GOLDEN HOUR IN ST Elevation Myocardialinfarction

GOLDEN HOUR IN STEMI

1. GOLDEN HOUR IN STEMI DR P S S CHOWDARY MD DM CARDIOLOGY HEAD OF THE DEPARTMENT DEPT OF CARDIOLOGY AAYUSH LEPL HOSPITALS PVT LIMITED

2. What is Golden hour? First one hour of heart attack is very crucial period for the management. Because the mortality and morbidity are highest during the first hour.

3. SPECTRUM OF ACUTE CORONARY SYNDROME

4. DEFINITION STEMI is a clinical syndrome defined by characteristic symptoms of myocardial ischemia in association with persistent electrocardiographic (ECG) ST elevation and subsequent release of biomarkers of myocardial necrosis.

5. LEVINE SIGN This is the universal sign of distress in angina pectoris and myocardial infarction. It is clenching of the fist in front of chest while describing the chest discomfort. This pain last more than 20 minutes.

6. CLASSIC TRIAD

7. LABORATORY MARKERS Biomarkers CK Less specific for cardiac muscle necrosis CK-MB Detectable within 6 hours , falls within 48 hours Troponin I or T Detectable within 6 hours , remains elevated for 7-14 days DiPiro J. Acute Coronary Syndrome. In: Pharmacotherapy: A Pathophysiological Approach, 2011

8. COMPLICATIONS OF MI Ventricular remodeling Cardiogenic shock Death Valvular dysfunction Arrhythmias (VF/VT) Heart failure Bradycardia Heart block Pericarditis CVA secondary to LV thrombus Free wall rupture (e.g. VSD, papillary muscle dysfunction) DiPiro J. Acute Coronary Syndrome. In: Pharmacotherapy: A Pathophysiological Approach, 2011

9. New ST-elevation at the J point (at least 2 contiguous leads): ≥ 2 mm (0.2 mV) in men ≥ 1.5 mm(0.15 mV) in women OR – ≥ 1 mm (0.1 mV) in other contiguous chest leads or limb leads ST-depression: ≥ 2 precordial leads (V 1 – V 4 ): may indicate transmural posterior injury Established MI Presence of Q waves of ≥ 0.03 s in leads V 1 – V 6 or II, aVL, aVF 12-LEAD ELECTROCARDIOGRAM (ECG) V 2 – V 3 O’Gara PT et al. Circulation ; 2013; 127

10. Electrographic Criteria For The Diagnosis of AMI In The Presence of L B C B r i t e B r i a Score ST-segment elevation > 1 mm concordant with QRS 5 ST-segment depression > 1 mm in leads V1, V2 or V3 3 ST-segment elevation > 5 mm discordant with QRS 2 Point scores for each criteria met are added. Total Point Score of # yields >90% s p ecificity and 88% positive predictive value.

11. ECG LOCALISATION OF STEMI

12. Category Anatomy of Occlusion ECG Findings Proximal LAD Proximal to first septal perforator ST V1-V6, I, aVL Fascicular or Bundle Branch Block Mid LAD Proximal to Large Diagonal but Distal to First Septal Perforator ST V1-V6, I, aVL Distal LAD or Diagonal Distal to Large Diagonal or Diagonal Itself ST ↑ V1–V4, or I, aVL, V5, V6 Moderate to Large Inferior (Posterior, Lateral, Right Ventricular) Proximal RCA or Left Circumflex ST ↑ II, III, aVF, and any of the following: V1, V3R, V4R V5, V6 R > S in V1, V2 Small Inferior Distal RCA or Left Circumflex Branch ST ↑ II, III, aVF only

13. BEYOND STEMI

14. Differentials for ST-Segment Elevation Myocardial Infarction Comorbid ischemia ST elevation but no ischemia Chest pain but no ischemia Aortic dissection Early repolarization Aortic dissection Systemic arterial embolism Left ventricular hypertrophy Myopericarditis Hypertensive crisis Left bundle branch block Pleuritis Aortic stenosis Hyperkalemia Pulmonary embolism Cocaine use Brugada syndrome Costochondritis Arteritis Gastrointestinal disorders

