ACUTE MYOCARDIAL INFARCTION:

COMPLICATIONS AND TREATMENT

Assoc Prof Serban Balanescu, MD

 COMPLICATIONS of AMI
Acute Chronic
Arrhythmia:
Arrhythmia: 72-96%
72-96% of
of pts
pts LVF
LVF and
and congestive
congestive heart
heart failure
failure
Tachyarrhythmia:
Tachyarrhythmia: Ischemic
Ischemic dilated
dilated CM
CM
Ventricular
Ventricular Ventricular
Ventricular arrhythmia
arrhythmia
Supraventricular
Supraventricular LV
LV aneurysm
aneurysm
Brady-arrhythmia:
Brady-arrhythmia: 33rdrd degree
degree AV
AV Ischemic
Ischemic mitral
mitral regurgitation
regurgitation
and
and BBB
BBB Late
Late post-infarction
post-infarction pericarditis
pericarditis
Mechanical
Mechanical complications:
complications: (Dressler
(Dressler Sdr)
Sdr)
LVF
LVF and
and cardiogenic
cardiogenic shock
shock Recurrent
Recurrent myocardial
myocardial ischemia
ischemia
IV
IV septum
septum and
and free
free wall
wall rupture
rupture (angina,
(angina, recurrent
recurrent MI)
MI)
Papillary
Papillary muscle
muscle rupture
rupture Sudden
Sudden cardiac
cardiac death
death
Early
Early post-infarction
post-infarction pericarditis
pericarditis
Early
Early post-infarction
post-infarction angina
angina
Systemic
Systemic cardio-embolization
cardio-embolization
 VENTRICULAR TACHYARRHYTHMIA

VPBs
VPBs and
and non-sustained
non-sustained VT
VT Accelerated
Accelerated idio-ventricular
idio-ventricular rhythm
rhythm
May
May be
be triggers
triggers for
for sustained
sustained VT
VT or
or VF
VF
(non
(non paroxysmal
paroxysmal VT)
VT)
VT
VT or
or VF
VF may
may occur
occur without
without warning
warning reperfusion
reperfusion arrhythmia;
arrhythmia; 20%
20% of
of STEMI
STEMI
arrhythmia
arrhythmia Increased
Increased automaticity
automaticity in
in Purkinje
Purkinje fibers
fibers
Lidocaine
Lidocaine 1-2
1-2 mg/kg
mg/kg in
in bolus,
bolus, IV
IV infusion
infusion favored
favored by
by bradycardia
bradycardia
22 mg/min
mg/min for
for 24-72h
24-72h Does
Does not
not need
need treatment,
treatment, surveillance
surveillance only
only
IV
IV amiodarone
amiodarone or
or beta-blockers
beta-blockers may
may be
be Does
Does not
not evolve
evolve to
to VF
VF (extremely
(extremely rare)
rare)
used
used
 Ventricular fibrillation and tachycardia

Primary
Primary VF:
VF: 10%
10% of
of pts
pts
in
in the
the first
first 24-28h
24-28h or
or reperfusion
reperfusion arrhythmia
arrhythmia
Good
Good prognosis
prognosis
VF
VF should
should be
be promptly
promptly cardioverted
cardioverted with
with external
external DC
DC
shock
shock
IV
IV lidocaine,
lidocaine, amiodarone,
amiodarone, beta-blockers;
beta-blockers; long
long term
term
prophylactic
prophylactic treatment
treatment not
not necessary
necessary
Secondary
Secondary VF:
VF:
Occurs
Occurs late,
late, >
> 48h
48h after
after symptom
symptom onset
onset
Associated with EF,
Associated with EF, LV
LV aneurysm
aneurysm
Ominous
Ominous prognosis:
prognosis: recurrent,
recurrent, leads
leads to
to SD
SD
Cardioversion
Cardioversion with
with external
external DC
DC shock
shock
ICD
ICD implantation,
implantation, full
full revascularization,
revascularization, amiodarone
amiodarone
PO,
PO, heart
heart transplantation
transplantation in
in CHF
CHF
 Supraventricular tachyarrhythmias
Sinus tachycardia:
-- high
high catecholamine
catecholamine serum
serum and
and intra-myocardial
intra-myocardial levels
levels in
in the
the first
first 24-48
24-48 hh
-- acute
acute LV
LV dysfunction
dysfunction
-- other
other causes
causes pulmonary
pulmonary thromboembolism,
thromboembolism, pericarditis
pericarditis
-- negative
negative impact
impact on
on myocardium
myocardium due to O
due to O22 consumption + dyastole
consumption + dyastole
-- ifif persistent
persistent more
more 48
48 hh prognostic
prognostic indicator
indicator =
= significant
significant LV
LV dysfunction
dysfunction

