وصف
ST-Elevation Myocardial Infarction (STEMI) is a severe and potentially life-threatening form of heart attack caused by a complete blockage of a coronary artery, usually due to a blood clot. It occurs when the blood supply to a portion of the heart muscle is suddenly cut off, leading to damage to the heart muscle if not promptly treated. STEMI is characterized by specific changes on an electrocardiogram (ECG), particularly elevation of the ST segment, which indicates a prolonged period of inadequate blood flow. Immediate medical intervention, often involving procedures such as angioplasty and stent placement to restore blood flow, is crucial to minimize heart damage and improve patient outcomes. Rapid recognition of symptoms such as chest pain or discomfort, shortness of breath, and nausea, followed by timely medical attention, is vital in managing STEMI effectively.
ملخص
- Coronary artery disease prevalence in India is rising, with urban areas seeing an increase from 1% to 10% and rural areas from less than 1% to about 6%. The death rate from the disease is higher in India at 272 per 100,000 population compared to the global average of 235. STEMI (ST-elevation myocardial infarction) is a prevalent and dangerous form of ACS (acute coronary syndrome) in India, occurring about 10 years earlier than in Western countries.
- STEMI is diagnosed based on symptoms, persistent ST elevation on ECG, and the release of myocardial infarction biomarkers. While chest pain is a common symptom, atypical presentations like diaphoresis, epigastric pain, or shortness of breath can occur, especially in women. Rapid diagnosis via ECG is essential, with criteria differing for men and women based on age and ECG lead location.
- Early STEMI diagnosis is crucial to minimize myocardial damage. A 30-minute delay in reperfusion (thrombolysis or PCI) increases one-year mortality by 8%. Delays are due to lack of awareness, misattribution of symptoms, ambulance delays, remote areas, and affordability issues. The acute coronary syndrome spectrum includes STEMI, NSTEMI (non-ST-elevation myocardial infarction), and unstable angina.
- The "ischemia time" concept encompasses symptom onset to reperfusion therapy. Patient delay, the time before seeking help, is a critical factor. Initial medical contact can be a PCI center, non-PCI center, or paramedic. ECG diagnosis should occur within 10 minutes. If a PCI center is accessible within 120 minutes, it is the preferred option; otherwise, thrombolysis should be initiated within 10 minutes.
- Post-diagnosis, loading doses of aspirin and P2Y12 inhibitors (clopidogrel, ticagrelor, or prasugrel) are administered, along with anticoagulants like enoxaparin. Choice of agent depends on potential resistance and patient factors. Prasugrel isn't recommended before thrombolysis.
- Thrombolysis contraindications include history of intracranial hemorrhage or stroke, CNS neoplasms, recent trauma, and gastrointestinal bleeding. Relative contraindications include pregnancy and uncontrolled hypertension. Fibrin-specific agents (tenecteplase) are preferred due to better patency rates and lower bleeding risk, but are costlier than non-fibrin specific agents (streptokinase).
- Primary PCI is the preferred treatment if available within 120 minutes and involves angioplasty and stenting without prior thrombolysis. Rescue PCI is performed if thrombolysis fails, indicated by ongoing chest pain or hemodynamic/electrical instability. Routine early PCI can occur within 24 hours after thrombolysis. The time from non-PCI center to PCI center is called door-in-door-out time, aimed to be less than 30 minutes.
- Post-PCI, dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor for at least 12 months is recommended, with potential modifications for high bleeding risk patients. Long-term management includes healthy lifestyle choices, optimal medication, influenza vaccination, and monitoring of blood pressure, lipids, and glucose. Common complications include arrythmias and heart failure.
- ECG criteria for rescue PCI includes a J-point ST elevation not coming down by 50% post-thrombolysis. After 12 months, aspirin monotherapy is recommended by default, while certain patients can benefit from continued dual antithrombotic therapy. Causes for anginal presentation with normal angiogram includes coronary embolism or spasm, myocardial bridging and Takatsubo cardiomyopathy.
نموذج شهادة
حول المتحدثين
Dr Amit Bharadiya
Consultant Interventional Cardiologist Director - Surabhi Hospital, Ahmednagar
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