminiter oxyhen support 2-4 LPM via nasal cannula or face
mask

Control Chest Discomfort

 Nitroglycerin
- given sublingually 0.4mg up to 3 doses at about 5 minutes intervals.
- is capable of decreasing myocardial demand and increasing the myocardial oxygen
supply.
 Morphine
- effective analgesic for pain
- it may cause venous pooling and may reduce cardiac output and arterial pressure.
 Beta Blockers
- useful in the control of pain, amd reduce the risk of reinfarction and ventricular
fibrillation.
- oral beta blockers should be initiated for the first 24 hours except patients who have
heart failure, low output state, increased risk for cardiogenic shock and other relative
contraindications such as PR interval of >.24 sec., second or third degree heart block,
active asthma, or reactive airway disease.

Primary Percutaneous Coronary Intervention

- Usually an angioplasty or stenting without preceding fibrinolysis. It is effective in
restoring perfusion in STEMI when carried out on an emergency basis in the first few
hours. It has the advantage in patients who are contraindicated in fibrinolytic therapy
but this are considered being the appropriate candidates for reperfusion. PCI is more
effective than fibrinolysis in opening the occluded coronary arteries; it also has a
better outcome and long-term clinical outcomes. Also is it preferred rather than
fibrinolysis when the diagnosis is in doubt, cardiogenic shock is present, bleeding risk
is increased, or symproms have been present for at least 2 – 3 hours whn the clot is
more mature and less easily lysed by fibrinolytic drugs.

Fibrinolysis Therapy
- If no contraindications are present fibrinolytic therapy should be initiated within 30
minutes of presentation. The goal of this therapy is to restore the coronary arterial
patency.
- Contraindication in using fibrinolytic agents; such as with a history of cerebrovascular
hemorrhage, non hemorrhagic stroke, or other cerebrovascular events for the past
 year, marked hypertension (SBP 180mmHG and DBP 110mmHg), suspicion of aortic
dissection and increase hemorrhagic complications, allergic to streptokinase.

Other Routine Medications

• Antithrombotic Agents - to maintain patency of infarct-related artery.
• Beta Adrenoreceptor Blockers - given in acute setting and maintenance therapy for secondary
prevention after infarct.
• ACE Inhibitors - reduce the rate of mortality after STEMI

• Angiotensin Recptor Blocker - given to patient who is intolerant to ACEi and with either clinical
or radiologic signs heart failure.

Supportive care
• Activity
- first 6-12 hours: bedrest
- next 12 hours: dangling of feet over at bedside and sitting on chair under supervision.
• Diet
- 4-2 hours: NPO or clear liquid.
• Bowel Management
- use of stool softener
• Sedation
- most of patients require sedation during hospitalization to withstand the period of
enforced activity.

Non-ST Elevation Myocardial Infarction (NSTEMI)

It is caused by an imbalance between Myocardial oxygen supply and demand resulting from one or more
of the following four process that lead to thrombus formation: 1. Disruption of an unstable coronary
plaque due to plaque rapture, erosion, or a calcified protruding nodule that leads to intracoronary
thrombus formation and an inflammatory response. 2. Coronary arterial vasoconstriction 3. Gradual
intraluminal narrowing. 4. Increase myocardial oxygen demand due to fever, tachycardia, and
thyrotoxicosis in the presence of fixed epicardial coronary obstruction

Severe chest discomfort with at least one of the three features: Occurrence at rest (or with minimal
exertion), lasting for >10 minutes, relatively recent in onset (i.e. Within the prior two weeks), a
crescendo pattern, i.e. distinctly more severe, prolonged, or frequent than previous episode. Other
physical findings include diaphoresis, pale, cool skin, sinus tachycardia, third or fourth heat sound,
basilar rales, sometimes Hypotension. Develops evidence of Myocardial necrosis is based on elevated
Cardiac Biomarkers.

DIAGNOSTICS

Electrocardiogram
New ST segment depression occurs. It may be transient and may occur for several days. T-wave changes
are more common but less specific signs of ischemia, unless they are new and deep T-wave inversion. It
is strongly recommended that a 12-lead electrocardiogram (ECG) be obtained immediately within 10
minutes of emergency room (ER) presentation in patients with ongoing chest discomfort.

Cardiac Biomarkers

Patients with NSTEMI have elevated cardiac biomarkers for necrosis, such as cardiac troponin I or T,
which are specific, sensitive, and the preferred markers of Myocardial necrosis. Additionally, troponins
are the best biomarker to predict short-term (less than 30 days) outcome with respect to MI and death.

