ST elevation myocardial infarction reperfusion therapy
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| Myocardial infarction Classification and external resources | |
 | |
|---|---|
| Diagram of a myocardial infarction (2) of the tip of the anterior wall of the heart (an apical infarct) after occlusion (1) of a branch of the left coronary artery (LCA, right coronary artery = RCA). | |
| ICD-10 | I21.-I22. |
| ICD-9 | 410 |
| DiseasesDB | 8664 |
| MedlinePlus | 000195 |
| eMedicine | med/1567 emerg/327 ped/2520 |
| Cardiology Network |
 Discuss ST elevation myocardial infarction reperfusion therapy further in the WikiDoc Cardiology Network |
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Reperfusion
Regardless of the mode of reperfusion, the overarching concept is to minimize total ischemic time, which is defined as the time from onset of symptoms of STEMI to initiation of reperfusion therapy.
It is increasingly clear that 2 types of hospital systems provide reperfusion therapy:
- Hospitals with percutaneous coronary intervention (PCI) capability
- Hospitals without PCI capability.
When PCI capability is available, the best outcomes are achieved by offering this strategy 24 hours per day, 7 days per week.[1]
The concept of reperfusion has become so central to the modern treatment of acute myocardial infarction, that we are said to be in the reperfusion era.[1][1] Patients who present with suspected acute myocardial infarction and ST segment elevation (STEMI) or new bundle branch block on the 12 lead ECG are presumed to have an occlusive thrombosis in an epicardial coronary artery. They are therefore candidates for immediate reperfusion, either with thrombolytic therapy, percutaneous coronary intervention (PCI) or when these therapies are unsuccessful, bypass surgery.
Individuals without ST segment elevation are presumed to be experiencing either unstable angina (UA) or non-ST segment elevation myocardial infarction (NSTEMI). They receive many of the same initial therapies and are often stabilized with antiplatelet drugs and anticoagulated. If their condition remains (hemodynamically) stable, they can be offered either late coronary angiography with subsequent restoration of blood flow (revascularization), or non-invasive stress testing to determine if there is significant ischemia that would benefit from revascularization. If hemodynamic instability develops in individuals with NSTEMIs, they may undergo urgent coronary angiography and subsequent revascularization. The use of thrombolytic agents is contraindicated in this patient subset, however.[1] [1] [1] [1] [1] [1] [1] [1] [1]
The basis for this distinction in treatment regimens is that ST segment elevations on an ECG are typically due to complete occlusion of a coronary artery. On the other hand, in NSTEMIs there is typically a sudden narrowing of a coronary artery with preserved (but diminished) flow to the distal myocardium. Anticoagulation and antiplatelet agents are given to prevent the narrowed artery from occluding.
At least 10% of patients with STEMI don't develop myocardial necrosis (as evidenced by a rise in cardiac markers) and subsequent q waves on EKG after reperfusion therapy. Such a successful restoration of flow to the infarct-related artery during an acute myocardial infarction is known as "aborting" the myocardial infarction. If treated within the hour, about 25% of STEMIs can be aborted.[1]
The emphasis on primary PCI should not obscure the importance of fibrinolytic therapy. Many hospital systems in North America do not have the capability of meeting the time goal for primary PCI. Therefore, because of the critical importance of time to treatment from onset of symptoms of STEMI in reducing morbidity and mortality, fibrinolytic therapy is preferred. In these settings, transfer protocols need to be in place for arranging rescue PCI when clinically indicated.[1] [1] [1]
For fibrinolytic therapy, the system goal is to deliver the drug within 30 minutes of the time that the patient presents to the hospital. The focus for primary PCI is from first medical contact because in regionalization strategies, extra time may be taken to transport patients to a center that performs the procedure. Consequently, it is important to consider the time from first medical contact.
Clinical Trial Data
Side Effects
Guidelines (DO NOT EDIT)
Class I
1. All STEMI patients should undergo rapid evaluation for reperfusion therapy and have a reperfusion strategy implemented promptly after contact with the medical system. (Level of Evidence: A)[1]
Available Resources
Guidelines (DO NOT EDIT)
Class I
1. STEMI patients presenting to a facility without the capability for expert, prompt intervention with primary PCI within 90 minutes of first medical contact should undergo fibrinolysis unless contraindicated. (Level of Evidence: A)[1]
References
Acknowledgement and Attribution Regarding Sources of Content
Some of the initial content on this page may be incorporated in part from copyleft sources in the public domain including wikis such as Wikipedia and AskDrWiki. Drug information for patients came from the The National Library of Medicine. Infectious disease information may have come from the Centers for Disease Control (CDC). Differential Diagnoses are drawn from clinicians as well as an amalgamation of 3 sources: 1.The Disease Database; 2. Kahan, Scott, Smith, Ellen G. In A Page: Signs and Symptoms. Malden, Massachusetts: Blackwell Publishing, 2004:3; 3. Sailer, Christian, Wasner, Susanne. Differential Diagnosis Pocket. Hermosa Beach, CA: Borm Bruckmeir Publishing LLC, 2002:7 .
