Extern interesting case: STEMI

71-year-old Thai womanwith chest discomfort

case presentation

Ext.Ekkapot Jitpun

1 July 2009

History

• อาการสำ�าคั�ญ : เจ็�บแน่�น่หน่าอก หายใจ็เหน่��อย 3 ชั่��วโมงก�อนมาโรงพยาบาล

• ประว�ติ�ป�จจ�บ�น : ผู้��ป วยหญ�งอาย� 71 ป" • underlying hypertension ,TIA

3 hr PTA ขณะก�าล�งน��งดู�โทรท�ศน) ผู้��ป วยม*อาการเจ,บแน�นหน�าอก บร�เวณกลางอก ไม�ร�าวไปท*�ใดู ไม�ปวดูหล�ง ล�กษณะเป1นแบบแน�นๆเหม3อนม*อะไรมาท�บ เหน3�อยหายใจไม�ออก ม*อาการเหง3�อแติกใจสำ��น ติ�วเย,น คัล3�นไสำ� อาเจ*ยน

ผู้��ป วยไม�ไดู�ใชั่�ยาใดูเพ3�อบรรเทาอาการ อาการแน�นหน�าอกหายใจไม�ออกเป1นอย��ติลอดูเวลา

History

• ร� �สำ4กแน�น หายใจเหน3�อย นอนราบไม�ไดู� หากนอน ราบจะร� �สำ4กแน�นหายใจไม�ออก ติ�องนอนยกห�วสำ�ง

ไม�ม*หายใจเสำ*ยงดู�ง หร3อหายใจม*เสำ*ยงว*5ดู• อาการเหน3�อยเป1นมากข45นขณะเดู�น• ไม�เคัยม*อาการเจ,บหน�าอก หร3อหายใจล�าบากมา

ก�อน• เดู�มผู้��ป วยนอนหน�นหมอน 2 ใบอย��แล�ว• ก�อนม*อาการผู้��ป วยเป1นคันท*�เหน3�อยง�าย เหน3�อย

เวลาเดู�น ร�วมก�บม*อาการปวดูเข�า จ4งไม�คั�อยเดู�น

• Underlying disease– hypertension on moduratic ½ x 1, atenolol ¼ x1 ,

adalat 1 x 2 ก�นยาไม�สำม��าเสำมอ คัวามดู�นเดู�มอย��ท*�150/80

– TIA• ปฏิ�เสำธโรคัเบาหวาน ไขม�นในเล3อดูสำ�ง• ปฏิ�เสำธโรคัห�วใจในคัรอบคัร�ว• No alcohol, no smoking

History

Physical Examination

• V/S : T37.2, PR 86/min, RR 26/min, BP 140/80 mmHg• GE : Obese Thai female, good consciousness,

dyspnea ,cold skin, diaphoresis, not pale, no jaundice, no pitting edema

• RS : Equal breath sound, Coarse crepitation both lungs• CVS : normal S1S2 , no murmur( ไดู�ย�น heart sound ไม�

ชั่�ดูเจนเน3�องจาก chest wall หนา), no carotid bruit, no engorge neck vein , JVP not elevated, peripheral pulse 2+ all extremities

• Abd : soft, not tender, liver and spleen not palpable, no abdominal bruit

Problem list

1.Severe substernal discomfort 3 hr

2.Diaphoresis, Nausea vomiting, Coolness of skin

3.Crepitation both lungs4.Underlying HT , TIA

Differential diagnosis

??? Y__Y

Acute chest discomfort

Typical clinical features


Acute ischemic heart disease

Pros• Prolonged and severe typical anginal

chest pain• Typical associated symptoms

• Diaphoresis• Nausea,vomiting• Cold skin• Dyspnea

• Crepitation : possible complication of IHD

• Risk factor : old age,obesity,hypertension

Cons : none


Acute aortic dissection

Pros• Acute and severe chest pain• Risk factor : hypertension

Cons• Character of chest pain : sharp pain

radiate to the back• Grade I hypertension• Normal peripheral pulse


Pulmonary embolism

Pros• Acute and severe chest

pain (most are lateral and pleuritic but in massive PE can be substernal pain)

