Exclusive guidelines for late presentation of STEMI

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Exclusive guidelines for late presentation of STEMI

November 22, 2011 by dr s venkatesan

Acute myocardial infarction is the number one cardiac emergency .
About a million papers and articles are available in medical literature about STEMI.
Management of STEMI when they present early is addressed by every text book.
It is really surprising to note there is no simple and specific guidelines to manage STEMI when they present late to the ER .
Such a scheme is vital for physicians, as experience suggest almost 40 % of all STEMI arrive late and are ineligible for specific reperfusion strategies.

The following flow chart is exclusively meant for usage in STEMI when they arrive late >12 hours .

This is a personalised version based on working in one of the oldest CCU in Asia which handles about 2000 acute coronary syndromes every year with a mortality rate of 6-7 % Hope one can bear with it !

Please click on the chart for a high resolution Image

Comments are welcome

Posted in Cardiology - Clinical, Cardiology -Interventional -PCI, cardiology -Therapeutics, cardiology- coronary care, Cardiology-Coronary artery disese | Tagged acc aha guidliens for stemi, common sense in stemi, defered pci, elective pci, emergency cabg in stemi, late pci, late presentation of stemi, prolonged time window in stemi, rescue pci, stemi > 12 hour how to manage, STEMI management guidelines | 6 Comments

6 Responses

on November 22, 2011 at 9:32 pm | Reply dr bir

shouldnot only the culprit vessel revascularised in hemodynamically stable symptomatic patient
on November 23, 2011 at 7:31 am | Reply Sujay Renga

So if the there is a critical lesion of the culprit IRA you shouldnt do a PCI? dotn you think thats totally unscientific ? If there is total occlusion beyond 24 hrs there is evidence for not opening it. If there is critical occlusion, tackilng that can prevent reinfarction.
- on November 23, 2011 at 2:33 pm | Reply drsvenkatesan
  
  Hi
  
  Thank you for your comment.
  
  I often fail to understand what the term scientific really means ! It is not the criticality of a lesion that would demand a PCI.
  Instead , what we are going to achieve by opening a critical lesion* after the myocardium is dead would matter more !
  Of course this is against the theory of open artery hypothesis.(OAH)
  But we also need to introspect why this remain as a hypothesis for over two decades , still struggling to prove a point ?
  
  Physiologically and hemodynamicaly opening a 100 % (or near 100 % ) IRA in STEMI (One can call it a ATO !) beyond 12 hours is expected to have the outcome similar to that of opening a CTO in chronic stable angina .
  
  We need to realise ATOs beyond 12 hours have it’s own natural history.
  At least 30 % open up spontaneously in the ensuing week or so and accrue the benefit of late open artery hypothesis (if at all any !)
  
  Ironically, it is well known, there is a significant and progressive occlusion rates for PCIs done in a thrombotic milieu of IRA (Done in delayed fashion with a double edged drugged metal stents which additionally carry a risk of sudden ATO once again resetting a fresh cycle of ACS ! . )
  
  This also nullifys the presumed benefit of the much hyped OAH !
  
  I agree it is a provoking idea ! but currently our profession seems to need more of such stuff !
  
  * A critical Non IRA deserves attention
  
  venkatesan
on November 23, 2011 at 5:12 pm | Reply dr bir

for 12-24 hour symptomatic critical ira should be opened in hemodyanamicaly stable patient after that asymtomatic patient critical ira should not be blindly opened
on November 23, 2011 at 11:25 pm | Reply Huda Alhashimy

thank you…… please tell more about medical treatment
on January 20, 2012 at 5:31 am | Reply Sujay Renga

Ideally one should demonstrate viable mycardium in the infarcted area, either clinically by symptoms of PIA or arrhy, or by doing a perfusion imaging / stress echo / predischarge TMT. Critical lesions in non infacted territory need to be addressed early.