What is Medicine – Acute Coronary Syndrome (STEMI)
BASICS DESCRIPTION The quick onset of myocardial necrosis brought on by a sustained lack of blood flow to a section of the myocardium is known as acute myocardial infarction (AMI). A major coronary artery is completely blocked by atherothrombosis, causing transmural ischemia, and this results in ST-segment elevation myocardial infarction (STEMI). Release of serum cardiac biomarkers and ST-segment elevation on an ECG occur concurrently with this. EPIDEMIOLOGY Incidence Annually, more than 650,000 cases of AMI are reported in the US. With a 95% 30-day survival rate, early revascularization and AMI therapy have reduced death. Prevalence Atherosclerotic heart disease, which affects 7.5 million individuals in the country and has a larger prevalence in males (5.5%) than in women (2.9%), is the main cause of morbidity and mortality in the country. PATHOPHYSIOLOGY AND AETIOLOGY Coronary artery disease (CAD) due to atherosclerosis: Lesions from atherosclerosis can be fibrotic, calcified, or lipid-rich. Atherothrombotic occlusion can more easily result from thin-capped atheromas rupturing. Non-atherogenic causes: - Embolism from infected vegetations, or thrombi coming from the right atrium across the foramen ovale ("paradoxical"), the left atrium, or the left ventricle - Spontaneous coronary artery dissection is common in young women and people with fibromuscular dysplasia (FMD). Chest injury, aortic and/or coronary artery dissection, mechanical or iatrogenic obstruction, coronary artery spasm due to elevated vasomotor tone, anginal variant - Hematologic causes (disseminated intravascular coagulation [DIC], severe anaemia), aortic stenosis, cocaine, IV drug usage, severe burns, and protracted hypotension are some of the aetiologies for arthritis. RISK FACTORS Growing older, high blood pressure, smoking, diabetes, dyslipidemia, a family history of early start of CAD, and a sedentary lifestyle GENERAL PREVENTION Smoking cessation and abstinence; a balanced diet; weight loss and control; regular exercise; and management of diabetes, hypertension, and hyperlipidemia CONDITIONS OFTEN Associated with Cerebrovascular disease, an abdominal aortic aneurysm, and atherosclerotic peripheral vascular disease DISEASE HISTORY Inferior MI patients may primarily experience stomach pain. Symptoms: - Classically, rapid onset of chest heaviness/tightness, with or without exercise, lasting minutes to hours. - Pain/discomfort radiating to neck, mouth, interscapular area, upper extremities, and/or epigastrium. Previous myocardial ischemia history, including stable or unstable angina, AMI, coronary bypass surgery, or percutaneous coronary intervention (PCI) Examine CAD risk factors, such as bleeding history, noncardiac surgery, and a family history of early CAD. Ask if you've recently taken phosphodiesterase type 5 inhibitors (if so, avoid taking nitrates at the same time). Abuse of tobacco, alcohol, and/or drugs, particularly cocaine Physical examination results include: General: restlessness, agitation, hypothermia, fever; Neurologic: dizziness, syncope, weariness, asthenia, and disorientation (particularly in the elderly); Cardiovascular (CV) symptoms include dysrhythmia, hypotension, expanded pulse pressure, S3 and S4, and jugular venous distention (JVD). Respiratory symptoms include dyspnea, tachypnea, crackles, and rales. GI symptoms include nausea, vomiting, and hiccups. Skin: pallor, diaphoresis, and chilly skin gender and geriatrics Considerations: Older patients may present in an unusual way, including with silent or undiagnosed MI. Syncope, weakness, shortness of breath, unexplained nausea, epigastric discomfort, changed mental status, or delirium may frequently be present. Symptoms of diabetes mellitus, such as weariness, dyspnea, and malaise, may be normal or "atypical" in women or individuals. DIFFERENTIAL DIAGNOSIS pericarditis, dysrhythmias, gastroesophageal reflux disease (GERD), esophageal spasm, biliary/pancreatic discomfort, hyperventilation syndrome, unstable angina, aortic dissection, perforating gastric ulcer, anxiety/panic DETECTION & INTERPRETATION OF DIAGNOSIS Initial examinations (lab, imaging) 12-lead ECG: - 1 mm ST elevation in a localised pattern encompassing at least two adjacent leads, with or without aberrant Q waves - STEMI of the posterior wall: tall R waves in V1-V2 with ST depression - The absence of Q waves indicates an early infarction or partial or temporary blockage. – If there is an inferior MI pattern, take into account the right-sided and posterior chest leads (look at V3R, V4R, and V7-V9). The Sgarbossa criterion or BARCELONA method (1) may be useful in the presence of ventricular pacing or a previous left bundle branch block (LBBB). 