Non-invasive imaging

It is recommended that an echocardiogram be done in all patients suspected to have ACS for evaluation
of global and regional left ventricular (LV) function, for ruling in or out differential diagnoses and for
prognostic information. It may be recommended to perform coronary computerized tomography
angiography (CTA) to exclude ACS in those with non-diagnostic ECG and troponin, and have a low to
intermediate likelihood of CAD.

Prognostication

It is recommended for patients who present with chest discomfort or other ischemic symptom to
undergo early risk stratification for risk of CV events (e.g., death or MI) based on an integration of the
patient’s history, physical examination, ECG findings and result of cardiac biomarkers. Risk assessment
tools: TIMI, and GRACE.

• TIMI Risk Score

• The TIMI risk score is determined by the sum of the presence of seven variables upon
admission, with 1 point given for each present variable: age 65 years or older; at least
three risk factors for CAD; prior coronary stenosis of 50% or more; ST-segment deviation
on ECG presentation; at least two anginal events in the prior 24 hours; use of aspirin in
the prior 7 days; and elevated serum cardiac biomarkers.
 • Rate of outcome of all-cause mortality, new or recurrent MI, or severe recurrent ischemia
requiring urgent revascularization using TIMI risk score.

GRACE Risk Model

There are 8 variables used: older age; Killip class; systolic blood pressure; ST-segment deviation; cardiac
arrest during presentation; serum creatinine level; positive initial cardiac markers; and heart rate. The
sum of scores is applied to a reference nomogram to determine the corresponding all-cause mortality
from hospital discharge to 6 months. It predicts cumulative risk of death and MI during a patient’s
admission, discharge and until 6 months after discharge
TREATMENT

Nitrates

It is recommended that nitrates (sublingual tablet or spray), followed by intravenous (IV) administration,
be administered for the immediate relief of ischemic and associated symptoms. Due to its Venodilator
effect, Reduced myocardial preload  better nyocardial oxygen consumption  improvement of
symptoms. For initial management of anginal pains, 0.4 mg sublingual NTG tablets or spray taken 5 min
apart can be administered until the pain is relieved, or a maximum of 1.2 mg has been taken within 15
minutes.

Beta Blockers

It is recommended to initiate a beta blocker by oral route for all patients within the first 24 hours unless
contraindications are present. Use of IV beta blockers should be considered with caution. Use of IV beta
blockers should be considered with caution. Beta blockers competitively block the effects of
catecholamines on cell membrane beta-receptors. Blocking beta 1 receptors results in decrease in
cardiac workload and less myocardial oxygen demand.

Calcium Channel Blockers

It may be recommended to use oral long-acting calcium antagonists for recurrent ischemia in the
absence of contraindication and when beta blockers and nitrates are maximally used.

ACEIs and ARBs

It is strongly recommended that an ACEI should be administered within 24 hours of admission to NSTE-
ACS patients with pulmonary congestion, with LVEF less than 40% in the absence of hypotension and
other contraindications.

Morphine sulfate

It is recommended that morphine sulfate be administered IV when symptoms are not immediately
relieved with NTG, or when acute pulmonary congestion and/or severe agitation is present. Morphine
sulfate 1 to 5 mg IV is recommended for patients whose symptoms are not relieved after three serials
sublingual NTG tablets, or whose symptoms recur despite adequate anti-ischemic therapy.

Aspirin

It is strongly recommended that non-enteric coated aspirin be chewed by patients as soon as possible at
initial presentation at an initial dose of 160 to 320 mg followed by 80 to 160 mg daily indefinitely. Aspirin
reduces the incidence of recurrent MI or death in patients with NSTEMI. Contraindication: Active
bleeding, or aspirin intolerance.

Anticoagulants

It is strongly recommended to start unfractionated heparin (UFH), enoxaparin or fondaparinux in

addition to antiplatelet therapy.

Conservative vs. Early Invasive Strategies

• Conservative strategy (low risk patient)- Ischemia guided strategy with anti-ischemic therapy
and antithrombotic therapy followed by close observation

• Invasive strategy (high risk patient)- Following treatment with anti-ischemic and anti-thrombotic
agents, coronary angiography is carried out, followed by coronary revascularization.

Long Term Advise

It is recommended that the following specific instructions should be given upon hospital discharge and
for long-term management: Lifestyle modification that includes smoking cessation, achievement or
maintenance of optimal weight (body mass index of 18.5 to 24.9 kg/ m2), exercise, and diet; Consider
referral of patients who are smokers to smoking cessation program or clinic and/or an out-patient
cardiac rehabilitation program, and; Continued education about long term follow up, adherence to
medications. Any recurrence or change in symptoms should be communicated to the healthcare team.