Stemi

CreatedOn: 26 Mar, 2024

LastUpdatedOn: 20 May, 2024

WHAT ABOUT ACS : STEMI?

STEMI is one of three conditions that fall under ACS (Acute Coronary Syndrome) , a disease that happens because of limited or no blood flow to a part of your heart.

ST-elevation myocardial infarction (STEMI) is a type of heart attack that is more serious and has a greater risk of serious complications and death. It gets its name from how it mainly affects the heart’s lower chambers and changes how electrical current travels through them.

Why is it called a STEMI?

Myocardial infarction is the medical term for a heart attack. An infarction is a blockage of blood flow to the myocardium, the heart muscle. That blockage causes the heart muscle to die.

STEMI is a myocardial infarction that causes a distinct pattern on an electrocardiogram – ECG- is a simple, non-invasive test that records the electrical activity of the heart. That activity is then displayed as a wave pattern on a paper readout or a digital display. The different parts of the wave are labeled using letters, starting at P and ending at U.

To best understand ST-elevation, it helps to know about two specific wave sections:

*QRS complex: This is the large peak that appears on a heart wave. The ventricles cause this wave when they pump blood out of your heart.

*ST-segment: This is a short section immediately after the QRS complex. Normally, there shouldn’t be any electrical activity in that segment, causing it to be flat and back to baseline.

What happens before and during a STEMI heart attack?

Blockages in the arteries that supply blood to your heart muscle are what cause most heart attacks. Usually, the blockage happens because plaque, a fatty, waxy buildup accumulates on the inside of your arteries. A blood clot can form on the plaque deposits, rapidly closing the artery and interrupting blood flow to the heart muscle.

Ischemic heart disease is the most common cause of mortality in our country as it leads to 61 deaths per 100,000 of population. The overall prevalence of coronary artery disease in KSA is 5.5%

Assessment

ASSESSMENT OF SYMPTOMS:

Any patient with chest pain in the PSCCQ - QAPAS scope of service and the STEMI diagnosed through ECG ,with appropriate physical and medical patient assessment and the healthcare professionals decide the eligibility for reperfusion.

He should send the ECG and other required documents in PSCCQ PCI WHATSAPP (0580359775) and immediately direct contact PSCCQ PCI HOTLINE (0580359775) and he will follow the QAPAS form.

Typical chest pain: Pain is :

substernal,
provoked by exertion
relieved by rest or nitroglycerin.

Atypical presentation:

2/3 of typical chest pain mentioned above.

Angina equivalent; symptoms like:

epigastric pain,
dyspnea
diaphoresis without chest pain.
Especially in high-risk people like elderly, diabetic and females in advance age.

Differential diagnosis

Cardiac Causes:

•ACS

•Pericarditis

•Aortic dissection

Other Causes:

•Costochondritis

•Herpes Zoster

•Anxiety

Pulmonary Causes:

Pneumonia
Pleuritis
Pneumothorax
Pulmonary embolism
Pulmonary hypertensionGIT Causes:

Esophageal reflux
PUD
Esophageal spasm
Mallory-Weiss
Biliary disease
Pancreatitis

Scheme of Myocardial Infarction

ECG fINdings - STEMI:

ST-segment elevation (at the J point) as follows:

•≥0.2 mV (≥2 small squares) in men ≥40 years of age

•or ≥0.25 mV (≥2.5 small squares) in men <40 years of age,

•or ≥0.15 mV (≥1.5 small squares) in women

and/or

• ≥0.1 mV (≥1 small square) in at least two other contiguous chest leads or two limb leads.

ATYPICAL ECG PRESENTATIONS

ATYPICAL ECGS

EXTENSIVE ANTERIOR STEMI

INFERIOR STEMI

Inferior STEMI + STE in V1? Right ventricular infarction

Lateral STEMI

Anterolateral STEMI

Acute Pericarditis

ECG findings

NSTE-ACS:

•ST segment depression.

•T wave flattening or inversion.

•You should do serial ECG to detect dynamic ST segment and T wave changes (i.e. different from baseline ECG or changing over time) that are strongly suggestive of myocardial ischemia.

Wellen's Syndrome

STE in AVR with widespread STd? DDx

Tachyarrhythmias and block

Patient with ACS should be monitored for either tachyarrhythmias or heart block because instant recognition and immediate action will save lives.

Monomorphic VT

Polymorphic VT Torsades de Pointes

Management

MANAGEMENT

Management of the patient according to MOH- ST elevation myocardial infarction (STEMI) assessment and management guideline

General management,

Cardiac bed, connection to monitor

Assess and stabilize airway, breathing and circulation

Maintaining the Oxygen saturation more than 95%by supplemental oxygen.

Withhold fluids and solid foods from the patient (NPO).

Establish iv access

Check hs-ctn, cbc, chemistry, Coagulation profile + CXR, but shouldn’t delay the transferring patient to catheterization laboratory.

Specific management:

Acetylsalicylic acid (ASA) chewable ASA 325 mg.

Clopidogrel 600 mg loading dose, or Ticagrelor 180 mg bolus.