2-Dimensional transthoracic echocardiography is helpful in assessing mural thrombus, left ventricular function, regional wall motion in MI, and mechanical consequences. Emergent coronary angiography with PCI is preferred whenever a diagnosis is suspected. Tests in the Future & Special Considerations Blood biomarkers Three to six hours after the onset of ischemia symptoms, troponin I and T (cTnI, cTnT) levels increase. cTnI elevations last 7 to 10 days after MI, whereas cTnT elevations last 10 to 14 days. Creatine kinase-MB (CK-MB) myoglobin fraction adds little diagnostic utility to troponin tests in the evaluation of potential AMI. pregnant women's issues Discussions about the advantages and disadvantages of invasive coronary angiography, which exposes the foetus to radiation, are necessary for pregnant patients who present with STEMI. Otherwise, treatment should be the same as for people who are not pregnant. Other/Diagnostic Procedures In some ambiguous presentations, a portable chest x-ray, transthoracic echocardiography, and chest computed tomography angiography (CTA) scan may be useful immediately to assess for alternative diagnosis (aortic dissection, PE, ventricular aneurysm). Coronary angiography is the conclusive examination. The amount of contrast medium used needs to be carefully monitored in patients with chronic renal disease. GENERAL MEASURES/TREATMENT Admit the patient to the coronary care unit (CCU) or a telemetry unit with continuous ECG monitoring and bed rest after emergency revascularization. Use: - Antiarrhythmics when necessary for dysrhythmia that is unstable Aspirin 81 mg/day continued along with clopidogrel 75 mg/day, prasugrel 10 mg/day, or ticagrelor 90 mg twice day as part of dual antiplatelet treatment (DAPT). MEDICATION The 2013 American College of Cardiology (ACC)/American Heart Association (AHA) guideline and the 2017 European Society of Cardiology (ESC) guideline (3)[C] are the foundations for the medication recommendations. Initial Line Nitroglycerin (NTG) sublingual 0.4 mg q5min for a total of 3 doses, followed by NTG IV if ongoing pain and/or hypertension and/or management of pulmonary congestion are present and there are no contraindications such as right ventricle (RV) infarction, use of sildenafil or vardenafil within 24 hours of tadalafil, or use of morphine within 48 hours of tadal Antiplatelet medications: - Non-enteric-coated aspirin (ASA), first dose: 162 to 325 mg chewed – For patients with STEMI for whom PCI is intended, a loading dose of a P2Y12 inhibitor is advised. It is advised to use ticagrelor or prasugrel. Prasugrel loading dosage of 60 mg. Patients who have had a past stroke or transient ischemic attack should not use prasugrel. Not advised for patients older than 75 years or who weigh less than 60 kg. 180 mg of ticagrelor as a loading dosage. Transient dyspnea could be brought on by ticagrelor. If neither prasugrel nor ticagrelor are available, clopidogrel 600 mg loading dosage should be administered. Cangrelor may be taken into consideration in patients who were not receiving oral P2Y12 receptor inhibitors prior to PCI or who were unable to take oral medications. The typical advice for the length of DAPT is 6 to 12 months following PCI, depending on the risk of ischemia and bleeding. Unfractionated heparin (UFH) 70- to 100-U/kg IV bolus OR Enoxaparin 0.5-mg IV bolus OR Bivalirudin 0.75-mg IV bolus and then 1.75-mg/kg/hr infusion for up to 4 hours following operation are all examples of anticoagulation therapy. The aim is to keep the entire ischemia time within 120 minutes, whether PCI is used or fibrinolysis. Door to needle or door to balloon should be reached in less than 30 or 90 minutes, respectively. - Primary PCI (balloon angioplasty, coronary stents) in the following situations: A 