This document discusses the emergency medical system network for managing ST-elevation myocardial infarction (STEMI). It outlines the importance of rapid diagnosis through early electrocardiograms and treatment through reperfusion therapies like primary percutaneous coronary intervention (PCI) or fibrinolysis. The target is first medical contact to reperfusion within 90 minutes for primary PCI or 30 minutes for fibrinolysis. It also discusses long-term secondary prevention therapies.

1. Emergency Medical System
Network for STEMI management
Dyah Siswanti
3rd PCU
August 24th 2013,Pekanbaru

2. CURRICULUM VITAE
Nama : dr. Dyah Siswanti Estiningsih, SpJP, FIHA
Tempat tanggal lahir : Yogyakarta, 5 Nopember 1964
Pendidikan : FK UKI lulus 1989
FK UI bagian kardiologi lulus 1999
Alamat : Jln. Diponegoro no. 22 Pekanbaru
• Rumah Sakit Tebet Jakarta 1989 - 1992
• Puskesmas Weluli, kab Belu, Nusa Tenggara Timur 1992 – 1995
• Kepala SMF Kardiologi dan Kedokteran Vaskuler RSUD Arifin Ahmad
Pekanbaru / FK Unri
• Direktur Medik dan Keperawatan di RSUD Arifin Ahmad Pekanbaru

3. Patofisiologi STEMI
Copyright ©2007 American College of Cardiology Foundation. Restrictions may apply.
Anderson, J. L. et al. J Am Coll Cardiol 2007;50:e1-e157

5. Chest painAdmission
Working
diagnosis
ECG
Bio-
chemistry
Risk
stratification
Treatment
Secondary
prevention
Suspicion of Acute Coronary
Syndrome
Persistent
ST-elevation
No Persistent
ST-elevation
Normal or
Undetermined
Troponin
(CKMB)
Troponin
ECG
Troponin
Twice negative
(+) High Risk (-) Low Risk Probably not ACS
Acute coronary syndromes : initial assessment
ESC ACS Guideline 2002

6. A 12-lead ECG must be obtained with
a target delay of ≤ 10 min.

7. ESC Guidelines for STEMI
• Management, including diagnosis and
treatment, starts at the point of first
medical contact.
• ECG monitoring must be initiated in all
patients with suspected STEMI.

9. • The pre-hospital management of STEMI
patients must be based on regional
networks designed to deliver reperfusion
therapy expeditiously and effectively, with
efforts made to make primary PCI
available to as many patients as possible.

10. Primary PCI-capable centres must
deliver 24/7 service, be able to start
primary PCI as soon as possible and
within 60 min from the initial call.

11. Target :
First medical contact to first ECG ≤10 min;
First medical contact to reperfusion therapy;
For fibrinolysis ≤30 min;
For primary PCI ≤90 min (≤60 min if the
patient presents within 120 minutes of symptom
onset or directly to a PCI-capable hospital).

12. • In all patients with symptoms of <12 hours
duration and persistent ST-segment elevation
or (presumed) new LBBB -- reperfusion
therapy
• Reperfusion therapy (preferably primary PCI) is
indicated if there is evidence of ongoing
ischaemia, even if symptoms may have started
>12 hours beforehand or if pain and ECG
changes have been stuttering.

14. REPERFUSION STRATEGY

15. Primary PCI
• Primary PCI is the recommended reperfusion
therapy over fibrinolysis if performed by an
experienced team within 120 minutes of FMC.
• Primary PCI is indicated for patients with
severe acute heart failure or cardiogenic shock,
unless the expected PCI related delay is
excessive and the patient presents early after
symptom onset.
• Stenting is recommended (over balloon
angioplasty alone) for primary PCI.

16. Routine PCI of a totally occluded artery >24
hours after symptom onset in stable patients
without signs of ischaemia (regardless of
whether fibrinolysis was given or not) is not
recommended.
If the patient has no contraindications to
prolonged DAPT and is likely to be compliant,
DES should be preferred over BMS.

17. • Dual antiplatelet therapy with aspirin
and an ADP-receptor blocker is
recommended with
Prasugrel in clopidogrel-naive
patients, if no history of prior
stroke/TIA and age <75
Ticagrelor
or Clopidogrel, if prasugrel or
ticagrelor are not available or
contraindicated

18. An injectable anticoagulant must be used
Bivalirudin is preferred over heparin and a
GPIIb/IIIa blocker
Enoxaparin may be preferred over
unfractionated heparin
Unfractionated heparin must be used in
patients not receiving either bivalirudin
or enoxaparin

19. Fibrinolytic therapy
• Fibrinolytic therapy is recommended within 12
hours of symptom onset in patients without
contraindications if primary PCI cannot be
performed by an experienced team within 120
min of first medical contact.
• In patients presenting early (<2 hours after
symptom onset) with a large infarct and low
bleeding risk, fibrinolysis should be considered if
time from first medical contact to balloon
inflation is >90 min.

20. • If possible, fibrinolysis should start in the pre-
hospital setting.
A fibrin-specific agent (tenecteplase, alteplase,
reteplase) is recommended (over non-fibrin
specific agents).
• Oral or i.v. aspirin must be administered.
Clopidogrel is indicated in addition to aspirin.

