Coronary Reperfusion STEMI Management of late presentation STEMI,Xử trí NMCT cấp đến muộn

Coronary Reperfusion STEMI Management of late presentation STEMI DR ZUBIN IBRAHIM Cardiology Unit UITM Medical Faculty MALAYSIA... DEFINITION: Late presentation or... Why do these p

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

• Reperfusion injury

• Complications – shock, bleeding

DEFINITION: Late presentation or

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

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%

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

Why is PCI in ‘latecomers’ different?

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

• Inferior STEMI

• Complete AV block

• Previous admission for unstable angina

• Shock- IV fluids and single ionotropic support

• Slow-flow post stent deployment/post dilatation with NC balloon

• Catheter thrombus

• Operator (co-operator) must focus on everything else

Case 3

Aspirated thrombus ++ and POBA

After thrombus aspiration

1st Angiojet Run with 5Fr catheter

Final result, after 4 Angiojet runs

Next Day

Post PCI 3.5-4.5x17mm (self-expanding coronary

stent)