12-hour symptom onset period The emergence of symptoms within 12 hours and the rejection of fibrinolytic therapy regardless of the elapsed time Regardless of the length of time since the start of a MI, cardiogenic shock or acute severe heart failure (HF) Signs of persistent ischemia 12 to 24 hours following the onset of symptoms: Considerations for the procedure It is advised to use radial access rather than femoral access. It is advised to perform PCI on infarct-related arteries (IRA). - Fiberylysis If a patient arrives to a hospital that cannot do PCI and cannot be moved to a facility that can within 120 minutes of the initial medical contact If there is evidence of continued ischemia and there are no contraindications, administer within 12 to 24 hours of the onset of symptoms. Alteplase (tPA) is administered as a 15-mg IV bolus, 0.75 mg/kg (up to 50 mg) IV over 30 minutes, and then 0.5 mg/kg (up to 35 mg) IV over 60 minutes. The maximum dosage is 100 mg over 90 minutes. Reteplase (rPA): 10 units IV bolus; administer second bolus after a 30-minute interval. Tenecteplase (TNK-tPA): 30- to 50-mg IV bolus, depending on weight. Recommend cutting the dose in half for those under 75. Adjunctive fibrinolysis with antiplatelet treatment Aspirin (loading dose of 162 to 325 mg, then 81 mg every day forever) and Clopidogrel (loading dose of 300 mg for patients under 75 years old, 75 mg dose for patients over 75 years old). Continue taking 75 mg of clopidogrel every day for at least 14 days and maybe up to a year. Fibrinolysis as an adjunct to anticoagulation therapy Use anticoagulants (UFH, enoxaparin, or fondaparinux) in conjunction with reperfusion therapy for at least 48 hours and ideally the entire admission period (up to 8 days), or until revascularization, if necessary. Glycoprotein IIb/IIIa receptor antagonists (abciximab, eptifibatide, or tirofiban) at the time of initial PCI in certain patients if there is no reflow or thrombotic problems In patients with anterior infarction, HF, diabetes, or ejection fraction (EF) 0.40, ACE inhibitors should be started orally within 24 hours of STEMI, unless contraindicated. Starting high-intensity statin medication as soon as feasible is advised. If there is no renal failure or hyperkalemia, a mineralocorticoid receptor antagonist (spironolactone, eplerenone) is advised for patients with EF 40%, HF, or diabetes who are already taking an ACE inhibitor and a beta-blocker (BB). When BB is ineffective or contraindicated and EF is normal, a second-line long-acting non-dihydropyridine calcium channel blocker (CCB) should be used; immediate-release nifedipine should not be used. QUESTIONS FOR REFERENCE As soon as possible, move high-risk patients who are receiving fibrinolytic therapy as their main form of reperfusion therapy to a facility that can perform PCI. SURGICAL AND OTHER PROCEDURE Patients with STEMI with coronary anatomy not susceptible to PCI who have continuing or recurrent oischemia, cardiogenic shock, severe HF, or other high-risk characteristics should undergo urgent coronary artery bypass graft (CABG) surgery. CONSIDERATIONS FOR ADMISSION, THE INPATIENT, AND NURSING For assessment and treatment, all STEMI patients should be hospitalised to a CCU or an intense cardiac care unit. CONTINUING CARE AFTERCARE RECOMMENDATIONS Following discharge, individuals with STEMI should see a cardiologist every three months for the first year, and subsequently once a year. Stress medication compliance and promote quitting smoking. Take into account a heart rehabilitation programme focused on exercise. Low-fat/healthy-fat diet: trans fatty acids are eliminated, and saturated fat intake is restricted to 7% of total calories. A healthy Mediterranean diet. EDUCATION OF PATIENTS Sexual activity can be resumed 1 to 2 weeks after an uncomplicated MI or 6 to 8 weeks after CABG; smoking cessation and a low-fat diet are also recommended. COMPLICATIONS Advanced age, diabetes, delayed or failed revascularization, decreased left ventricular systolic function, and indications of congestive HF are all linked to poor prognosis. HF, acute mitral regurgitation, myocardial wall rupture, left ventricular aneurysm, pericarditis, dysrhythmias, and depression (common)
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