22. Brief Review of Thrombolytic Trials
GISSI-1: Streptokinase 18% reduction in mortality at 21 d
GUSTO-1: tPA. 15% reduction in 30-day mortality compared
to Streptokinase
GUSTO-3: Reteplase had no benefit over tPA but is easier to
use (double bolus)
ASSENT: TNKase is similar to tPA but with less non-cerebral
bleeding and better mortality with symptoms>4 hrs: Single
bolus, fibrin selective, resistance to PAI-1
*Overall risk of ICH is 0.7%; Strokes occurred in 1.4%

23. Contraindications and Cautions
for Fibrinolysis in STEMI
Absolute
Contraindications
• Any prior intracranial hemorrhage
• Known structural cerebral vascular lesion (e.g.,
arteriovenous malformation)
• Known malignant intracranial neoplasm (primary
or metastatic)
• Ischemic stroke within 3 months EXCEPT acute
ischemic stroke within 3 hours
NOTE: Age restriction for fibrinolysis has been removed
compared with prior guidelines.

24. Contraindications and Cautions
for Fibrinolysis in STEMI
Absolute
Contraindications
• Suspected aortic dissection
• Active bleeding or bleeding diathesis
(excluding menses)
• Significant closed-head or facial trauma within
3 months

25. Contraindications and Cautions
for Fibrinolysis in STEMI
• History of chronic, severe, poorly controlled
hypertension
• Severe uncontrolled hypertension on
presentation (SBP > 180 mm Hg or DBP > 110
mm Hg)
• History of prior ischemic stroke greater than 3
months, dementia, or known intracranial
pathology not covered in contraindications
• Traumatic or prolonged (> 10 minutes) CPR or
major surgery (< 3 weeks)
Relative
Contraindications

26. Contraindications and Cautions
for Fibrinolysis in STEMI
Relative
Contraindications
• Recent (< 2 to 4 weeks) internal bleeding
• Noncompressible vascular punctures
• For streptokinase/anistreplase: prior exposure (>
5 days ago) or prior allergic reaction to these
agents
• Pregnancy
• Active peptic ulcer
• Current use of anticoagulants: the higher the INR,
the higher the risk of bleeding

27. • Anticoagulation is recommended in STEMI patients
treated with lytics until revascularization
(if performed) or for the duration of hospital stay up to 8
days. The anticoagulant can be:
 Enoxaparin i.v followed by s.c. (preferred over
unfractionated heparin),
 Unfractionated heparin given as a weight adjusted IV
bolus and infusion,
 In patients treated with streptokinase, Fondaparinux
i.v. bolus followed by s.c. dose 24 hours later.
• Transfer to a PCI-capable centre following fibrinolysis is
indicated in all patients after fibrinolysis.

28. • Rescue PCI is indicated immediately when
fibrinolysis has failed (<50% ST-segment resolution
at 60 min).
• Emergency PCI is indicated in the case of
recurrent ischaemia or evidence of re-occlusion
after initial successful fibrinolysis.
• Emergency angiography with a view to
revascularization is indicated in heart failure/shock
patients after initial fibrinolysis.

29. Logistics
• All hospitals participating in the care of STEMI
patients should have a coronary care unit
equipped to provide all aspects of care, including
treatment of ischaemia, severe heart failure,
arrhythmias and common comorbidities.
• Patients undergoing uncomplicated successful
reperfusion therapy should be kept in the
coronary care unit for a minimum of 24 hours,
after which they may be moved to a step-down
monitored bed for another 24–48 hours.

30. Risk assessment and imaging
• In the acute phase, when diagnosis is uncertain,
emergency echocardiography may be useful.
However, if inconclusive or unavailable and persistent
doubt, emergency angiography should be considered.
• After the acute phase, all patients should have an
echocardiography for assessment of infarct
size and resting LV function, If echocardiography is not
feasible, MRI may be used as an alternative.
• For patients with multivessel disease, or in whom
revascularization of other vessels is considered,
stress testing or imaging for ischaemia and viability is
indicated.

31. Long term therapies
• Risk factor control, particularly smoking, must be
stringent.
• Antiplatelet therapy is indicated indefinitely.
• Dual antiplatelet therapy is indicated up to 12
months.
• Oral treatment with beta-blockers is indicated in
patients with heart failure or left ventricular
dysfunction.

32. A fasting lipid profile must be obtained in all
patients.
• A high-dose statin should be initiated or
continued early after admission in all patients
without contraindication or history of intolerance.
• ACE inhibitors are indicated in patients with
heart failure, LV systolic dysfunction diabetes or
an anterior infarct.
• An ARB is an alternative to ACE inhibitors.
• Aldosterone antagonists are indicated if EF
≤40% or heart failure or diabetes, provided there
is no renal failure or hyperkalaemia.

33. Emergency Medical System
Network
Diagnosis :as soon and as accurate as
possible
Management : prehospital
setting,ambulatory,hospital non
PCI,hospital PCI

34. Emergency medical system
network for STEMI
Community in populationCommunity in population
primary care physician
2º
3º
4º

35. Emergency medical system
network for STEMI

36. Thank youThank youThank youThank you