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Introduction

A cute Coronary Syndromes comprise a spectrum of increasingly severe ischemic conditions,
including unstable angina, non ST-elevation myocardial infarction (NSTEMI)and ST-elevation myocardial infarction (STEMI).
In the Gulf, STEMI represents 49% of Acute Coronary Syndromes. The majority of patients are males (85%), who on average are younger than females (58 years vs 62 years). According to the current practice, 75% of the patients receive thrombolytic therapy, while primary PTCA is performed in 5% of patients only. 54% of these patients are diabetics; 38% are hypertensives; 25% are smokers and 30% have hyperlipidemia.
Over the past few years, considerable improvement has occurred in the care for patients with STEMI. Newer and more sensitive and specific biochemical markers for the diagnosis of AMI were introduced which promoted the American College of Cardiology, American Heart Association and the European Society of Cardiology to redefine MI in 2002. Furthermore, newer therapeutic modalities including newer fibrinolytic, antithrombic and antiplatetelet agents were introduced. The Gulf Heart Association has recently published guidelines for the management of patients with acute coronary syndrome without STEMI elevation; Here in the GHA working group for the study of STEMI publishes guidelines for the management of STEMI adopted from the recently updated ACC/AHA guidelines, modified on the basis of more recent data and tailored to the need of our patients.
These guidelines refer to the management of patients with STEMI. The guidelines should be used as “Guidelines”, which will apply to the majority of cases.
However it should be appreciated, that specific findings in individual patients may and should result in deviation from the proposed strategy. for every patient, the physician should make an individual decision taking into account the patient’s history, presentation, findings during observation or investigation in hospital, and the available treatment facilities.

Fig 1: Myocardial Infarction

Initial Recognition and Management in the Emergency Department

Emergency Department Algorithm/For Patients With ACS/For Patients With Symptoms and Signs of STEMI

Brief Physical Examination in Emergency Department

1. Airway, Breathing, Circulation (ABC)
2. Vital signs, general observation
3. Presence or absence of jugular venous distension
4. Pulmonary auscultation for rales
5. Cardiac auscultation for murmurs and gallops
6. Presence or absence of stroke
7. Presence or absence of pulses
8. Presence or absence of systemic hypoperfusion (cool, clammy, pale, ashen)

Differential Diagnosis of STEMI

STEMI = ST-elevation myocardial infraction; LV = left venticular

Assessment of Reperfusion Options for Patients With STEMI

Step 1: Assess Time and Risk

Time since onset of symptoms
Risk of STEMI
Risk of fibrinolysis
Time required for transport to a skilled PCI laboratory

Step 2: Determine Whether Fibrinolysis or an Invasive Strategy Is Preferred

If presentation is less than 3 hours and there is no delay to an invasive strategy, there is no preference for either strategy

Fibrinolysis is generally preferred if: An invasive strategy is generally preferred if:
Early Presentation (less than or equal to 3 hours from symptom onset) and delay to invasive strategy	Skilled PCI laboratory †‡ available with surgical backup · Medical contact-to-balloon or door-to-balloon is less than 90 minutes
Invasive strategy is not an option · Catheterization laboratory occupied/not available · Vascular access difficulties · Lack of access to a skilled PCI laboratory†‡	High risk from STEMI · Cardiogenic shock · Killip class is greater than or equal to 3
Delay to invasive strategy ·Prolonged transport ·Medical contact-to-balloon or door-to-balloon time is more than 90 minutes	Contradictions to fibrinolysis, including increased risk of bleeding an intracranial hemorrhage Late Presentation The symptom onset was more than 3 hours ago

STEMI = ST-elevation Myocardial Infarction; PCI = Percutanious Coronary Intervention

      Contraindications and Cautions for Fibrinolysis in STEMI*

                       Absolute Contraindication

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
Suspected aortic dissection
Active bleeding or bleeding diathesis (excluding menses)
Significant closed-head or facial trauma within 3 months

                      Relative Contraindications

History of chronic, severe, poorly controlled hypertension
Severe uncontrolled hypertension on presentation (SBP greater than 180mm Hg or DBP greater than 110 mm Hg)†
History of prior ischemic stroke greater than 3 months, demetia, or known Intracranial pathology not covered in contraindications
Traumatic or prolonged (greater than 10 minutes) CPR or major surgery (within less than 3 weeks)
Recent (within 2-4 weeks) internal bleeding
Non-compressible vascular punctures
For streptokinase/anistreplase: prior exposure (more than 5 days ago) or prior allergic reactions to these agents
     Pregnancy
     Active peptic ulcer
     Current use of anticoagulants: the higher the INR, the higher the risk of bleeding

STEMI = ST-elevation Myocardial Infarction; SBP = Systolic Blood Pressure; DBP = Diastolic Blood Pressure;
INR = International Normalized Ratio
* Viewed as advisory for clinical decision making and may not be all-inclusive or definitive
† Could be an absolute contradiction in low-risk patients with STEMI

Pharmacological Support During Primary PCI

Unfractionated Heparin No GP IIb/IIIa Inhibitor GP IIb/IIIa Inhibitor Used

Bollus:                                                                     70-100 U/kg                                       50-70 U/kg
Targets ACT                                                           HemoTec:250-300s                         With either device:200
                                                                                  Hemochron:300-350s

Thienopyridine

Administer loading dose of 300 mg - 600 mg (if not already given)
Clopidogrel

Maintenance dose: 75 mg orally per day

Duration:
                                                                                 i) Bare metal stent-1 month minimum
                                                                                ii) Drug-eluting stent-minimum of 3 months after sirolimus and
                                                                                    6 months after paclitaxel
                                                                                    Continue for 12 months after stent implantation (both types of
                                                                                    stents) in patients who are not at risk of bleeding.
GP IIB/IIIa Inhibitors

It is reasonable to start abciximab as early as possible before
                                                                               primary PCI (with or without stenting). The recommended dosage
                                                                               of abciximab in adults is a 0.25 mg/kg intravenous bolus
                                                                               administered 10 to 60 minutes before the start of PCI,followed by a
                                                                               continuous intravenous infusion of 0.125 mcg/kg/min (to a
                                                                              maximum of 10 mcg/min) for 12 to 18 hours.

