1. ST Elevation Myocardial
Infarction
Salah Abusin, MD, MRCP
Cardiology Fellow
Chicago, IL
Secretary General
Sudanese American Medical Association

2. Outline
• Definition
• STEMI
– Definition
– H&P DD
– ECG DD
• Reperfusion therapy
– Fibrinolysis
– Primary PCI

3. Acute Coronary Syndromes
• Refers to any constellation of clinical
symptoms that are compatible with
acute myocardial ischemia

4. ACS Spectrum
AHA.ACC 2004 STEMI guidelines

5. STEMI

6. Case
• A 56 year old male with no PMH presents with
sudden onset of severe crushing retrosternal
chest pain that woke him from sleep. It
radiated down his left arm.
• It was accompanied with sweating, and
shortness of breath

7. Physical Examination
• HR 70/min, BP 130/80, RR 22/min
• JVP not raised
• Chest clear
• Normal S1 and S2, ?S3
• Soft non tender abdomen
• No LE edema

8. Differential Diagnosis of Acute
Chest Pain
• Cardiac • Chest wall
– ACS – Rib fracture
– Aortic Dissection* – Costochondritis
– Pericarditis – Herpes zoster (before rash)
• Pulmonary • Gastrointestinal
– Pulmonary Embolism* – Biliary
– Pneumonia – Esophageal
– Pneumothorax* • Spasm
• Rupture
– Pancreatitis
– Peptic Ulcer*

9. Pneumothorax

10. Pulmonary Embolism

11. Aortic Dissection

12. ECG Criteria for STEMI
• New ST elevation
– >0.1 mV in 2 contiguous leads
– Any 2 (II, III, aVF) or (V2-V6, I, aVL)
– Not aVR or V1
• In V2 & V3
– >=0.2 mV in men
– >= 0.15mV in women
• New LBBB
Thygsen et al. Universal Definition of MI
Circulation 2010

13. Proposed Criteria to determine
who gets ECG in ER STAT
• >30 with chest pain
• >50 with dyspnea, altered mental status,
upper extremity pain, syncope or weakness
• >80 with abdominal pain, nausea and
vomiting
DOESN’T REPLACE CLINICAL JUDGEMENT
Glickman et al
Am Heart J 2012

14. Anteroseptal wall STEMI

15. Anterolateral STEMI

16. Inferior Wall STEMI

17. Evolution of ECG changes in STEMI

18. Not Every ST Elevation
is a STEMI!!!

19. Early Repolarization

20. Pericarditis

21. Left Bundle Branch Block

22. Back to our patient - ECG
PATIENT HAS A STEMI!!!

23. Management
• Initial measures • Medication
– IV access – Antiplatelet Agents
– Continuous cardiac – Anticoagulants
monitoring – Beta Blockers
– Oxygen – Statin
• Reperfusion therapy
– Fibrinolysis
– Primary PCI
– Bypass Surgery

24. Fibrinolysis- Streptokinase
• First generation
• Given as a 60 minute infusion
• 1.5 million unit
• 25% relative risk reduction in mortality
compared to Aspirin*
*ISIS 2
Lancet, 1988

25. Additional advantages of
Streptokinase
• Low bleeding rates/Less strokes compared to
newer agents
• Cheap , 150 Sudanese pounds
• Most widely used agent worldwide

26. Other features
• Highly antigenic so can only be used once,
otherwise patient develops allergic reactions
• Achieves TIMI 3 flow in only 1/3 of patients
• Less efficacious compared to newer agents

27. Alteplase
• 100mg infusion over 90minutes (1/2 dose
within first 30minutes)
• Superior to Streptokinase in GUSTO trial*
• Fibrin specific (no antibody formation)
• More bleeding
*GUSTO 1
NEJM 1993

28. Reteplase,
Tenecteplase
• Given as IV bolus
• Comparable to alteplase in GUSTO-III and
ASSENT
• Convenient for administration prehospital
setting

29. Contraindications
• Absolute Contraindications
– Intracranial neoplasm
– Recent (<3 months) intracranial surgery or trauma
– recent (<3 months) ischemic stroke
– h/o hemorrhagic stroke
– Active or recent bleeding

30. • Relative Contraindications
– BP > 180 systolic
– H/o ischemic stroke
– Recent (<4 weeks) internal bleeding
– Thrombocytopenia

31. Additional Notes
• Treatment window
– Within 12 hours of onset of chest pain
– Never give after 24 hours
– If ongoing chest pain after 12 hours and low risk of
bleeding may give thrombolysis
• Success of thrombolysis is assessed by
– Resolution of Chest pain
– >50% reduction in ST elevation
– Development of accelerated idioventricular rhythm

32. 50% reduction in mortality with lytics
if given promptly

33. Fibrinolytics-Risk of ICH
• Elderly
• <70kg
• Uncontrolled
hypertension
• Lowest risk with
streptokinase

34. Primary Percutaneous Coronary
Intervention
• Superior to thrombolysis in most cases
• Less reinfarction, death
• Less stroke, bleeding

35. Coronary
Angiography

37. Normal Coronary Angiogram

38. Back to our patient

39. Limited Availability

40. Targets

41. Beyond Reperfusion
• Aspirin
– For all patients
• Clopidogrel for one year
– For all patients regardless of type of reperfusion
therapy, and if no reperfusion performed
• Heparin
– All patients who receive the newer thrombolytic
agents
– Use maybe considered with streptokinase (II b
indication)

42. Further Investigations
• Electrolytes
• CBC
• LFTs
• Fasting Blood Sugar
• Fasting lipid profile
• Echocardiography

43. After STEMI Care
• All patients should be admitted to a bed with
continuous cardiac monitoring
• All patients should be given (if no
contraindications)
– Beta Blocker (lifelong)
– ACE inhibitor (lifelong)
– Statin (lifelong)
• Additional medication
– Spironolactone (if low EF, diabetic)

44. Post STEMI Risk Assessment
• Coronary Angiography after STEMI
– Patients who fail thrombolysis (continued chest
pain, failure of ST segment resolution)
– Patients who have high risk features
• Heart failure (either clinical or Low EF)
• Serious Arrhythmias
• Patients who don’t have high risk features after
STEMI should undergo Exercise ECG stress testing for
risk stratification