DR ZUBIN IBRAHIM Cardiology Unit UITM Medical Faculty MALAYSIA - - PowerPoint PPT Presentation

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DR ZUBIN IBRAHIM Cardiology Unit UITM Medical Faculty MALAYSIA - - PowerPoint PPT Presentation

Mar 03, 2024 132 likes •556 views

Coronary Reperfusion STEMI Management of late presentation STEMI DR ZUBIN IBRAHIM Cardiology Unit UITM Medical Faculty MALAYSIA The debate is still on! Definition Guidelines -? Randomised trials/Meta analysis Open artery theory

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Coronary Reperfusion STEMI Management of late presentation STEMI

DR ZUBIN IBRAHIM Cardiology Unit UITM Medical Faculty MALAYSIA

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The debate is still on!

  • Definition
  • Guidelines -?
  • Randomised trials/Meta analysis
  • Open artery theory
  • Reperfusion injury
  • Complications – shock, bleeding
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DEFINITION: Late presentation or “Late comers”

  • The current reperfusion paradigm in STEMI  reperfusion

attempted within 12 hours

  • Late presentation – 12 hours after symptom onset
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Why do these patients present late?

– Unaware/in denial/awareness/education – Atypical/no chest pain – Stuttering chest pain (UA to NSTEMI to STEMI) – Heart failure/ syncope/ Lethargy (Elderly) – refusal to seek medical attention/alternative medicine – Geography/socioeconomic status – Wrong diagnosis – Atypical presentation (pregnancy: coronary dissection) – Non-PCI hospital

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Our patient

48 diabetic male, smoker, fisherman ‘Stuttering’ chest pain for > 16 hours ECG inferior leads- STEMI Complete AV block LV failure + shock (Killip IV) In the Emergency Department- Still has chest pain, ECG ST’s are still raised, echocardiogram LVEF 40%

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Indications for PCI of an Infarct Artery in Patients Who Were Managed With Fibrinolytic Therapy or Who Did Not Receive Reperfusion Therapy

*Although individual circumstances will vary, clinical stability is defined by the absence of low output, hypotension, persistent tachycardia, apparent shock, high-grade ventricular or symptomatic supraventricular tachyarrhythmias, and spontaneous recurrent ischemia.

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Why is PCI in ‘latecomers’ different?

  • Thrombus
  • Microvascular injury (reperfusion injury)
  • Slow flow-no-reflow
  • Arrhythmia
  • Shock-LV dysfunction**
  • Elderly/Multiple co-morbidities**
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Thrombus

  • direct stenting
  • deferred stenting (after TIMI III)
  • thrombus aspiration in selected patients?
  • anticoagulation
  • anti platelets (?Ticagrelor)
  • catheters (7Fr for all?)
  • GP IIIbIIa inhibitors in selected patients
  • temporary pacing in RCA’s
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Slow-flow/no-reflow

  • related to thrombus/microemboli
  • previous slide
  • intracoronary Adenosine/Verapamil/nitroprusside
  • avoidance, treatment of shock (vicious cycle)
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  • Inferior STEMI
  • Complete AV block
  • Previous admission for unstable angina
  • Shock- IV fluids and single ionotropic support
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  • Slow-flow post stent deployment/post

dilatation with NC balloon

  • Catheter thrombus
  • Operator (co-operator) must focus on

everything else

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Patient 2

  • 54, male- Inferior STEMI (presented 10 hours

after initial symptoms)

  • DM/HT/hyperlipidemia
  • previous admissions- ACS + LVFailure- medical

therapy only

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Case 3

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Aspirated thrombus ++ and POBA

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After thrombus aspiration

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1st Angiojet Run with 5Fr catheter

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Final result, after 4 Angiojet runs

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Next Day

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Post PCI 3.5-4.5x17mm (self-expanding coronary stent)

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summary

  • recognise difficulties, potential complications
  • multidisciplinary approach
  • some evidence to guide us—> no clear

answers

  • multiple tools/equipment may be used
  • thrombosis,no-reflow, shock
  • defer invasive therapy in selected patients