Atrial fibrillation and flutter:

-- are
are due
due to:
to: -- associated
associated atrial
atrial infarction
infarction
-- atrial
atrial dilatation
dilatation
-- high
high catecholamine
catecholamine serum
serum levels
levels
-- peri-infarction
peri-infarction pericarditis
pericarditis
-- LV
LV failure
failure
-- amiodarone
amiodarone IV,
IV, lower
lower HR
HR with
with beta
beta blockers
blockers (depending
(depending onon LV
LV function)
function)
-- poor
poor tolerance
tolerance with
with hemodynamic
hemodynamic instability
instability or
or ischemia
ischemia worsening
worsening == electrical
electrical
defibrillation
defibrillation
 BRADY-ARRYTHMIAS

Grade II AV block, Mobitz 1 Grade II AV block, Mobitz 2

Usually
Usually associated
associated with
with inferior
inferior MI
MI Usually
Usually inin anterior
anterior AMI
AMI
Due
Due to
to supra-His
supra-His disturbance
disturbance Due
Due to
to infra-His
infra-His conduction
conduction
Does
Does not
not evolve
evolve to
to grade
grade III
III AV
AV block
block disturbance
disturbance
temporary,
temporary, periinfarction
periinfarction edema
edema May
May evolve
evolve 33rdrd degree
degree AV
AV block
block
IV
IV atropine,
atropine, corticoids
corticoids Needs
Needs temporary
temporary PM PM implantation,
implantation,
Does then
then permanent
permanent PM PM implantation
implantation (in
(in
Does not
not need
need temporary
temporary PM PM
(seldom, grade
grade III
III AV
AV block)
block)
(seldom, with
with low
low cardiac
cardiac output)
output)
Grade II AV block, Mobitz 2, 2/1 in inferior MI
Day 3 after primary PCI for inferior STEMI
 Grade III AV block in inferior MI

temporary
temporary PM
PM insertion
insertion (jugular
(jugular vein
vein access
access preferred,
preferred, but
but any
any vein
vein access
access is
is good!)
good!)
Permanent
Permanent PM
PM in
in grade
grade III
III AV
AV block
block persists
persists >> 77 days
days post
post MI
MI
Permanent PM if grade III AV block persists > 7 days post MI
LVF and cardiogenic shock: main causes
Acute
Acute MI
MI with
with > 20%
20% necrosis
necrosis of
of LV
LV myocardium
myocardium
Recurrent
Recurrent MI,
MI, added to previous working myocardium loss
AMI
AMI occurring
occurring over
over compensated
compensated chronic
chronic heart
heart failure
failure
AMI
AMI with
with mechanical
mechanical complications: IV septum or free wall rupture,
acute
acute MR
MR due
due to papillary muscle rupture
Persistent
Persistent refractory,
refractory, severe,
severe,
tachy-
tachy- or brady-arryhthmias
AMI
AMI with
with early
early recurrent ischemia
ischemia
Aortic
Aortic valve
valve disease
disease (AoS, AR)
High
High prevalence
prevalence of:
of:
Multi-vessel
Multi-vessel coronary disease
disease
Left
Left main
main stenosis
stenosis
 LVF-acute PE / cardiogenic shock: treatment