Treatment with tirofiban (bolus dose of 10 mcg per kilogram of
                                                                               body weight, followed by an infusion of 0.15 mcg/kg/min for 18 to
                                                                                24 hours) or eptifibatide (for patients with serum creatinine less
                                                                                than 2.0 mg/dL,* an intravenous bolus of 180 mcg/kg
                                                                                administered immediately before the initiation of PCI followed by a
                                                                                continuous infusion of 2.0 mcg/kg/min and a second 180 mcg/kg
                                                                                bolus 10 minutes after the first bolus. Infusion should be
                                                                                continued 18 to 24 hours.

For patients with a serum creatinine greater than 2.0 mg/dL,an
                                                                               intravenous bolus of 180 mcg/kg administered immediately before
                                                                               initiation of the procedure,immediately followed by a continuous
                                                                               infusion of 1.0 mcg/kg/minand a second 180 mcg/kg bolus
                                                                               adminis-tered 10 minutes after the first.

GP = glycoprotein; ACT = activated clotting time; U = units; s = seconds.

Laboratory Evaluations for Management of STEMI

Serum biomarkers for cardiac damage

(do not wait for results before implementing reperfusion strategy)

Complete blood count with platelet count
INR (international normalized ratio)
Activated partial thromboplastin time
Electrolytes and magnesium
BUN (blood urea nitrogen)
Creatinine
Glucose
Serum lipids

Biochemical Markers

Acute CCU Management

Sample Admitting Orders for Patients With STEMI
1. IV:NS on D5W to keep vein open. Start a second IV if IV medication is being given. This may be a saline lock.
2. Vital signs: Every 1.5 hours until stable, then every 4 hours and as needed. Notify physician if HR is less than 60 bpm or greater than 100 bpm, BP is less than 100 mm Hg systolic or greater than 150 mm Hg diastolic, respiratory rate is less than 8 or greater than 22 bpm.
3. Monitor: Continuous ECG monitoring for arrhythmia and ST-segment deviation.
4. Diet: NPO except for sips of water until stable. Then start diet with 2 g of sodium per day, low saturated fat (less than 7% of total calories/day), low cholesterol (less than 200 mg/day), such as Total Lifestyle Change (TLC) diet.
5. Activity: Bedside commode and light activity when stable.
6. Oxygen: Continuous oximetry monitoring. Nasal cannula at 2 L/min when stable for 6 hours, reassess for oxygen need (i.e., O2saturation less than 90%), and consider discontinuing oxygen.
7. Medications:
a. Nitroglycerin
1. Use sublingual NTG 0.4 mg every 5 minutes as needed for chest pain or discomfort.
2. Intravenous NTG for CHF, hypertension, or persistent ischemia that responds to nitrate therapy.
b. Aspirin
1. If aspirin not given in the ED, give chewable non-enteric-coated aspirin† 150 mg to 300mg
2. If aspirin has been given, start daily maintenance of 75 to 150 mg. May use enteric-coated aspirin for gastro-intestinal protection.
c. Clopidgrel
Maintain Clopidgrel 75 mg daily (For patients with PCI: Refer to PCI section)
d. Oral Beta-Blocker
1. If not given in the ED, assess for contraindications, i.e., bradycardia and hypotension. Continue daily assessment to ascertain eligibility for beta-blocker.
2. If given in the ED, continue daily dose and optimize as dictated by HR and BP.
e. ACE Inhibitor
Consider oral ACE inhibitor for all patients specially those with anterior infarction, pulmonary congestion, or LVEF less than 40% if the following are absent: hypotension (SBP less than 100 mm Hg or less than 30 mm Hg below baseline) or known contraindications to this class of medications.
f. Angiotensin Receptor Blocker
Start ARB orally in patients who are intolerant of ACE inhibitors and who have either clinical or radiological signs of heart failure or LVEF less than 0.40.
g. Pain Medications
IV morphine sulfate 2 to 4 mg with increments of 2 to 8 mg IV at 5-to 15-minute intervals as needed to control pain.
h. Anxiolytics (based on a nursing assessment)
i. Daily Stool Softener

Appendix

STEMI = ST-elevation myocardial infarction; IV = intravenous; NS = normal saline; D5W = 5% dextrose in water; HR = heart rate; BP = blood pressure; NPO = nothing by mouth; NTG = nitroglycerin; CHF = congestive heart failure; ED = emergency department; ACE = angiotensin converting enzyme; LVEF = left ventricular ejection fraction; SBP = systolic blood pressure; ARB = angiotensin receptor blocker; CBC = complete blood count; INR = internationalnormalized ratio; aPTT = activated partial thromboplastin time; BUN = blood urea nitrogen.

Emergency Management of Complicated STEMI: