Diagnosis and Treatment of ST-Segment Elevation Myocardial Infarction (original) (raw)
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ST-Segment Elevation Myocardial Infarction: Part II Management
2013
ST-segment elevation myocardial infarction (STEMI) is a medical emergency where the coronary artery previously affected by atherosclerosis is abruptly occluded by a thrombus at the site of vascular injury. Oxygen and blood supply are blocked off to the heart muscle being supplied by the affected artery, causing death to the muscle. Outcomes following a STEMI may range from mild to severe heart failure to multi-system organ-failure and death. Immediate activation of the emergency cardiology STEMI team for reperfusion therapy followed by necessary medical treatments give the patient with STEMI possible improved outcomes. An interprofessional team approach is needed to maximize care and make critical treatment decisions aimed at providing timely treatment and mitigating complications. This second of a 2-part series of articles highlights specific effective treatments that support early goal achievement to improve outcomes for the patient, as well as common complications that might aris...
Management of ST segment elevation myocardial infarction
Medicine, 2022
The degree of adherence to current guidelines for clinical management of ST-segment elevation myocardial infarction (STEMI) is known in developed countries and large Chinese cities, but in predominantly rural areas information is lacking. We assessed the application of early reperfusion therapy for STEMI in secondary and tertiary hospitals in Henan province in central China. Data were retrospectively collected from 5 secondary and 4 tertiary hospitals in Henan concerning STEMI patients treated from January 2011 to January 2012, including management strategy, delay time, and inhospital mortality. Among 1311 STEMI patients, 613 and 698 were treated at secondary and tertiary hospitals, respectively. Overall, 460 (35.1%) patients received early reperfusion therapy including thrombolysis in 383 patients and primary percutaneous coronary intervention in 77. Compared with secondary centers, early (37.2% vs 32.6%) and successful reperfusion (34.5% vs 25.1%) was significantly higher, whereas thrombolysis was lower in the tertiary hospitals (26.4% vs 32.5%). Median symptom onset-to-first medical contact, and door-to-needle and door-to-balloon time was 168, 18, and 60 minutes, respectively. Delay times closely approached recommended guidelines, especially in secondary centers. Use of recommended pharmacotherapy was low, particularly in secondary hospitals. Inhospital mortality was 5.8%, and similar between secondary and tertiary hospitals (6.0% vs 5.6%; P = 0.183). Two-thirds of STEMI patients did not receive early reperfusion, and tertiary hospitals mostly failed to take advantage of around-theclock primary percutaneous coronary intervention. Actions such as referrals are warranted to shorten prehospital delay, and the concerns of patients and doctors regarding reperfusion risk should be addressed.
ST-segment elevation myocardial infarction
Coronary artery disease (CAD) most of the time refers to coronary atherosclerotic disease that results in severe coronary artery narrowing, leading to inadequate blood supply to the heart muscle (myocardium). Acute coronary syndromes (ACSs) comprise the acute manifestations of CAD, including unstable angina (myocardial ischaemia without necrosis), non-ST-segment elevation myocardial infarc-tion (NSTEMI) and ST-segment elevation myo cardial infarction (STEMI). Myocardial infarction (MI) is commonly defined as cardiomyocyte death caused by substantial and sustained ischaemia due to an imbalance of oxygen supply and demand. On the basis of the electro cardiogram (EKG or ECG) trace, MI is differentiated between STEMI and NSTEMI. STEMI is the result of transmural ischaemia (that is, ischaemia that involves the full thickness of the myocardium) (Fig. 1), whereas NSTEMI does not spread through all the myocardial wall. With the introduction of highly sensitive cardiac biomarkers, new definitions of MI that include biochemical and clinical aspects have been developed. The fourth universal definition of MI 1 is based on a classification system with five subcategories. This Primer focuses mostly on type 1 MI, which is caused by atherothrombotic CAD and usually precipitated by rupture or erosion of the atherosclerotic plaque. In most STEMI cases, the transmural myocardial ischaemia results from a total occlusion of an epicardial coronary artery caused by a thrombus (a blood clot) that developed on a coronary atherosclerotic plaque. STEMI is suspected when a patient presents with chest pain and persistent ST-segment elevation in two or more anatomically contiguous ECG leads (Fig. 1). In addition, STEMI should be suspected if the clinical presentation is compatible and the ECG trace shows left bundle branch block (LBBB) and no ST-segment elevation, as in some cases total coronary occlusion manifests as LBBB 2. By contrast, ECG findings of ST-segment depressions, T wave inversions or transient ST-segment elevations are suggestive of non-ST-segment elevation ACS and may reflect NSTEMI or unstable angina 3. STEMI is the most acute manifestation of CAD, with substantial morbidity and mortality. Early reperfusion (re-establishing the blood flow in the occluded artery) is the most effective way to preserve the viability of the ischaemic myocardium and limit infarct size. Early diagnosis of STEMI is crucial to initiate appropriate treatment and should ideally be made within 10 minutes of first medical contact 2. Initiatives have raised awareness on the importance of minimizing time to reperfusion with early Abstract | ST-segment elevation myocardial infarction (STEMI) is the most acute manifestation of coronary artery disease and is associated with great morbidity and mortality. A complete thrombotic occlusion developing from an atherosclerotic plaque in an epicardial coronary vessel is the cause of STEMI in the majority of cases. Early diagnosis and immediate reperfusion are the most effective ways to limit myocardial ischaemia and infarct size and thereby reduce the risk of post-STEMI complications and heart failure. Primary percutaneous coronary intervention (PCI) has become the preferred reperfusion strategy in patients with STEMI; if PCI cannot be performed within 120 minutes of STEMI diagnosis, fibrinolysis therapy should be administered to dissolve the occluding thrombus. The initiation of networks to provide around-the-clock cardiac catheterization availability and the generation of standard operating procedures within hospital systems have helped to reduce the time to reperfusion therapy. Together with new advances in antithrombotic therapy and preventive measures, these developments have resulted in a decrease in mortality from STEMI. However, a substantial amount of patients still experience recurrent cardiovascular events after STEMI. New insights have been gained regarding the pathophysiology of STEMI and feed into the development of new treatment strategies. *
Treatment of a cohort of patients with acute myocardial infarction and ST-segment elevation
Arquivos brasileiros de cardiologia, 2009
Although thrombolysis and primary CTA are well-established procedures, they are not administered in a large proportion of the patients with STEMI who arrive to the emergency rooms. Describe initial and final the results in a cohort of STEMI patients The study included, from hospital admission to the discharge, 158 patients diagnosed with STEMI, from a total of 351 patients with ACS admitted to hospitals in Campos dos Goytacazes, RJ, Brazil, between 2004 and 2006. Of the 158 patients with STEMI, 67.7% arrived to the hospital within 180 minutes, 81.3% within 360 minutes, and 8.4% after twelve hours from the symptoms. Cinecoronariographic studies (148) were performed (93,7%). Lesions of over 70% were observed in 266 artery territories. The initial treatment was CTA in 41 (26%), thrombolytics in 50 (32%), 80% of success. Clinical treatment in 67 (42%). Approximately 35% of the patients should have undergone thrombolysis, but they didn't. During the final treatment, 93 CTAs were perf...
Overview of the acute management of ST-elevation myocardial infarction
The value of supplemental oxygen in normoxemic patients (oxygen saturation ≥90 percent) with suspected acute myocardial infarction (AMI) has been debated for years. In the DETO2X-AMI trial, over 6500 such patients were randomly assigned to receive supplemental oxygen (delivered through an open face mask) or ambient air [1]. There was no benefit or harm from supplemental oxygen. We do not treat normoxemic AMI patients with supplemental oxygen. (See "Overview of the acute management of STelevation myocardial infarction", section on 'Oxygen'.) Read more Once the diagnosis of an acute STEMI is made, the early management of the patient involves the simultaneous achievement of several goals:
The American Journal of Cardiology, 2011
Current guidelines state that patients with compatible symptoms and ST-segment elevation (STE) in >2 contiguous electrocardiographic leads should undergo immediate reperfusion therapy. Aggressive attempts at decreasing door-to-balloon times have led to more frequent activation of primary percutaneous coronary intervention (pPCI) protocols. However, it remains crucial to correctly differentiate STE myocardial infarction (STEMI) from nonischemic STE (NISTE). We assessed the ability of experienced interventional cardiologists in determining whether STE represents acute STEMI or NISTE. Seven readers studied electrocardiograms of consecutive patients showing STE. Patients with left bundle branch block or ventricular rhythms were excluded. Readers decided if, based on electrocardiographic results, they would have activated the pPCI protocol. If NISTE was chosen, readers selected from 12 possible explanations as to why STE was present. Of 84 patients, 40 (48%) had adjudicated STEMI. The percentage for which readers recommended pPCI varied (33% to 75%). Readers' sensitivity and specificity ranged from 55% to 83% (average 71%) and 32% to 86% (average 63%), respectively. Positive and negative predictive values ranged from 52% to 79% (average 66%) and 67% to 79% (average 71%), respectively. Broad inconsistencies existed among readers as to the chosen reasons for NISTE classification. In conclusion, we found wide variations in experienced interventional cardiologists in differentiating STEMI with a need for pPCI from NISTE.