LVF pulmonary edema CARDIOGENIC SHOCK

Analgesics:
Analgesics: morphine
morphine 2-4
2-4 mg
mg IV,
IV, Emergency
Emergency myocardial
myocardial revascularization:
revascularization: primary
primary
pethidine
pethidine 10-20
10-20 mg
mg IV
IV repeatedly
repeatedly or
or salvage
salvage PCI
PCI
IV
IV GTN 10-100 /min
GTN 10-100 /min CABG
CABG indicated
indicated for
for mechanical
mechanical complications
complications
Frusemide
Frusemide 20-60
20-60 mg
mg IV
IV IV
IV norepinephrine,
norepinephrine, milrinone,
milrinone, levosimendan
levosimendan
IV
IV Dobutamine,
Dobutamine, dopamine
dopamine IV
IV dobutamine
dobutamine ++ dopamine 5-10 /kgc/min
dopamine 5-10 /kgc/min
PO
PO or
or IV
IV ACEI:
ACEI: enalapril,
enalapril, ramipril,
ramipril,
trandolapril Respiratory
Respiratory support,
support, mechanical
mechanical ventilation
ventilation
trandolapril
In
In hypodyastolic
hypodyastolic HF
HF (RV
(RV AMI)
AMI) IV
IV liquid
liquid Intra-aortic
Intra-aortic balloon
balloon pump,
pump, LVADs
LVADs
volume
volume overload
overload
 Treatment of LV failure
FORRESTER CLASS II:
IV
IV Furosemide
Furosemide 80-120
80-120 mg
mg
IV
IV Nitroglycerine 10-100 /min
Nitroglycerine 10-100 /min
IV
IV dobutamine
dobutamine or
or dopamine
dopamine

FORRESTER CLASS III:

IV
IV volume
volume overload
overload (fast
(fast IV
IV saline
saline infusion
infusion and
and dextran
dextran 40)
40)
IV
IV Dopamine
Dopamine
Stop
Stop IV
IV GTN
GTN and
and diuretic
diuretic therapy
therapy

FORRESTER CLASS IV:

Emergency
Emergency reperfusion
reperfusion by
by PCI
PCI on
on all
all interventionally
interventionally treatable
treatable lesions
lesions
Intra-aortic
Intra-aortic balloon
balloon counterpulsation
counterpulsation or
or Impella
Impella device
device in
in LV-Ao
LV-Ao
IV
IV Dopamine
Dopamine 5-10-20
5-10-20 g/kc/min
g/kc/min +
+ Norepinephrine
Norepinephrine 0,5
0,5 g/kc/min)
g/kc/min) up-titrated
up-titrated for
for mean
mean BP
BP >
>
60
60 mmHg
mmHg
IV
IV Levosimendan
Levosimendan (not
(not approved
approved by
by FDA)
FDA)
IV
IV Milrinone
Milrinone 0.3
0.3 0.75
0.75 g/kc/min
g/kc/min
 POSTINFARCTION MYOCARDIAL ISCHEMIA
Active residual myocardial ischemia occurring early after acute
coronary occlusion:

Clinical patterns:
early postinfarction angina due to:
Ischemia
Ischemia in
in other
other coronary territory: other than
than infarct
infarct related
related vessel
vessel
Ischemia
Ischemia in
in the
the same
same territory:
territory: re-occlusion
re-occlusion of
of IRA
IRA treated
treated with
with
primary
primary PCI
PCI or
or systemic
systemic thrombolysis
thrombolysis
Extension of infarct zone:
Myocardial necrosis in myocardium at
at risk, in the peri-infarct zone
Recurrent MI:
In the same coronary region or in a different coronary territory
Silent ischemia
Peri-infarction pericarditis (early post MI)

