STEMI management

Question 1

flow chart of STEMI management

Answer 1

1. 12 lead ECG
2. O2 2-4L aim for SpO2 94-98%
3. IV access
   (Bloods for FBC, U+E, glucose, lipids)
4. Brief assessment (Hx of CVD and risk factors, Thrombolysis CIs, CV exam)
5. Antiplatelet (Aspirin 300mg PO (then 75mg/d) + Clopidogrel 300mg PO (then 75mg/d)
6. Analgesia (Morphine 5-10mg IV + Metoclopramide 10mg IV)
7. Anti-ischaemia (GTN 2 puffs or 1 tablet SL
   + β-B atenolol 5mg IV (CI: asthma, LVF)
8. LMWH: e.g. enoxaparin IV then SC
9. Admit to CCU for monitoring (Arrhythmias + Continue meds except Calcium Channel Blockers)
10. Primary PCI or thrombolysis

Question 2

features of PCI

Answer 2

1. Rx of choice if <12h
2. Angioplasty and stenting
3. • Glycoprotein IIb/IIIa antagonist (tirofiban) if high risk
     - Delayed PCI, DM, complex procedure

Question 3

complications of PCI

Answer 3

• Bleeding
• Emboli
• Arrhythmia

Question 4

ECG criteria for thrombolyis

Answer 4

• ST elevation > 1mm in 2+ limbs or > 2mm in 2+ chest leads.
• New LBBB
• Posterior: Deep ST “depression” and tall “R” waves in V1-V3

Question 5

acronym for contraindications of thrombolysis

Answer 5

AGAINST

• Aortic dissection
• GI bleeding
• Allergic reaction previously
• Iatrogenic: recent surgery
• Neuro: cerebral neoplasm or CVA Hx
• Severe HTN (200/120)
• Trauma, inc. CPR
• • contraindicated if beyond 24hrs from pain onset

Question 6

agents used in thrombolysis

Answer 6

1st: streptokinase, alteplase (rt-PA), tenecteplase

Question 7

complications of thrombolysis

Answer 7

• Bleeding
• Stroke
• Arrhythmia
• Allergic reaction

Question 8

what should patients not receiving any form of reperfusion therapy be given?

Answer 8

fondaparinux

Question 9

continuing therapy following STEMI

Answer 9

(address risk factors)

• ACEi: start w/i 24hrs of MI (e.g. lisinopril 2.5mg)
• β-blocker: e.g. bisoprolol 10mg OD (or, CCB)
• Cardiac rehabilitation (group exercise and info) / Heart Manual
• DVT prophylaxis until fully mobile (Continue for 3mo if large anterior MI)
• Statin: regardless of basal lipids (e.g. atorvastatin 80mg)
• Continue clopidogrel for 1mo following STEMI
• Continue aspirin indefinitely.

Question 10

advice following STEMI

Answer 10

• Stop smoking
• Diet: oily fish, fruit, veg, ↓ sat fats
• Exercise: 30min OD
• Work: return in 2mo
• Sex: avoid for 1mo
• Driving :avoid for 1mo