ST-Segment Elevation Myocardial Infarction (STEMI) is a life-threatening medical emergency characterized by complete coronary artery occlusion, leading to myocardial ischemia and subsequent necrosis. Over the years, STEMI has remained a significant cause of morbidity and mortality worldwide, necessitating a comprehensive understanding of its pathophysiology, accurate diagnostic strategies, and effective treatment approaches. This review article aims to thoroughly analyze the current knowledge surrounding STEMI, emphasizing key aspects crucial for optimizing patient outcomes. Firstly, the pathophysiology of STEMI will be explored, elucidating the sequence of events from coronary artery plaque rupture to thrombus formation and occlusion. This section will also cover the underlying risk factors contributing to STEMI development, including atherosclerosis, hypertension, and diabetes. Secondly, the diagnostic modalities for STEMI will be critically evaluated. Traditional electrocardiography remains the cornerstone of STEMI diagnosis. Still, advancements in imaging techniques such as cardiac magnetic resonance imaging and coronary angiography have enhanced accuracy and allow for better risk stratification. Furthermore, the review will delve into the latest treatment approaches for STEMI. Prompt reperfusion therapy through primary percutaneous coronary intervention or thrombolytic therapy is essential in restoring blood flow and salvaging the jeopardized myocardium. The role of adjunctive medical treatment, including antiplatelet agents, beta-blockers, and statins, will also be discussed in post-STEMI management.
Acta Cardiologica …, 2012
ST-segment elevation myocardial infarction (STEMI) is one of the most common cardiovascular diseases in Taiwan. The management strategies for STEMI are to do early diagnosis, minimize delay of medical contact, and administration of reperfusion therapy as rapidly as possible. Initial evaluation in emergency department for STEMI includes concise history taking, physical examination, electrocardiogram and cardiac biomarkers measurement. A 12-lead electrocardiogram should be performed within 10 minutes of emergency department arrival. Oxygen, nitroglycerin, analgesia, dual antiplatelet therapy and anticoagulation drugs should be given immediately. Patients with STEMI should receive reperfusion therapy either by primary percutaneous coronary intervention with door-to-balloon time within 90 minutes or by thrombolytic therapy with door-to-needle time within 30 minutes. The pharmacological treatment after admission includes antiplatelet drugs, anticoagulation drugs, beta blockers, angiotensin converting enzyme inhibitors/angiotensin receptor blockers and statins. STEMI patients should be watched out for hypotension, heart failure or even cardiogenic shock. Mechanical complications, such as acute mitral regurgitation, septum rupture and free wall rupture, cause high mortality after STEMI. Tachy-and bradyarrhythmias are also common in patients with STEMI and should be treated accordingly. Permanent cardiac pacing and implantable cardioverter defibrillator may be necessary after STEMI. Coronary artery bypass grafting surgery may be performed as a definitive or adjunctive revascularization therapy after STEMI. Surgery is also necessary if there are mechanical complications. Before discharge, cardiac rehabilitation should be considered when patients are stabilized. Referral for outpatient rehabilitation should also be encouraged. Antiplatelet drugs, beta blockers, angiotensin converting enzyme inhibitors/angiotensin receptor blockers and statins should be continued after discharge for secondary prevention. Effective hypertension, diabetes and lipid control are important after STEMI.