Persistent
Persistent dull
dull central
central chest
chest pain:
pain:
differential
differential Dx
Dx with early post MI
angina
angina
Temporary
Temporary pericardial
pericardial rub
rub
More
More prevalent
prevalent in
in antero-apical
antero-apical MI
MI
It
It suggests
suggests a large
large sub-epicardial
sub-epicardial MI
Risk
Risk hemorrhagic
hemorrhagic transformation
transformation with
with
DAPT
DAPT and
and anticoagulation
anticoagulation
Needs
Needs echocardiographic
echocardiographic surveillance
surveillance
Treatment:
Treatment: NSAIDs,
NSAIDs, analgesics therapy
Late post MI pericarditis: Dressler sdr.
Occurs
Occurs later than
than 77 -14
-14 days
days post MI 1year
post MI 1year
Immunologic
Immunologic reaction
reaction due to autoimmunity with self anti-pericardial or
anti-myocardium
anti-myocardium antibodies
antibodies
Similar
Similar to
to post-pericardiotomy
post-pericardiotomy sdr
sdr after
after cardiac surgery
Clinical
Clinical signs
signs of pleuro-pericarditis, sometimes
sometimes sero-hemorrhagic
Associated
Associated with
with major
major systemic inflammatory reaction
New
New onset
onset of
of chest
chest pain or pleuritic
pleuritic pain
pain
Treatment:
Treatment: NSAIDs
NSAIDs or Prednisone 0.5-1 mg/kg 4-6 weeks
Usually
Usually recurrent
recurrent
LV free wall rupture in STEMI
LV free wall rupture in STEMI:
cardiac tamponade
 LV free wall rupture in
STEMI: pseudo-aneurysm
Acute VSD in STEMI
 Papillary muscle
rupture: acute MR
LV aneurysm post MI
Difference between aneurysm and pseudo
aneurysm
Apical thrombus post
anterior MI
THE TREATMENT OF ACUTE

MYOCARDIAL INFARCTION
 General therapeutic measures
Acute
Acute MI
MI is
is aa MAJOR
MAJOR MEDICAL
MEDICAL EMERGENCY
EMERGENCY
Emergency
Emergency admission
admission to
to an
an Intensive
Intensive Coronary
Coronary Care
Care Unit
Unit (ICCU)
(ICCU)

Bed
Bed rest
rest
Continuous
Continuous monitoring:
monitoring: heart
heart rhythm,
rhythm, BP,
BP, diuresis,
diuresis, pulse
pulse oxymetry
oxymetry
repeated
repeated ECG
ECG and
and continuous
continuous monitoring
monitoring of
of ST
ST segment
segment
4-6h
4-6h serum
serum enzyme
enzyme necrosis
necrosis markers
markers in
in first
first 24h,
24h, then
then every
every 24h
24h
O2
O2 6l/min
6l/min on
on aa face
face mask
mask or
or nostril
nostril tubes
tubes
Aspirin
Aspirin 160-325
160-325 mg
mg chewed
chewed or
or IV
IV on
on admission;
admission; then
then indefinitely
indefinitely
Heparin
Heparin 5-10.000
5-10.000 UI
UI IV
IV bolus,
bolus, then
then 1000-1500
1000-1500 UI/h
UI/h for
for aPTT
aPTT 50-70
50-70 sec
sec
Alternative
Alternative treatment:
treatment: LMWH:
LMWH: enoxaparin
enoxaparin 11 mg/kgc
mg/kgc SC
SC xx 22 // day
day
Antalgics:
Antalgics: IV
IV NSAIDs
NSAIDs (i.e.
(i.e. metamizole)
metamizole) or
or opioids:
opioids: morphine,
morphine, pethidine,
pethidine, pentazocine
pentazocine IV
IV
GIK
GIK infusion:
infusion: glucose
glucose 10%
10% +
+ 20
20 UI
UI insulin
insulin +
+ KCl
KCl mmol/l;
mmol/l; 11 ml/kgc/h
ml/kgc/h for
for 24
24 ore
ore
IV
IV GTN:
GTN: 10-100
10-100 gamma/min
gamma/min IV;
IV; avoided
avoided in
in inferior
inferior MI
MI with
with RV
RV involvement
involvement
IV
IV Betablockers:
Betablockers: propranolol,
propranolol, metoprolol
metoprolol 1mg
1mg IV
IV or
or esmolol
esmolol
Statins:
Statins: atorvastatin
atorvastatin 80
80 mg/zi;
mg/zi; simvastatin
simvastatin 40
40 mg/zi
mg/zi
 PATHOGENIC TREATMENT:
REPERFUSION THERAPY

DRUG THERAPY: SYSTEMIC THROMBOLYSIS

MECHANIC REPERFUSION: PRIMARY PCI

FACILITATED PCI (LYSIS + PCI)

 Relatiship between time to reperfusion,
myocardial salvage and mortality in AMI
myocardial salvage (%)