• Dyspnea

Cons• No detectable source of emboli (no

murmur, no vascular bruit, no embolic sign)

• Usually pleuritic chest pain


Pneumothorax

Pros• Sudden onset , several hour chest pain• Dyspnea• may occur without a precipitating

event in persons without lung disease

Cons• Character of chest pain : pleuritic,

often unilateral• Physical exam : decreased breath

sound

Initial Investigation

EKG

• Normal sinus rhytm rate 100/min • Left axis deviation• ST segment elevation at V1-V5• No LVH by voltage criteria

Laboratory Investigation

• CBC : Hb 12.0 , Hct 38.6 , WBC 11150 ,N 63,L 29Plt 441,000

• Blood chemistry : Na 137, K 3.8, Cl 105, HCO3 19

• CK 36, Troponin T 1.80• F/U CK, Troponin T every 6 hr– CK 2750, Troponin T >2– CK 6685, Troponin T >2

• FBS 104, cholesterol 177, TG 95, HDL 48 ,LDL 110

Ischemic heart diseaseChroni

c stable angina

Acute coronar

y syndro

me

Ischemic heart disease

Acute coronary syndrome

Unstable anginaNon-ST elevation MI ST elevation MI

Spectrum of acute coronary syndrome

Dx UA NSTEMI STEMI

Coronary trombosis subtotal total

History Angina that is new onset,crescendo or at rest,usually < 30 min

Angina at rest usually>30 min

EKG ± ST depression and/or T wave inversion ST elevation

Troponin/CK-MB - + ++

Acute coronary syndrome• Clinical manifestation– Typical angina : • retrosternal pain/pressure/tightness ± radiation to

neck,jaw or arms • precipitate by exertion, emotional stress• Relieved within 5-15 min by rest and/or sublingual

nitroglygerinIn acute coronary syndrome :• Angina pectoris or equivalent ischemic discomfort with at least

one of three feature1. It occurs at rest (or with minimal exertion) usually lasting>10 min2. It’s severe and of new onset3. It occurs with crescendo pattern (more severe,prolonged,or

frequent than previously)

• Clinical manifestation– Associated symptoms • Dyspnea• Diaphoresis• Nausea/vomiting• Palpitation• Lightheadedness


• Other less common presentations– Painless ACS is greater in patients with DM, old age– In elderly, ACS may present as sudden onset

breathlessness– Sudden loss of consciousness– Confusion– Sensation of profound weakness– Arrhythmia– Evidence of peripheral embolism– Unexplained drop in arterial blood pressure


• Physical finding– Most are anxious,restless , attempting

unsuccessfully to relieve the pain by moving about in bed, altering their position

– Pallor, coolness of skin– Diaphoresis– Precordium is usually quiet ,apical impulse may be

difficult to palpate


• Physical finding– Sign of ischemia : S4, new MR murmur secondary

to papillary muscle dysfunction– Sign of heart failure : crepitation, ↑ JVP, S3– Sign of other area of atherosclerotic disease :

carotid or femoral bruit, ↓ distal pulse


Laboratory findings

EKG

Serum cardiac biomarkers

Imagings

Nonspecific index of tissue necrosis and inflammation

EKG• A 12-lead ECG should be performed and shown

to an experienced emergency physician within 10 minutes of ED arrival on all patients with chest discomfort

• If the initial ECG is not diagnostic of STEMI but the patient remains symptomatic, and there is a high clinical suspicion for STEMI, serial ECGs at 5- to 10-minute intervals or continuous 12-lead ST-segmentmonitoring should be performed to detect the potential development of ST elevation

EKGDefinitionSTEMI or new LBBB: • EKG ท*�ม* ST segment elevation ≥ 1mm (0.1 mV)

ติ�ดูก�นไม�น�อยกว�า 2 leads• New LBBB ( ม* EKG เปร*ยบเท*ยบว�าเดู�มไม�เคัยม* LBBB

sinus at about 80 bpm with marked ST elevations in I, aVL and VI-V5. ST depressions, consistent with reciprocal changes, are seen in II, III and aVF

sinus rhythm at about 90 bpm with acute ST elevations in leads I, aVL and V2-V6Q waves are present in leads V3-V6. Borderline left axis deviation is present

