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Treatment & Guidelines

Aims

  • Prevent death
  • Minimise patient's discomfort and distress
  • Limit the extent of myocardial damage

Strategy

Re-establish myocardial reperfusion before irreversible damage occurs:

REMEMBER: TIME IS MUSCLE

ESC STEMI guidelines 2017: reperfusion strategies

ESC STEMI reperfusion treatment guidelines 2012: Time FMC to first balloon inflation must be shorter than 90 min after onset of symptoms. If PCI is not possible <2 h of FMC, fibrinolytic therapy should be initiated immediately.

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Aims

Early reperfusion has many advantages such as preventing death, limiting the extent of myocardial damage as well as reducing a patient’s distress and discomfort1

Strategy

Re-establishing myocardial reperfusion before irreversible damage occurs is crucial. This can be done:2

  • Mechanically (PPCI, primary percutaneous coronary intervention)
  • Pharmacologically (induction of thrombolysis by thrombolytic agent)
  • Pharmaco-invasive means (combination of pharmacological and mechanical intervention)

AMI, acute myocardial infarction

Influence of time-to-treatment on odds ratio (or) of mortality

Influence of time-to-treatment on odds ratio (or) of mortality

 

Time delay elements in thrombolysis

Time delay elements in thrombolysis

There are several factors that can help improving the time to treatment of acute myocardial infarction (AMI) patients. Public education and raising awareness can lead to reducing symptom-onset to call times. Medical professionals also play a key role in reducing the first medical contact (FMC)-to-treatment times.

STEMI networks

STEMI networks foster strong communication among medical professionals involved in the treatment of acute myocardial infarction. They also facilitate pre-hospital diagnosis and thrombolysis or referral to a PCI-capable facility within guideline-specific timeframes.

Reperfusion treatments

Time is critical for STEMI management. Organised STEMI networks can be an invaluable asset in enabling STEMI patients. Various reperfusion treatments possible are:

Mechanical reperfusion
Pharmacological reperfusion
Pharmaco-invasive therapy

Primary percutaneous
coronary intervention (PPCI)

Pre-hospital / in-hospital thrombolysis (PHT / IHT)

Thrombolysis followed by early angiography and mechanical intervention if indicated

 

Percutaneous coronary intervention (PCI) & primary PCI (PPCI)

  • PPCI is the gold standard in STEMI care if performed within 120 min of FMC2,3
  • Timely PPCI is difficult to achieve in many regions, when patients do not present directly to a PCI-capable facility via EMS or arrival at a facility is delayed2,3
  • PCI involves re-vascularisation of the blocked coronary artery by mechanical means
  • Using the femoral or radial artery as an access point, a catheter with a balloon (and often a stent) is passed through the occlusion4
  • The balloon is then inflated to open the vessel, and the stent is put in place to maintain the re-vascularisation4

EMS, emergency medical services

FMC, first medical contact

PPCI, primary percutaneous coronary intervention

Stent in coronary artery

Stent in coronary artery
Robert Welsh

For more information on tailoring STEMI treatment to achieve optimal efficacy with minimal risk, see our virtual symposium video by Robert Welsh

References: 

  1. Steg PG, et al. Task Force on the management of ST-segment elevation acute myocardial infarction of the European Society of Cardiology (ESC). ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J 2012;33:2569-2619.

  2. Choi SW et al. Effect of emergency medica service use and inter-hospital transfer on time to percutaneous coronary intervention in patients with ST elevation myocardial infarction: A multicenter observational study. Prehosp Emerg Care 2016;20:66-75.

  3. Sinnaeve  PR & Van de Werf. Transporting STEMI patients for primary PCI: a long and winding road paved with good intentions? Eur Heart J 2016;37:1041-1043.

  4. Keeley EC & Hillis LD. Primary PCI for myocardial infarction with ST-segment elevation. N Engl J Med 2007;356:47-54.