Hours
Hours from chest pain onset Mortality
Mortality depending
depending on
on time
time elapsed
elapsed
to
to thrombolytic
thrombolytic treatment
treatment
 Thrombolytic treatment: indications
Class
Class II
STEMI
STEMI with
with ST
ST elevation
elevation >0.1
>0.1 mV
mV in
in at
at least
least 22 contiguous
contiguous leads
leads in
in the
the same
same
myocardial
myocardial territory
territory <
< 12h
12h form
form onset,
onset, age
age <
< 7575 yo
yo
LBBB
LBBB with
with recent
recent onset
onset and
and clinical
clinical signs
signs
suggesting
suggesting AMI
AMI
Class
Class IIa
IIa
STEMI
STEMI and
and age
age >
> 75
75 yo
yo
Clasa
Clasa IIb
IIb
STEMI
STEMI with
with late
late presentation
presentation 12-24h
12-24h from
from chest
chest pain
pain onset
onset
BP
BP >
> 180/110
180/110 mmHg
mmHg on
on admission
admission (risk
(risk for
for intra-cerebral
intra-cerebral hemorrhage)
hemorrhage)
Clasa
Clasa III
III
STEMI
STEMI >
> 24
24 hh form
form onset
onset
ST
ST depression
depression AMI
AMI (NSTEMI)
(NSTEMI)

AHA/ACC
AHA/ACC Guidelines
Guidelines for
for the
the management
management of
of patients
patients wit
wit AMI.
AMI. Circulation
Circulation 1999;
1999;
 Thrombolytic treatment: absolute
contraindications
1.
1. Ongoing
Ongoing hemorrhage
hemorrhage (physiologic
(physiologic 7.
7. Any
Any previous
previous hemorrhagic
hemorrhagic stroke
stroke
monthly
monthly periods
periods excepted)
excepted) 8.
8. BP
BP on
on admission
admission >
> 200/120mmHg
200/120mmHg
2.
2. Trauma,
Trauma, major
major surgery
surgery in
in previous
previous 14
14
9.
9. Proliferative
Proliferative retinopathy
retinopathy in
in DM
DM
days;
days; neuro-surgery
neuro-surgery or
or
10.
10. Any
Any hemorrhagic
hemorrhagic diathesis
diathesis
ophthalmologic
ophthalmologic surgery
surgery in
in last
last month
month
3. 11.
11. Liver
Liver cirrhosis
cirrhosis with
with hepatic
hepatic failure
failure
3. Prolonged
Prolonged CPR
CPR with
with costal
costal fractures
fractures
4.
4. Suspicion
Suspicion of
of MI
MI with
with acute
acute aortic
aortic 12.
12. Ongoing
Ongoing pregnancy
pregnancy
dissection
dissection 13.
13. Allergy
Allergy to
to SK
SK
5.
5. Active
Active peptic
peptic ulcer
ulcer with
with upper
upper GI
GI tract
tract 14.
14. Non-ST
Non-ST MI
MI or
or unstable
unstable angina
angina
bleeding
bleeding in
in the
the last
last 33 weeks
weeks
6.
6. Well
Well known
known neoplastic
neoplastic disease
disease
 Thrombolytic treatment: relative
contraindications
1.
1. Major
Major trauma or surgery older than 14 days
2.
2. History
History of ischemic stroke or TIA < 1 year
3.
3. History
History of severe hypertension
4.
4. Arterial
Arterial puncture
puncture in non-compressible
non-compressible sites
sites in
in the
the last
last 14
14 days
days
5.
5. heparin
heparin or
or oral
oral anticoagulant
anticoagulant treatment
treatment
6.
6. History
History of peptic ulcer
7.
7. Chronic
Chronic kidney
kidney disease
disease >
> stage
stage IV
IV
8.
8. Treatment
Treatment with
with SK
SK or
or similar
similar compounds
compounds in
in the
the previous
previous 12
12 months
months
9.
9. Age
Age >75
>75 yo
yo
Global mortality (cardiac, cerebral, other
vascular) at day 35 in ISIS-2 study
 Can we give thrombolysis to 100% of pts
with AMI ?

