STEMI – ST Elevation Myocardial Infarction · In STEMI, thrombolysis is indicated if first medical contact to primary PCI time is judged to be > 2 hrs Transfer to PCI capable hospital,

9/21/2017

1

STEMI – ST Elevation Myocardial InfarctionBreakout Session One

Moderators: Quinn Capers IV, MD and Scott M. Lilly, MD, PhD

Cases Presented by: Umair S. Ahmad, MD

9/21/2017

2

3

Outline

1. Multivessel Revascularization2. Radial Artery Access for STEMI with shock3. STEMI Nightmares

Case 1 Patient Demographics

38 y/o Male

4

Past Medical History

None

Risk Factors

None Clinical presentation

Presented to ED with continued anterior chest pain after playing volleyball radiating to LUE

9/21/2017

3

EKG

5

Right Coronary Artery with collaterals to left

6

9/21/2017

4

Occluded Mid LAD

7

Angioplasty to Mid LAD

8

9/21/2017

5

Post PCTA angiogram

9

Post PCTA caudal projection

10

9/21/2017

6

Post DES placement angiogram

11

DES of distal Left Circumflex

12

9/21/2017

7

Final Angiogram

13

Discussion

14

9/21/2017

8

Case 2 Patient Demographics

44 y/o F

15

Past Medical History

Nephrolithiasis

Risk Factors

Early onset family hx of MI

Father (33) , Brother (27)

30 pack year smoking

Clinical presentation

Severe chest pressure radiating to LUE associated with diaphoresis

EKG on presentation

16

9/21/2017

9

Mid Left Circumflex 95% stenosis

17

Cranial View of LAD

18

9/21/2017

10

PCTA of mid Left Circumflex

19

Mid RCA 95% Stenosis

20

9/21/2017

11

Post PCTA angiogram

21

Post DES of RCA angiogram

22

9/21/2017

12

Post PCI EKG

23

Discussion

24

9/21/2017

13

CvLPRIT Trial

25

0

15

30

Death, MI, heart failure, or repeatrevascularization

CvLPRIT

Death, MI, heart failure, or ischemia-driven revascularization at 12 months: 10.0% of the complete revascularization group vs. 21.2% of the culprit-only group (p = 0.009)

All-cause mortality: 1.3% vs. 4.1% (p = 0.14), respectively

MI: 1.3% vs. 2.7% (p = 0.39), respectively

Heart failure: 2.7% vs. 6.2% (p = 0.14), respectively

Repeat revascularization: 4.7% vs. 8.2% (p = 0.2), respectively

Trial design: Participants with STEMI were randomized to complete revascularization (n = 150) vs. culprit-only PCI (n = 146). Results

Conclusions• Among STEMI patients, complete revascularization

appears beneficial at reducing major adverse cardiac events

• Benefit was primarily due to reduction in repeat revascularization procedures

(p = 0.009)

Complete revascularization

%

10.0

21.2

Culprit-only revascularization

9/21/2017

14

Case 3 Patient Demographics

61 y/o M

27

Past Medical History

HTN, HLD, DMII

Risk Factors

23 pack years Clinical presentation

Witnessed arrest s/p ACLS with 1 round of CPR / defibrillation and ROSC

BP on presentation 70/40

EKG

9/21/2017

15

Anterior-Lateral MI with Cardiogenic Shock

DES in to proximal LAD

9/21/2017

16

Post DES angiogram

Ultrasound guided Radial artery access

Right Radial Ultrasound

32

9/21/2017

17

Ultrasound

Use of higher frequency vascular ultrasound probes in the frequency range of 5- 12 mHz

Other uses of ultrasound guided Radial artery access include patients with continuous flow support devices ie LVAD and ECMO patients.

33

Case 4 Patient Demographics

60 y/o Male

34

Past Medical History

Hypertension

Hyperlipidemia

Risk Factors

Smoking Clinical presentation

Acute substernal CP

Called EMS and arrived to Non PCI center

2.5 hour delay due to weather

Received Tenectaplace, ASA , Clopidogrel, and Heparin

9/21/2017

18

Initial ECG via EMS

35

EKG upon transfer

36

9/21/2017

19

RCA angiogram

37

Left Circumflex Occlusion

38

9/21/2017

20

PCTA of Left Circumflex

39

DES of Left Circumflex

40

9/21/2017

21

Boersma et al. 1996 Lancet 348: 771‐75

• 22 randomized trials 1983 – 1993, n = 50,246

• Thrombolysis v placebo in STEMI

• Mortality benefit if < 2 hours from symptoms

• Stroke rate 1-2%

Thrombolysis: Clinical Efficacy

Horowitz et al. Lancet 2013; 128:803‐810Pinto, ACC.13 “Pharmacotherapy if delay to reperfusion”

New PCI Centers, 1997 - 2008

PCI in 1997

PCI in 2008

No PCI in 1997

Thrombolysis: Why Now?

400 new PCI centers 2001-2006pPCI access increased from 79% to 79.9%

9/21/2017

22

Case Conclusion and Take Home Points Rescue PCI, drug-eluting stent of Left circumflex

Pre-discharge ejection fraction 55% with mild inferior wall hypokinesis.

In STEMI, thrombolysis is indicated if first medical contact to primary PCI time is judged to be > 2 hrs

Transfer to PCI capable hospital, evaluate for angiography on arrival

Case 5 Patient Demographics

59 y/o M

44

Past Medical History

Never seen a physician

Risk Factors

30 pack year smoking Clinical presentation

Developed acute onset chest heaviness and headache took 3 ASA then drove to to local ED.

9/21/2017

23

EKG

45

RCA angiogram

46

9/21/2017

24

Initial LCA view

47

LAD

48

9/21/2017

25

Left Circumflex

49

Repeat EKG

50

9/21/2017

26

IVUS of ostial and proximal LAD

51

IVUS

52

9/21/2017

27

DES to LAD

53

Final Angiogramwith DES to LAD

54

9/21/2017

28

Discussion

55

Thank you

56