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9/21/2017
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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
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Outline
1. Multivessel Revascularization2. Radial Artery Access for STEMI with shock3. STEMI Nightmares
Case 1 Patient Demographics
38 y/o Male
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Past Medical History
None
Risk Factors
None Clinical presentation
Presented to ED with continued anterior chest pain after playing volleyball radiating to LUE
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EKG
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Right Coronary Artery with collaterals to left
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Occluded Mid LAD
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Angioplasty to Mid LAD
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Post PCTA angiogram
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Post PCTA caudal projection
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Post DES placement angiogram
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DES of distal Left Circumflex
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Final Angiogram
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Discussion
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Case 2 Patient Demographics
44 y/o F
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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
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Mid Left Circumflex 95% stenosis
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Cranial View of LAD
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PCTA of mid Left Circumflex
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Mid RCA 95% Stenosis
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Post PCTA angiogram
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Post DES of RCA angiogram
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Post PCI EKG
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Discussion
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CvLPRIT Trial
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0
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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
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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
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Anterior-Lateral MI with Cardiogenic Shock
DES in to proximal LAD
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Post DES angiogram
Ultrasound guided Radial artery access
Right Radial Ultrasound
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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.
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Case 4 Patient Demographics
60 y/o Male
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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
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Initial ECG via EMS
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EKG upon transfer
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RCA angiogram
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Left Circumflex Occlusion
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PCTA of Left Circumflex
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DES of Left Circumflex
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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%
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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
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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.
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EKG
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RCA angiogram
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Initial LCA view
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LAD
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Left Circumflex
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Repeat EKG
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IVUS of ostial and proximal LAD
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IVUS
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DES to LAD
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Final Angiogramwith DES to LAD
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Discussion
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Thank you
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