ST , ST : ST , Age Contraind.
early 15% late > 75 yo: lysis:
present: present: 10% 20%
35% 20%

GISSI.
GISSI. Lancet
Lancet 1986;I:397-401.
1986;I:397-401. ASSET.
ASSET. Lancet
Lancet 1988;2:525-30.
1988;2:525-30.
 Fibrinolytic medication used in STEMI
SK alteplase reteplase
DOSE 1,5 mil UI in 15 mg bolus, 50 mg 10 U bolus x 2 la
30-60 min IV in 1st h, 35 mg IV 30 min
in next 30
90 EFICACY of 50% 75% 75%
REPERFUSION
ACUTE 5-20% 10-20% 10-20%
REOCCLUSION
FIBRINOGEN LYSIS Yes (marked) No Yes (moderate)
ALERGIC REACTION Yes No No
HYPOTENSION 5% No No
TREATMENT RE- No (antibodies) Yes Yes
ADMINISTRATION
 Myocardial reperfusion syndrome
CLINICAL
CLINICAL signs
signs and
and symptoms:
symptoms:
1.
1. Sudden
Sudden decrease
decrease of
of chest
chest pain
pain
2.
2. Temporary
Temporary increase
increase of
of chest
chest pain
pain
3.
3. Bradycardia,
Bradycardia, hypotension
hypotension
4.
4. electro-mechanic
electro-mechanic dissociation
dissociation
ECG:
ECG:
1.
1. Temporary
Temporary increase
increase of
of ST
ST elevation
elevation followed
followed by
by rapid
rapid regression
regression more
more than
than
50%
50% of
of baseline
baseline
2.
2. Tachyarrhythmia:
Tachyarrhythmia: non-paroxysmal
non-paroxysmal VT,
VT, polymorphic
polymorphic VPBs,
VPBs, sustained
sustained VT
VT or
or
primary
primary VF
VF
3.
3. Brady-arrhythmia:
Brady-arrhythmia: sinus
sinus bradycardia,
bradycardia, AV
AV block-
block- different
different degrees
degrees
4.
4. Disappearance
Disappearance of
of ischemic
ischemic arrhythmias:
arrhythmias: paroxysmal
paroxysmal AFib,
AFib, AV
AV block
block
Serum
Serum markers:
markers: early peak
peak of
of troponin,
troponin, CK-MB,
CK-MB, CK
CK and
and Mb
Mb
 Electrocardiogram: relationship
relationship between
between ST
ST
segment
segment resolution
resolution and
and TIMI
TIMI flow
flow 90
90 min
min after
after SK
SK

s-ST>70% s-ST 30- 70% s-ST < 30%

TIMI
8% 24% 59%
0/1
TIMI 2 23% 27% 24%

TIMI 3 69% 49% 16%

Zeymer
Zeymer U
U et
et al.
al. Angiographic
Angiographic substudy
substudy of
of HIT
HIT 4.
4. EHJ
EHJ 2001;22:769-75.
2001;22:769-75.
 Importance of TIMI 3 flow for
post AMI mortality
100
100
TIMI
TIMI 33 flow
flow
survival
% survival

90
90
TIMI
TIMI 0,
0, 1,
1, 22 flow
flow
%

80
80
p
p == 0.0001
0.0001

00 100
100 200
200 300
300 400
400 500
500 600
600 700
700

Days
Days after
after AMI
AMI

Ross
Ross AA et
et al.
al. Circulation
Circulation 1998;97:1549.
1998;97:1549.
Complications of thrombolysis
HEMORRHAGIC COMPLICATIONS:
Vascular access sites
Gastro-intestinal
Cerebral: the
the most severe
severe
MALIGNANT REPERFUSION SDR:
Repetitive VF
electro-mechanic dissociation or asystole
Intra-myocardial hemorrhage
no-reflow
no-reflow phenomenon:
phenomenon: 1/3
1/3 of
of cases
cases
IMMUNOLOGIC COMPLICATIONS: anaphylactic reaction
(confounded with hypo-BP due to SK: serum bradykinin)
 Thrombolysis issues