Sinus bradycardia, left bundle branch block (LBBB ) with ST-T wave changes

Ischemic ST segment depression in UA/NSTEMI• ST segment depression ≥ 0.5mm (0.05 mV) • หร3อม* dynamic T wave inversion ในขณะท*�ม*เจ,บหน�าอก

sinus rhythm, rate 90 bpm ,marked ST segment depressions in leads V2-4 with T wave inversions in leads V3-6

Localization of MIAnatomic area EKG leads with STE Coronary artery

Septal V1-V2 Proximal LAD

Anterior V3-V4 LAD

Apical V5-V6 Distal LAD,left circumflex or RCA

Lateral I , aVL Left circumflex

Inferior II,III,aVF RCA, Left circumflex

RV V1-V2 & V4R Proximal RCA

Posterior ST depression V1-V2 RCA or left circumflex

Cardiac biomarkers

Cardiac enzyme Advantage Disadvantage

Cardiac troponin 1. Greater sensitivity and specificity than CK-MB

2. Detection of recent MI up to 2 wk after onset

3. Useful for selection of therapy4. Detection of reperfusion

1. Low sensitivity in very early phase of MI (less than 6 hr after symptom onset) and require repeat measurement at 8 to 12 hr if negative

2. Limited ability to detect late minor reinfarction

CK-MB 1. Rapid ,cost effective accurate assay

2. Ability to detect early reinfarction

1. Loss of specificity in setting of skeletal muscle disease or injury, including surgery

2. Low sensitivity during very early MI (less than 6 hr after onset) or later after symptom onset (more than 36 hr) and for minor myocardial damage (detectable with troponin

Cardiac enzyme Advantage Disadvantage

Myoglobin 1. High sensitivity2. Useful in early detection of

MI3. Detection of reperfusion4. Most useful in ruling out MI

1. Very low specificity in setting of skeletal muscle injury or disease

2. Rapid return to normal range limits sensitivity for later presentation

STEMIManagement

Initial management : pre-hospital

• ACC/AHA Practice Guidelines 2004 for STEMI recommends empirical treatment of patients with suspected STEMI with Morphine, Oxygen, Nitroglycerin,and Aspirin (MONA)

Initial management : ER

• Monitor EKG, เติร*ยมชั่�ดู CPR , defribrillator ให�พร�อม• ติรวจว�ดู V/S, O2 sat• EKG 12 leads• ให� O2 4 LPM (keep O2 sat> 90℅)• ให� Aspirin Gr V (300 mg) เคั*5ยวท�นท* ถ้�าผู้��ป วยไม�ม*ประว�ติ�แพ�

ยา aspirin หร3อ ไม�ม*ประว�ติ� active bleeding• Sublingual NTG (Up to three doses of 0.4 mg should be

administered at about 5-min intervals )• Morphine 2-5 mg IV ถ้�าให� NTG แล�วย�งม* chest pain• เป9ดูเสำ�นเล3อดู เจาะเล3อดูเก,บไว� เป9ดูเสำ�นเล3อดูเพ3�อเติร*ยมให� IV

Management of STEMI

Copied slide from E.Antman ppt on reperfusion therapy with STEMI Pt ,Nov 30,2007,AHA

patients from an urban area

patients from rural areas

patients from the study areawho received prehospital fibrinolysis

Management of STEMI

Assessment of reperfusion options in patient with STEMI

Reperfusion therapy : PCI• PCI usually angioplasty and/or stenting without preceding

fibrinolysis, referred to as primary PCI• effective in restoring perfusion in STEMI when carried out on

an emergency basis in the first few hours of MI. • It has the advantage of being applicable to patients who have

contraindications to fibrinolytic therapy but otherwise are considered appropriate candidates for reperfusion.

• It appears to be more effective than fibrinolysis in opening occluded coronary arteries and, when performed by experienced operators [75 PCI cases (not necessarily primary) per year] in dedicated medical centers (36 primary PCI cases per year), is associated with better short-term and long-term clinical outcomes. Compared with fibrinolysis,

• primary PCI is generally preferred when – the diagnosis is in doubt, – cardiogenic shock is present,– bleeding risk is increased, – or symptoms have been present for at least 2–3 h when the

clot is more mature and less easily lysed by fibrinolytic drugs.

• However, PCI is expensive in terms of personnel and facilities, and its applicability is limited by its availability, around the clock, in only a minority of hospitals.

Reperfusion therapy : PCI

Reperfusion therapy : fibrinolysis

• If no contraindications are present fibrinolytic therapy should ideally be initiated within 30 min of presentation

• The principal goal of fibrinolysis is prompt restoration of full coronary arterial patency.

• The fibrinolytic agents tissue plasminogen activator (tPA), streptokinase, tenecteplase (TNK), and reteplase (rPA) have been approved for intravenous use in patients with STEMI.

• These drugs all act by promoting the conversion of plasminogen to plasmin, which subsequently lyses fibrin thrombi

• Fibrinolytic therapy can reduce the relative risk of in-hospital death by up to 50% when administered within the first hour of the onset of symptoms of STEMI, and much of this benefit is maintained for at least 10 years.

• When appropriately used, fibrinolytic therapy appears to reduce infarct size, limit LV dysfunction, and reduce the incidence of serious complications such as septal rupture, cardiogenic shock, and malignant ventricular arrhythmias

• Although reduction of the mortality rate is more modest, the therapy remains of benefit for many patients seen 3–6 h after the onset of infarction, and some benefit appears to be possible up to 12 h, especially if chest discomfort is still present and ST segments remain elevated.

• Compared with PCI for STEMI (primary PCI), fibrinolysis is generally the preferred reperfusion strategy for patients presenting in the first hour of symptoms

Reperfusion therapy : fibrinolysis

Fibrinolytic drugs

• Fibrinolytics ท*�น�ยมใชั่�มากท*�สำ�ดูในประเทศไทย คั3อstreptokinase– Non-selective fibrinolytics – 90 ℅patency rate : 50 ℅ , TIMI 3 flow : 32℅• 90 นาท* ท*�ผู้��ป วยไดู� SK ถ้�าไปฉี*ดูสำ*ดู�จะม*เพ*ยงคัร4�งเดู*ยวเท�าน�5น

ท*�หลอดูเล3อดูเป9ดูดู*– ราคัาถ้�กกว�า fibrinolytics ชั่น�ดูอ3�นๆ– ว�ธ*การให� คั3อ ให�ชั่�าๆผู้สำมใน NSS หร3อ 5℅D/W 100 ml

IV drip in 1 hr– อาจให� hydrocortisone 100 mg ก�อนให� SK เพ3�อลดู

reaction

• Streptokinase– ติ�อง monitor EKG และ blood pressure ติลอดู เพราะ

อาจเก�ดู arrhythmia ระหว�างหยดูยาไดู�ติลอดูเวลา โดูย เฉีพาะ VT และ VF หร3ออาจเก�ดู bradycardia ไดู�

– ก�อนให�หร3อหล�งให�ไม�คัวรท�าห�ติถ้การติ�างๆ ถ้�าติ�องการ ท�าห�ติถ้การจร�งๆคัวรรอหล�งให�ยาไปแล�วนานกว�า 24

ชั่��วโมง– ไม�จ�าเป1นติ�องให� heparin หร3อ LMWH ติ�ออ*ก

Fibrinolytic drugs

• t-PA– Fibrin specific fibrinolytic drug– ประสำ�ทธ�ถ้าพดู*กว�า และ patency rate สำ�งกว�า– โอกาสำเก�ดู intracerebral hemorrhage สำ�งกว�า– ราคัาแพงกว�ามาก– ใชั่�ไดู�ง�าย เพราะให�เป1น bolus dose ติามน�5าหน�กติ�วไดู�– Side effect น�อยกว�า– จ�าเป1นติ�องให� unfractionated heparin (UFH) หร3อ

LMWH ติ�อ

Fibrinolytic drugs

Adjunct medications

• คัวรให�ในท�กรายท*�ไม�ม*ข�อห�าม เพราะ ลดูmortality rate, infarct size และ reinfarction• ข�อห�าม : heart block, heart failure, bronchospasm