15. Other Investigation Cardiac Imaging : Echocardiography : Wall motion Defect LV Impairment Chest X Ray : Pulmonary edema Cardiomegaly Widened mediastinum Routine Blood Tests:

16. Risk Stratification Five simple baseline parameters have been reported to account for > 90% of the prognostic information for 30-day mortality. These characteristics are given in descending order of importance: Age Systolic blood pressure Killip classification Heart rate Location of MI In addition, various risk models have been created to improve risk prediction.

17. EARLY RISK ASSESSMENTS Global Registry of Acute Coronary Event ( GRACE ) risk score: Predicts in-hospital and 6-months mortality rate http://www.outcomes- umassmed.org/grace/acs_risk/acs_risk_content.html Thrombolysis In Myocardial Infarction ( TIMI ) risk score: Estimates overall mortality of STEMI http://www.mdcalc.com/timi-risk-score-for-stemi/ O’Gara PT et al. Circulation ; 2013; 127

18. MA N A GEMENT Reperfusion Therapy Pharmacological Non- Ph a r m a c ol o gical

19. Treatment Delayed is Treatment Denied Increasing loss of myocytes Delay in Initiation of Reperfusion Therapy Symptom Recognition Call to Medical System PreHospital ED Cath Lab

20. STEMI Management Outline

21. REPERFUSION THERAPY Prompt and effective reperfusion therapy is the cornerstone for treatment of STEMI Selection of reperfusion depends on chance of achieving early and persistent reperfusion with lowest risk of major complications Guideline recommendation: Should be administered to all eligible patients with STEMI with symptoms onset within the prior 12 hours(Class 1; LOE: A) 12-24 hours for patient with ongoing ischemia (Class IIa; LOE: B) DiPiro J. Acute Coronary Syndrome. In: Pharmacotherapy: A Pathophysiological Approach, 2011

22. TYPES OF REPERFUSION Primary Percutaneous Coronary Intervention (PPCI) Fibrinolytics Balloon angiography 1. Strptokinase 2. Alteplase Placement of intracoronary stent: Bare-metal stent (BMS) Reteplase Tenecteplase Drug-eluting stent (DES) O’Gara PT et al . Circulation ; 2013; 127

23. TIMING TO REPERFUSION THERAPY Treatment Recommended Time for Initiation of Treatment PCI Door-to-balloon time ≤ 90 min Fibrino l yt i c agents Door-to-needle time ≤ 30 min Hilleman DE et al. Pharmacotherapy. 2007;27(11):1558-1570

24. PPCI >>> FIBRINOLYTICS Greatest survival benefit in high risk patient Higher rates of infarct artery patency with TIMI 3 flow (90%-PCI vs. <60%-fibrinolysis) Reduction in recurrent ischemia/reinfarction 30-day mortality reduction (6.5% to 4.4%) Reduction in stroke (2.0% to 0.7%) Reduced risk of bleeding Van De Wefr F. et al. Circulation. 2002;105: 2813-16 O’Gara PT et al. Circulation ; 2013; 127 TIMI Flow Grade Characteristics No perfusion 1 P enet r ati o n without perfusion 2 Partial r e p er f usion 3 C o m ple t e p e r f usion TIMI: Thrombolysis in Myocardial Infarction

25. Fibrinolytic Therapy When There Is an Anticipated Delay to Performing Primary PCI Within 120 Minutes of FMC

26. Indications for Fibrinolytic Therapy When There Is a >120-Minute Delay From FMC to Primary PCI

27. Adjunctive Anticoagulant Therapy Patients with STEMI undergoing reperfusion with fibrinolytic therapy should receive anticoagulant therapy for a minimum of 48 hours, and preferably for the duration of the index hospitalization, up to 8 days or until revascularization if performed. Recommended Regimen : UFH adm. as a weight-adjusted intravenous bolus and infusion to obtain an aPTT time of 1.5 to 2.0 times control, for 48 hours or until revascularization.(COR IC) Enoxaparin adm. a/c to age, weight, and creatinine clearance, given as an i.v bolus, followed in 15 min. by s/c inj. for the duration of the index hospitalization, up to 8 days or until revascularization; or

