Acute STElevation Myocardial Infarction

1
Acute ST-ElevationMyocardial Infarction
Craig M. Oliner, M.D., F.A.C.C.
Leah, age 2
2
All of the following therapies, except one, have
proven beneficial at decreasing mortality in
patients with acute ST-segment elevation MI.
Which therapy does NOT decrease mortality of
acute MI?
Acute ST-Elevation Myocardial Infarction Craig
Oliner, M.D.

• Nitroglycerin
• Thrombolytic therapy
• Aspirin
• Primary angioplasty

3
All the following events, except one, predict an
unfavorable long-term prognosis in patients with
acute myocardial infarction. Which event has the
LEAST effect on long-term prognosis?
Acute ST-Elevation Myocardial Infarction Craig
Oliner, M.D.

• Congestive heart failure
• Recurrent angina 3 days after MI onset
• Sustained VT lt 48 hours after MI onset

4
Which of the following patient subgroups with
acute myocardial infarction benefits from
thrombolytic therapy?
Acute ST-Elevation Myocardial Infarction Craig
Oliner, M.D.

• ST-segment depression
• ST-segment elevation
• T-wave inversion
• Non Q-wave MI with troponin elevation

5
Acute ST-ElevationMyocardial Infarction
Craig M. Oliner, M.D., F.A.C.C.
Leah, age 2
6
Case - Alice M. Inker
Name is fictitious

• 62 yo woman
• 90 minutes of central chest pain

I
aVR
V1
V4
II
aVL
V2
V5
III
aVF
V3
V6
7
Case - Alice M. Inker

• Is Ms. Inker having a good day?

8
Case - Alice M. Inker

• Is Ms. Inker likely to die?

9
Case - Alice M. InkerIn-Hospital Mortality
13
5
1980
2008
10
Case - Alice M. Inker

• How much blood is going to Ms. Inkers inferior
  wall?

What does the lumen of her right coronary artery
look like?
11
Case - Alice M. InkerRight Coronary Artery
Angiogram
occluded RCA
12
Case - Alice M. Inker Ruptured Plaque with
Thrombosis
Right Coronary Artery
thrombus
atherosclerotic plaque
13
Acute ST-Elevation MIPathogenesis
plaque rupture
14
Plaque Severity Vs. Instability
Severity
Unstable
15
Plaque Severity Vs. Stability
lumen
fibrous cap
Stable Plaque Severe Stenosis
lipid core
Unstable Plaque Mild Stenosis
lipid
lumen
16
Stable Plaque
thick fibrous cap
lumen
small lipid core
17
Unstable PlaqueRuptured Plaque with Thrombosis
thrombus
thin fibrous cap
lipid core
18
Plaque Severity Vs. Stability Angiography Several
Days After MI
RCA
very stenotic, stable
less stenotic, unstable
19
Plaque Severity Vs. Stability
Stable Plaque lt 50 stenosis
Stable Plaque 50 stenosis
Unstable Plaque lt 50 stenosis
20
CaseAlice M. Inker

• How is the diagnosis of acute infarction
  confirmed?

Leah, age 4 Nina, age 12
21
Diagnosis of Acute ST-Elevation MI

• ECG ST-Elevation

• Chest Pain

• Cardiac Markers
• Troponin (cTnI, cTnT)
• Creatine Kinase (CK)
• CK-MB
• Myoglobin

22
Diagnosis of Acute MI
8
7
Cardiac Markers
6
5
x Upper Limit of Normal
4
3
2
1
80
60
100
120
140
160
0
20
40
Hours From MI Onset
23
Diagnosis of Acute MISensitivity of Cardiac
Markers
100
80
60
Sensitivity
40
20
0
8
12
16
0
4
20
24
Hours from MI Onset
24
Diagnosis of Acute MIFalse Positive Cardiac
Troponins
25
ECG is Pivotal
Ischemic Chest Pain
no ST-Elevation or LBBB not lytic eligible
ST-Elevation or LBBB lytic eligible
26
Case - Alice M. Inker

• Acute inferior MI with ST-segment elevation
• What therapy might save her life?