Bolus dose of Heparin 4000 units

Morphine Sulphate when necessary PRN (2-4 mg IV every 5-15 minutes).

Nitroglycerine (0.4 mg sublingual every 5 minutes with total 3 doses if no contraindication).

PPCI

Activation of STEMI team (include a doctor,2 nurse, and fully equipped ambulance) for shifting the patient immediately after acceptance of the patient without any delay to achieve door in - door out time less than 30 minutes.

Obtain patient consent using unified cluster consent.

Receiving hospital (PSCCQ) Patient should be accepted for primary PCI immediately (within 10 minutes) after direct contact with the referring hospital.

Activation of the Cath Lab after discussion with referring hospital.

Patient will be crossed through a rapid ER assessment by cardiology fellow and will be shifted to the Cath Lab

Patient will be received in Cath Lab and will undergo primary PCI.

Post PCI the patient will be re-evaluated by interventionist for transfer back to the referring hospital. (As in policy on patient transfer after delivery of coronary angioplasty procedure)

Accompanied physician and nurse will be instructed about the procedure, medications and removal of TR band.

All QAPAS (STEMI) patients who are brought in to PSCCQ from referring hospitals and underwent Coronary Angiography with/without Angioplasty should undergo reverse triage.

Transfer back :

Patients who meet all of the below criteria shall be approved for safe and immediate transfer back. Patients who do not meet even one of these criteria shall be admitted at PSCCQ.

· Hemodynamically stable

· Angiographically successful PCI

· Absence of Coronary dissection

· Absence of Coronary perforation

· No significant arrhythmias

· No major bleeding

· No new neurological event

· No Anaphylaxis

Patients who meet any one of the below criteria shall be admitted at PSCCQ

· Cardiogenic shock

· Bleeding complications

· Complex PCIs

· Significant LM/Equivalent disease

· Persistent post-procedure chest pain

· Mechanical Circulatory support (IABP)

· Suspected Mechanical Complication of AMI

· Poor Angiographic result (no reflow/TIMI 0)

· Recommended for CABG and with critical Coronary anatomy

Initial management of ACS patient

•Assess and stabilize airway, breathing and circulation.

Attach Cardiac monitor; treat sustained ventricular arrhythmia rapidly according to ACLS protocols.
Attach O2 saturation monitor; provide as needed to maintain O2 saturation > 90%.
Establish IV access.

•Give loading doses of:

Aspirin 325 mg (nonenteric coated) to chewed and swallowed (unless aortic dissection is being considered) then keep on daily dose.
Loading dose of either Clopidogrel 300 mg or Ticagrelor 180 mg then keep on daily dose.

•Pain Control:

Nitroglycerin sublingual or spray under tongue (x3 times, spaced five minutes apart) IF not contraindicated like; sign of hemodynamic compromise (e.g., RV infarction) or use of PDEi (e.g., for erectile dysfunction)
Start IV nitroglycerin for persistent symptoms despite x3 doses of SL.
Morphine sulfate (2 to 4 mg slow IV push every 5 to 15 minutes) for unacceptable, persistent discomfort or anxiety related to myocardial ischemia.
Therapeutic anticoagulation: •IV UFH as per infusion protocol. Or •Enoxaparin 1mg/kg S.C BID.

High intensity Statin:

•Atorvastatin 80 mg ODOr

•Rosuvastatin 40 mg OD

•If the case is STEMI:

•Follow QAPAS protocolOr

•Pharmacoinvasive protocol for hospitals outside the scope of QAPAS; DHARIAH, ALNABBHANIAH, QIBAH and OGLAT ALSUGOOR.

(ACS Pathway)Time frameDoor to ECG:

•Any patient arrive to ED C/O chest pain, ECG should be done for him within 10 minutes of arrival to ED. (Door to ECG time ≤ 10 min)

•Initial treatment as previously mentioned:As soon as ACS is suspected

Door-In Door-Out:•If STEMI is the diagnosis and patient is in hospitals that is within the scope of QAPAS, and patient accepted via QAPAS hotline for Primary PCI then he should leave ED within 30 minutes of arrival to ED (Door-in Door-out ≤ 30 min)

Door to Needle:•If STEMI is the diagnosis and patient is in hospitals that is outside the scope of QAPAS and there is no contraindication for thrombolytic therapy, thrombolytic infusion should start within 30 minutes of arrival to ED (Door to Needle time ≤ 30 min)

Door to Device:

•If STEMI is the diagnosis and patient is in hospitals that is within the scope of QAPAS, and patient accepted via QAPAS hotline for Primary PCI then he should receive revascularization (in Cathlab) within 120 minutes of arrival to ED of referring hospital (Door to Balloon ≤ 120 min)

Which means; transportation time should not be longer than 60 minutes

Monitoring and stabilization

All patients with ACS should be monitored closely and if electrical instability happened like tachyarrhythmias or high-grade AV block will be treated according to ACLS protocol.

Mechanical complications

•Rupture of the left ventricular free wall.