TIMI 3 flow in maximum 50% (SK) - 80% (tPA) of pts

time lapse to obtaining TIMI 3 flow

Residual coronary stenosis

Low long term patency (early reocclusion)

Systemic contraindications
 Primary PCI issues
TIMI 3 flow in 85-95% of pts
Rapid reperfusion and TIMI 3 flow
No residual coronary stenosis
coronary patency (87% of arteries), early reocclusion
Can be performed in pts with contraindications for systemic
thrombolysis: > 90% of patients
NECESSARY CONDITIONS:
Door
Door to
to needle
needle <
< 30
30 min;
min; door
door to
to balloon
balloon <
< 60
60 min
min (90
(90 min)
min)
Trained
Trained team:
team: Interventional
Interventional Cardiologist
Cardiologist >
> 75
75 PCI
PCI // year;
year; center
center >
> 200
200
PCI
PCI // year,
year, >
> 30
30 primary
primary PCI
PCI // year
year
 First
primary PCI in AMI
Hartzler et al. PTCA with and without thrombolytic therapy for

treatment of acute myocardial infarction. Am Heart J

1983;106:965-73.
SK
SK and
and t-PA:
t-PA: approved
approved for
for clinical
clinical use
use in
in AMI
AMI in
in 1987
1987

The
The first
first coronary
coronary angioplasty
angioplasty in
in aa cathlab:
cathlab: Zurich,
Zurich, Sept
Sept 1977.
1977.
Gruentzig
Gruentzig ARAR et
et al.
al. Nonoperative dilation of coronary artery
stenosis:
stenosis: percutaneous
percutaneous transluminal
transluminal coronary
coronary angioplasty.
angioplasty. N Engl
Engl JJ
Med
Med 1979;301:618.
1979;301:618.
 Primary angioplasty in AMI: indications
Class I:
as
as an
an alternative
alternative to
to thrombolytic
thrombolytic treatment
treatment in
in pts
pts with
with STEMI
STEMI or
or new
new onset
onset LBBB
LBBB
who
who can
can be
be treated
treated with
with angioplasty
angioplasty on
on the
the infarct
infarct related
related artery
artery in
in <
< 12h
12h from
from
ischemic
ischemic symptoms
symptoms onset
onset or
or >
> 12h
12h with
with persistent
persistent ischemic
ischemic symptoms,
symptoms, ifif
performed
performed in
in due
due time
time by
by aa doctor
doctor trained
trained with
with this
this procedure
procedure supported
supported by
by aa
trained
trained medical
medical team
team in
in an
an adequately
adequately fitted
fitted cath-lab.
cath-lab. (LOE:
(LOE: A).
A).

in
in the
the first
first 36h
36h from
from STEMI
STEMI onset
onset in
in pts
pts with
with new
new Q
Q waves
waves or
or new
new LBBB
LBBB who
who
develop
develop cardiogenic
cardiogenic shock,
shock, have
have less
less than
than 75
75 yo
yo and
and revascularization
revascularization can
can be
be
performed
performed in
in less
less than
than 18h
18h from
from shock
shock onset
onset by
by aa doctor
doctor trained
trained with
with this
this
procedure
procedure supported
supported by
by aa trained
trained medical
medical team
team in
in an
an adequately
adequately fitted
fitted cath-lab.
cath-lab.
(LOE:
(LOE: A).
A).

ACC/AHA Guidelines for PCI. JACC 2001;37;2239.

Primary PCI in the 3rdrd
hour from chest pain
onset
 Relative indications for primary PCI

Class II indications:

As a reperfusion strategy in patients with

contraindications for thrombolytic therapy. (LOE: C).

ACC/AHA Guidelines for PCI. JACC 2001;37;2239.

