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
Diagnosis
Diagnostic ST elevation in the absence of left
ventricular (LV) hypertrophy or left bundle-branch block (LBBB) is defined by the European Society of Cardiology/ACCF/AHA/World Heart Federation Task Force for the Universal Definition of Myocardial Infarction
new ST elevation at the J point in at least 2 contiguous leads of 2 mm (0.2 mV) in men or 1.5 mm (0.15 mV) in women in leads V2V3 and/or of 1 mm (0.1 mV) in other contiguous chest leads or the limb leads. The majority of patients will evolve ECG evidence of Qwave infarction.
paced rhythm, LV hypertrophy, Brugada syndrome) ST depression in 2 precordial leads (V1V4) may indicate transmural posterior injury Multilead ST depression with coexistent ST elevation in lead aVR left main or proximal left anterior descending artery occlusion Hyperacute T-waves
Diagnosis
Transthoracic echocardiography evidence of focal wall motion abnormalities facilitate triage in patients with ECG findings that are difficult to interpret. If doubt persists invasive angiography
diagnosis of MI.
Epidemiology
STEMI
Age Killip class Time to reperfusion Cardiac arrest Tachycardia Hypotension Anterior infarct location Prior infarction Diabetes mellitus Smoking status Renal function Biomarker findings
score was developed specifically in patients with STEMI The GRACE model predicts in-hospital and 6-month mortality rate across the spectrum of patients presenting with ACS, including those with ST elevation or ST depression. Risk assessment is a continuous process that should be repeated throughout hospitalization and at time of discharge.
In the absence of contraindications, fibrinolytic therapy should be given to patients with STEMI and onset of ischemic symptoms within the previous 12 hours when it is anticipated that primary PCI cannot be performed within 120 minutes of FMC (Level of Evidence: A) In the absence of contraindications and when PCI is not available, fibrinolytic therapy is reasonable for patients with STEMI if there is clinical and/or ECG evidence of ongoing ischemia within 12 to 24 hours of symptom onset and a large area of myocardium at risk or hemodynamic instability. (Level of Evidence: C) Fibrinolytic therapy should not be administered to patients with ST depression except when a true posterior (inferobasal) MI is suspected or when associated with ST elevation in lead aVR (Level of Evidence: B)
Class IIa
elevation or bundle-branch block MI are well established, with a time-dependent reduction in both mortality and morbidity rates during the initial 12 hours after symptom onset Benefit from fibrinolytic therapy in patients who present >12 hours after symptom onset has not been established although there remains consensus that consideration should be given to administering a fibrinolytic agent in symptomatic patients presenting >12 hours after symptom onset with STEMI and a large area of myocardium at risk or hemodynamic instability if PCI is unavailable
time from onset of symptoms the clinical and hemodynamic features at presentation patient comorbidities risk of bleeding presence of contraindications time delay to PCI
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 (Level of Evidence: A) Recommended regimens include
UFH administered as a weight-adjusted intravenous bolus and infusion to obtain an activated partial thromboplastin time of 1.5 to 2.0 times control, for 48 hours or until revascularization. (Level of Evidence: C); Enoxaparin administered according to age, weight, and creatinine clearance, given as an intravenous bolus, followed in 15 minutes by subcutaneous injection for the duration of the index hospitalization, up to 8 days or until revascularization(Level of Evidence: A); or Fondaparinux administered with initial intravenous dose, followed in 24 hours by daily subcutaneous injections 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 (Level of Evidence: B)
an improvement in or relief of chest pain resolution of ST elevation the presence of reperfusion arrhythmias (eg, accelerated idioventricular rhythm)
coupled with >70% ST resolution is highly suggestive of restoration of normal myocardial blood flow The combination of <50% ST resolution and the absence of reperfusion arrhythmias at 2 hours after treatment predicts TIMI flow <3 in the infarct artery with a sensitivity of 81%, specificity 88%, positive predictive value 87%, and negative predictive value 83%. Lack of resolution of ST elevation by at least 50% in the worst lead at 60 to 90 minutes should prompt strong consideration of a decision to proceed with immediate coronary angiography and rescue PCI.