•Diagnosis — clinical and echocardiographic signs of pericardial tamponade.

•Management — Initially; IV fluids & inotropes. Curative; emergency pericardiocentesis.

•Rupture of the interventricular septum.

•Diagnosis — auscultation of a new cardiac murmur. The next step is usually echocardiography, which in majority of cases will lead to the definitive diagnosis.

•Management — Survival after ventricular septal rupture may occur only after surgical repair.

•Papillary muscle rupture.

•Diagnosis — by echocardiography, which usually demonstrates a flail segment of the MV.

•Management — Initially; nitrates, nitroprusside, and diuretics if adequate BP and inotropic support if cardiogenic shock. Curative; emergent surgery

Revascularization therapy

STEMI:

•Primary PCI. (90 min Vs 120 min)

•Thrombolytic therapy (30 min) then PCI

•Rescue PCI 2-3 H after lytic Rx if:

Cardiogenic shock

Acute severe HF

Persistent chest pain

Arrythmia

Non adequate ST-segment resolution

Coronary angiography.

NSTE-ACS:

•Urgent (within 2 H)

•If hemodynamic or electrical instability

•Invasive strategy (within 72 H)

§Early (within 24 H)

•If dynamic ECG/Trop changes or GRACE score > 140

§Delayed (within 72 H)

•DM, EF<40%, GFR<60, TRS>3, GRACE 109-140, prior PCI or CABG

role of cardiac enzymes

It is recommended that cardiac-specific troponin (troponin I or T) be drawn on first assessment (designated as 0 hours)
Repeated 3-6 hours later, or earlier with high-sensitivity assays.
Sampling beyond 6 hours may be required if further ischemic episodes occur, or in high-risk patients.

Request

Acute Coronary Syndrome Pathway

For Hospitals within the Scope of Pharmacpinvasive

TIME IS MUSCLE

Objectives

1.Identify ACS pathway and scope of services

2.Role of individuals and institutions in pathway.

3.Highlight the policies, protocols, and forms related to ACS pathway.

4.Explain the standard timeframe for all actions in ACS pathway

5.Discuss possible case scenarios.

pathway and scope of service

This pathway is designed to:

1.Facilitate access of patient with ACS to cardiac care in the appropriate setting and at the right time.

2.Provide evidence-based and efficient cardiac care across the patient pathway.

3.Ensure that geographic location of patient in need of advance cardiac services will not affect his quality of care.

Key Performance Indexes

	No	Indicator	Numerator	Denominator	Target
ACS	1	Door to ECG	Total number of patients presenting to hospital or PHCC with acute chest pain	Patients with a final diagnosis of acute STEMI Exclusions: < 18 years, patients received from transfer of another facility	< 10 min
	2	Door to Balloon (PCI capable hospital)	Patients with acute STEMI who receive primary PCI and arrive at a PCI capable hospital with a balloon time during primary PCI is ≤90 min	Patients with a final diagnosis of acute STEMI Exclusions: < 18 yrs, documented medical reasons for delay or exclusion	< 90 min
	3	Door in Door out	Patients with a STMI diagnosed at a non-PCI capable hospital, assessed as being eligible for primary PCI who are transferred to a PCI-capable hospital	Patients with a final diagnosis of acute STEMI Exclusions: < 18 yrs, documented medical reasons for delay or exclusion	< 30 min
	4	Door to needle	Patients with acute STEMI that receive IV thrombolytics as the primary reperfusion intervention	All patients with a final diagnosis of acute STEMI Exclusions: < 18 years, patients received transfer from another facility, documented contraindications for thrombolysis	< 30 min
	ECG: electrocardiogram; PHCC: Primary Health Care Center; STEMI: ST elevation myocardial infarction; PCI: percutaneous coronary intervention; acute symptoms: within 12 hours of symptoms

Request :

· CBC, CHEMISTARY, BLEEDING PROFILE, LIPID PROFILE, HbA1c, SEROLOGY, BLOOD GROUP,

· Chest X-ray

· Echocardiogram

Information

Initiatives integrated with ACS pathway :

To improve the quality of pathway implementation and to ensure sustainability we merged the pathway with related initiative.

QAPAS : “Qassim Primary Angioplasty Services” aiming to provide primary angioplasy as treatment options for patients with STEMI in more than 20 facilities.

Drip Ship : “Pharmacoinvasive protocol” aiming to start fibrenolytic therapy within golden time and shift patients immediately to PCI-Capable facility.

CAPASITY : “Coronary Angioplasty Procedure & Safely, Immediate Transfer-back Yielding” aiming to manage the bed capacity while managing the flow of ACS patients to cardiac center.

Consult : “Cardiology Tele-Consultation” aiming to provide specialized physician-to-physician consultation and more through QHC facilities.

C4 : “Cardiac Care Command Center” aiming to emphasize that emergency cardiology referral approached in proper time and place

For more information,follow links below:

- ACS Toolkit
toolkit-STEMI

- QAPAS Form
Qapas Form

- Pharmacoinvasive form
Pharmaco invasive form