27
ST-Elevation/LBBB Acute MI
or
28
ST-Elevation/LBBB Acute MI
or
29
Thrombolytic Therapy

• alteplase (t-PA)
• anistreplase (APSAC)
• reteplase (r-PA)
• streptokinase (SK)
• tenecteplase (TNK)
• urokinase (UK)

indicated for ST-Elevation or LBBB acute MI
30
Thrombolytic TherapyTenecteplase
31
Thrombolytic Therapy
Benefits
Risks

• ? Mortality
• Smaller infarct ? ? Heart failure
• Improved healing ? ? Infarct expansion
• ? Thromboemboli
• ? VT/VF
• ? Pericarditis

All Lytics

• Bleeding
• hemorrhagic stroke

Streptokinase

• Allergy
• Hypotension

32
Thrombolytic Therapy
Indications

• Clinical suspicion of acute MI
• ST-Elevation or LBBB

• Recent bleeding, surgery, trauma
• Non-hemorrhagic CVA gt 3 months
• BP gt 180/110
• CPR gt 10 minutes

33
Thrombolytic Therapy
81

• Decision Point
• 90 minutes
• Clinical Criteria
• 50 ? ST-elevation

Reperfusion _at_ 90 minutes
GUSTO N. Engl. J. Med. 19933291615
34
Rescue PCI/CABG
Thrombolytic Therapy

• Shock
• Severe HF
• Serious Arrhythmias
• Persistent Ischemia
• Failed Lytic Therapy, Large MI

35
Primary PCI Vs. Lytic Therapy
PCI Advantages
Lytic Advantages

• lower cost
• 2000 Vs. 5000
• wider availability
• easier
• less expertise
• fewer staff
• ? major bleeds 2

• better early patency
• gt 90 Vs. 81
• ? residual stenosis

• ? mortality 1
• ? re(MI) 5
• ? recurrent angina 15
• ? hemorrhagic stroke 1

36
1 Percutaneous Coronary InterventionPrimary
Angioplasty
37
Aspirin
38
Anticoagulation
39
Anticoagulation
40
Clopidogrel
41
ACE Inhibitor
42
Statin
43
Beta-Blocker
44
Nitrate
45
Summary of Hospital TherapyST-Elevation or LBBB
Acute MI
Treatment
Indication
46
Summary of Hospital TherapyST-Elevation or LBBB
Acute MI
13
Mortality
5
1980
2008
47
Summary of Hospital TherapyST-Elevation or LBBB
Acute MI

• ECG monitoring
• Bedrest
• Oxygen
• Normalize K, Mg

• Stool softener
• Antianxiety
• D/C NSAIDs

48
Case - Alice M. Inker

• Ms. Inker is treated with TNK, aspirin, heparin,
  clopidogrel, atorvastatin, metoprolol, and
  nitroglycerin.

• One hour later, what might her right coronary
  artery look like?

49
Case - Alice M. Inker
RCA
RCA
thrombus
occlusion
One Hour Later
Before Therapy
50
Case - Alice M. Inker

• Twelve hours after admission, she develops
  dizziness and her systolic BP is 70 mmHg.
• What may be causing her hypotension?

Mariel, age 8
51
Complications of Acute MIHypotension

• Sinus bradycardia, A-V block
• Ventricular tachycardia
• Right Ventricular MI
• Severe LV dysfunction
• Ventricular septal rupture
• Acute mitral regurgitation
• Medication induced hypotension
• Medication induced bleeding
• Cardiac tamponade

52
Complications of Acute MISinus Bradycardia

• Causes
• Sinus node ischemia
• Bezold-Jarisch reflex
• ?-blocker, calcium channel blocker, nitroglycerin
• Treat Only If Symptoms
• d/c ?-blocker, calcium blocker, nitroglycerin
• Atropine, pacemaker

53
Complications of Acute MIA-V Block
54
Complications of Acute MIVT/VF

• VT with ? BP, or VF (CPR)
• Shock
• Epinephrine ? vasopressin
• Shock
• Amiodarone ? lidocaine
• Shock

Remember K, Mg
55
Complications of Acute MI VT/VF Long Term
Prognosis

• lt 48 hours, no effect
• long term treatment not indicated

• gt 48 hours, increased risk
• long term treatment indicated

56
Complications of Acute MIRight Ventricular MI

• Diagnosis
• triad hypotension, jugular venous distention,
  clear lungs
• V4R ST-elevation 1 mm
• echo RV dilatation and dysfunction
• Therapy if MI lt 12-24 Hours Old
• lytic therapy or PCI
• Therapy if MI gt 12-24 Hours Old
• fluids, dobutamine
• A-V pacing