28. Continue….. Fondaparinux administered with initial i.v dose, followed in 24 hrs by daily s/c inj. if the estimated creatinine clearance is greater than 30 mL/min, for the duration of the index hospitalization, up to 8 days or until revascularization. Enoxaparin: ● If age 75 y: 30-mg IV bolus, followed in 15 min by 1 mg/kg subcutaneously every 12 h (maximum 100 mg for the first 2 doses) ● If age> 75 y: no bolus, 0.75 mg/kg subcutaneously every 12 h (maximum 75 mg for the first 2 doses) ● Regardless of age, if CrCl 30 mL/min: 1 mg/kg subcutaneously every 24 h ● Duration: For the index hospitalization, up to 8 d or until revascularization

29. Routine M edical Therapies

30. DELAYED INVASIVE MANA G EMENT Indications for Coronary Angiography in Patients Who Were Managed With Fibrinolytic Therapy or Who Did Not Receive Reperfusion Therapy

31. FIBRINOLYTIC THERAPY Acts on converting plasminogen to plasmin  cleaves fibrin  causing clot dissolution and restoration of blood flow Indications: Recommendations COR† LOE† 1. Ischemic symptoms <12 h I A 2. Evidence of ongoing ischemia 12 to 24 h after symptom onset and a large area of myocardium at risk or hemodynamic instability IIa C 3. ST depression, except if true posterior MI is suspected or when associated with ST elevation in lead aVR III: Harm B O’Gara PT et al. Circulation ; 2013; 127 Hilleman DE et al. Pharmacotherapy. 2007;27(11):1558-1570

32. CHOICE OF FIBRINOLYTIC AGENTS Adjunctive antiplatelet and/or anticoagulant therapies are indicated, regardless of the choice of fibrinolytic agent Agents Fibrin Specificity Half-life (h) Patency Rate Alteplase (tPA) ( Activase® ) ++ 5 73%-84% Reteplase (rPA) ( Retavase® ) ++ 13-16 84% Tenecteplase ( TNKase® ) ++++ 20-24 85% St r e p t okin a se ( Streptase® ) No 18-23 60%-68%

33. EFFICACY AND SAFETY DATA Hilleman DE et al. Pharmacotherapy. 2007;27(11):1558-1570

34. DOSE AND ADMINISTRATION Agents Dose and Administration Alteplase (tPA)* 90 min infusion : 15 mg bolus, then Infusion 0.75 mg/kg for 30 min (max 50 mg), then 0.5 mg (max 35 mg) over the next 60 min; total dose not to exceed 100 mg; 60 mg administered within first hour, then 20 mg during second and third hour Reteplase (rPA) Two 10 unit boluses, each administered over 2 min, 30 min apart T enec t e p lase (TNK) Single bolus administration over 5 sec; dose based on patient weight (max dose 50 mg): <60 kg: 30 mg; 60-69 kg: 35 mg; 70-79 kg: 40 mg; 80-89 kg: 45 mg; and ≥ 90 kg: 50 mg Streptokinase 1,500,000 units IV infusion over 30-60 min Hilleman DE et al. Pharmacotherapy. 2007;27(11):1558-1570 *KFSH&RC formulary

35. CONTRAINDICATIONS TO FIBRINOLYTIC THERAPY O’Gara PT et al. Circulation ; 2013; 127

36. PRIMARY PCI FOR STEMI:INDICATIONS &LOGISTICS

37. AFTER THE PANDEMIC STRIKES….

38. TREATING THE PUBLIC MENTALITY MORE TOUGH THAN THE DISEASE PER SE…. LOT OF LOGISTIC ERRORS OCCUR MORE COMMONLY THAN MEDICAL ERORS