Beta-blockers

• ลดู ventricular remodelling และปร�บเปล*�ยนhemodynamic ของheart failureให�ดู*ข45น• ข�อคัวรระว�งคั3อ BP ไม�คัวร <100, คัวรให�หล�ง 24 hrแรก•ARB ไดู�ผู้ลเหม3อน ACEI ใชั่�เม3�อทนผู้ลของ ACEI ไม�ไดู�

ACEI/ARB

Adjunct medications

• ให�แทน aspirin ไดู� เม3�อม*ข�อห�ามของการให�aspirin• การให� clopidogrel ร�วมก�บ aspirin ลดูการ

เก�ดู recurrent infarction ไดู�ดู*กว�าการให�aspirin อย�างเดู*ยว

Clopidogrel

• ลดู inflammation และ complication ติ�างๆ เชั่�น reinfarction, recurrent angina,

arrhythmia•ให�ไดู�อย�างปลอดูภั�ยแม�จะไม�ม*ไขม�นในเล3อดูสำ�ง

HMG-CoA reductase inhibitor (statin)

Adjunct medications

•IV NTG is indicated in the first 48 hours after STEMI for treatment of persistent ischemia, CHF, or hypertension• ไม�ชั่�วยลดู mortality rate•Intravenous, oral, or topical nitrates are useful beyond the first 48 hours after STEMI•Nitrates should not be administered to patients with systolic blood pressure less than 90 mm Hg or greater than or equal to 30 mm Hg below baseline, severe bradycardia (less than 50 bpm), tachycardia (more than 100 bpm), or RV infarction

nitroglycerin

Adjunct medications

•Intravenous UFH or LMWH should be used in patients after STEMI who are at high risk for systemic emboli (large or anterior MI, AF, previous embolus, known LV thrombus, or cardiogenic shock)•It is reasonable that STEMI patients not undergoing reperfusion therapy who do not have a contraindication to anticoagulation be treated with IV or SC UFH or with SC LMWH for at least 48 hours

Antithromboti

cs

Killip classificationKillip class description Hospital mortality rate

I no signs of pulmonary or venous congestion

0–5%

II moderate heart failure as evidenced by rales at the lung bases, S3 gallop, tachypnea, or signs of failure of the right side of the heart, including venous and hepatic congestion

10–20%

III severe heart failure, pulmonary edema 35–45%

IV shock with systolic pressure <90 mmHg and evidence of peripheral vasoconstriction, peripheral cyanosis, mental confusion, and oliguria.

85–95%

Our patient

ICU เติ,ม

• Morphine 3 mg IV stat• O2 canula 3 LPM• ISDN 5 mg SL stat

then ISDN (10) 1 tab tid pc• ASA Gr V 1 tab oral stat then

ASA (80) 1 tab oral OD

• Plavix (75mg) 4 tab oral stat then 1 tab oral OD

• NTG (1:10) IV drip 5 mdrop/min x 3 d• Enoxaparin 0.6 ml SC q 12 hr X 5 d• Enalapril (5) 1 tab oral OD • Lasix 40 mg V stat

with lasix(40) 1 tab oral bid and prn dose

• Simvastatin (20) 1 tab oral hs• Ativan(0.5) 1 tab oral hs• MOM 30 cc prn for constipation

Progression

• 1 day after admission :– Clinical chest pain ลดูลงมาก ย�งม*เหน3�อยเล,กน�อย– อาการกระสำ�บกระสำ�ายลดูลง ผู้��ป วยพ�ดูไดู� ไม�ม*ติ�วเย,น

systemic perfusion ดู*ข45น– ย�งม* crepitation both lung ประเม�นว�าย�งม* volume

overload– Vital sign stable : BP 150/90, RR 26– Lab : FBS WNL, lipid profile : OK– CK,Trop T increased

• 4 days after admission– Clinical stable, no chest pain, no dyspnea– Increased BUN,Cr : BUN 38.8,Cr 3.1– CXR : cardiomegaly , no congestion , R/O lung

mass– Rx : Off enalapril, lasix , เปล*�ยน antihypertensive

เป1น HDZ– Plan D/C

Progression

Extern interesting case: STEMI

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