57
Right Ventricular MI Right Sided Precordial Leads
V4r
V1r
I
aVR
RV MI
ST-Elevation
II
V5r
V2r
aVL
V6r
III
aVF
V3r
V4r
I
V1r
aVR
No RV MI
no ST-Elevation
aVL
V5r
V2r
II
V3r
V6r
III
aVF
58
Complications of Acute MISevere LV Dysfunction
Cardiogenic Shock

• hypotension
• poor tissue perfusion
• pulmonary edema

• LV Dysfunction

59
Complications of Acute MIVentricular Septal
RuptureAcute Mitral Regurgitation

• Diagnosis
• Sudden
• Pulmonary edema
• ? Hypotension
• New systolic murmur
• Echo VSR or MR

• Therapy
• Surgery
• IABP

60
Complications of Acute MIVentricular Septal
Rupture
LA
Tricuspid Regurgitation
VSR
RA
LV
RV
61
Complications of Acute MIMedication Induced
Hypotension

• ?-Blockers
• ACE-inhibitors
• Nitrates
• Calcium Channel Blockers

62
Complications of Acute MIMedication Induced
Bleeding

• Thrombolytic
• Anticoagulant
• Aspirin
• Clopidogrel
• /- GP 2B3A

63
Complications of Acute MICardiac Tamponade

• Etiology
• Pericarditis
• Contained rupture
• Diagnosis
• Hypotension, tachycardia, jugular venous
  distension, pulsus paradoxus
• Echocardiogram

64
Case - Alice M. Inker

• Sinus bradycardia at 28 bpm
• SBP 70 mmHg
• Treatment
• atropine
• reduction in metoprolol

Nina, age 12
65
All of the following therapies, except one, have
proven beneficial at decreasing mortality in
patients with acute ST-segment elevation MI.
Which therapy does NOT decrease mortality of
acute MI?
Acute ST-Elevation Myocardial Infarction Craig
Oliner, M.D.

• Nitroglycerin
• Thrombolytic therapy
• Aspirin
• Primary angioplasty

66
All of the following therapies, except one, have
proven beneficial at decreasing mortality in
patients with acute ST-segment elevation MI.
Which therapy does NOT decrease mortality of
acute MI?
Acute ST-Elevation Myocardial Infarction Craig
Oliner, M.D.

• Nitroglycerin
• Thrombolytic therapy
• Aspirin
• Primary angioplasty

67
All the following events, except one, predict an
unfavorable long-term prognosis in patients with
acute myocardial infarction. Which event has the
LEAST effect on long-term prognosis?
Acute ST-Elevation Myocardial Infarction Craig
Oliner, M.D.

• Congestive heart failure
• Recurrent angina 3 days after MI onset
• Sustained VT lt 48 hours after MI onset

68
All the following events, except one, predict an
unfavorable long-term prognosis in patients with
acute myocardial infarction. Which event has the
LEAST effect on long-term prognosis?
Acute ST-Elevation Myocardial Infarction Craig
Oliner, M.D.

• Congestive heart failure
• Recurrent angina 3 days after MI onset
• Sustained VT lt 48 hours after MI onset

69
Which of the following patient subgroups with
acute myocardial infarction benefits from
thrombolytic therapy?
Acute ST-Elevation Myocardial Infarction Craig
Oliner, M.D.

• ST-segment depression
• ST-segment elevation
• T-wave inversion
• Non Q-wave MI with troponin elevation

70
Which of the following patient subgroups with
acute myocardial infarction benefits from
thrombolytic therapy?
Acute ST-Elevation Myocardial Infarction Craig
Oliner, M.D.

• ST-segment depression
• ST-segment elevation
• T-wave inversion
• Non Q-wave MI with troponin elevation

71
Questions from the Audience?
Mariel, age 8
72
ReferencesAcute ST-Elevation MI

• 2007 focused update of the ACC/AHA 2004
  guidelines for the management of patients with
  ST-Elevation myocardial infarction. J. Am. Coll.
  Cardiol. 51210-47, 2008.
• Primary PCI for myocardial infarction with
  ST-segment elevation. N Engl J Med 35647-54,
  2007.

73
ReferencesAcute ST-Elevation MI

• ACC/AHA guidelines for the management of patients
  with ST-elevation myocardial infarction. J. Am.
  Coll. Cardiol. 44671-719, 2004.
• Pitt B, Remme W, Zannad F et al. for the
  Eplernone post-acute myocardial infarction heart
  failure efficacy and survival study
  investigators. Eplernone, a selective aldosterone
  blocker, in patients with left ventricular
  dysfunction after myocardial infarction. N Engl
  J Med 3481309-1321, 2003.