Primary PCI in a patient
with pulmonary TB
and multiple caverns under
treatment:4thth h form onset
Primary PCI in a patient
with metallic aortic prosthesis
on oral anticoagulant
therapy: 5thth from onset
 Contraindications for primary PCI
Class III indications:
Angioplasty
Angioplasty in
in an
an artery
artery not
not responsible
responsible for
for infarction
infarction at
at the
the same
same time
time with
with
primary
primary PCI.
PCI. (LOE:
(LOE: C)
C)

In
In patients
patients with
with STEMI
STEMI who:
who:

Received
Received fibrinolysis
fibrinolysis in
in the
the first
first 12
12 hh from
from symptom
symptom onset
onset and
and have
have no
no
residual
residual ischemic
ischemic symptoms;
symptoms;

Have
Have an
an indication
indication for
for fibrinolysis
fibrinolysis and
and are
are treated
treated with
with angioplasty
angioplasty by
by aa non-
non-
experienced
experienced operator
operator (<
(< 75
75 PCI/year);
PCI/year);

More
More than
than 12h
12h from
from symptom
symptom onset
onset and
and have
have no
no proof
proof of
of ongoing
ongoing myocardial
myocardial
ischemia;
ischemia; (LOE:
(LOE: C)
C)

ACC/AHA Guidelines for PCI. JACC 2001;37;2239.

TIMI 3 flow after efficient thrombolysis,
severe residual stenosis of the mid LAD
PCI with direct stenting on mid LAD 10
days after thrombolysis
Primary PCI (n=3872) vs thrombolysis (n=3867)
- meta-analysis on 23 trials -
% pts
18 p<
p< 0.0001
0.0001
16
14
14 p=
p= 0.0002
0.0002
12 p<
p< 0.0001
0.0001 p=
p= 0.0004
0.0004
10 9
8 PTCA
8 7 7
liza
6

4 3
2
2 1
0
deces IM nonfatal AVC MACE

Keeley
Keeley EC,
EC, Boura
Boura JA,
JA, Grines CL. Lancet
Grines CL. Lancet 2003;
2003; 361:1320.
361:1320.
 No reflow phenomenon at reperfusion for AMI:
microcirculation impairment
1) Distal embolization

2) Endothelial injury:
leukocyte margination

3) Capillary thrombosis

4) Vasoconstriction
adrenergically
mediated

5) interstitial edema and

of distal endothelium;
microvascular
compression

Rezkalla
Rezkalla S,
S, Kloner
Kloner R.
R. Circulation
Circulation 2002;105:656-62.
2002;105:656-62.
TIMI score to predict 30-day mortality
in AMI
Long term mortality predictors after AMI
residual
residual systolic
systolic function
function post-MI
post-MI
the
the severity
severity of CAD
CAD
spontaneous
spontaneous ventricular arrhythmias
arrhythmias

Reduced
Reduced heart
heart rate variability
variability
Reduced
Reduced baroreceptor
baroreceptor sensitivity
sensitivity
Presence
Presence of
of late
late ventricular
ventricular potentials
potentials
Residual
Residual myocardial ischemia induced at exercise testing
testing
ST
ST segment
segment TT wave
wave variability
variability

Disputed
Disputed prognostic
prognostic usefulness:
silent
silent myocardial
myocardial ischemia
ischemia
QT
QT interval
interval dispersion
dispersion
 Long term treatment after MI
Aspirin
Aspirin 75-325 mg/day life long treatment with with no
no CI
CI
Beta
Beta blockers (beta1-selective):
(beta1-selective):
Metoprolol
Metoprolol 50-200
50-200 mg/day
mg/day
Atenolol
Atenolol 50-100 mg/day
Carvedilol
Carvedilol 6.25-50
6.25-50 mg/day
mg/day inin heart
heart failure
failure
ACEI:
ACEI:
Enalapril
Enalapril 10-40
10-40 mg/day
mg/day
Captopril
Captopril 50-150 mg/day
mg/day
Ramipril
Ramipril 5-10 mg/day
Trandolapril
Trandolapril 2-4 mg/day
Statins:
Statins: irrespective
irrespective of
of LDL;
LDL; LDL
LDL target
target << 100
100 mg/dl,
mg/dl, TC
TC < 200
200 mg/dl
mg/dl
Chronic
Chronic OAC:
OAC: severe HF, AFib,
AFib, cardio-embolism,
cardio-embolism, LV LV aneurysm
aneurysm
intraventricular
intraventricular thrombus
thrombus
Digitalis,
Digitalis, diuretics (including
(including spironolactone):
spironolactone): in in ischemic
ischemic HF
HF