Coronary Reperfusion STEMI Management of late presentation STEMI

Coronary Reperfusion STEMI 
Management of late presentation STEMI 
DR ZUBIN IBRAHIM 
Cardiology Unit 
UITM Medical Faculty 
MALAYSIA 
The debate is still on! 
• Definition 
• Guidelines -? 
• Randomised trials/Meta analysis 
• Open artery theory 
• Reperfusion injury 
• Complications – shock, bleeding 
DEFINITION: Late presentation or 
“Late comers” 
 • The current reperfusion paradigm in STEMI  reperfusion 
attempted within 12 hours 
• Late presentation – 12 hours after symptom onset 
Why do these patients present late? 
– Unaware/in denial/awareness/education 
– Atypical/no chest pain 
– Stuttering chest pain (UA to NSTEMI to STEMI) 
– Heart failure/ syncope/ Lethargy (Elderly) 
– refusal to seek medical attention/alternative medicine 
– Geography/socioeconomic status 
– Wrong diagnosis 
– Atypical presentation (pregnancy: coronary dissection) 
– Non-PCI hospital 
Our patient 
48 diabetic male, smoker, fisherman 
‘Stuttering’ chest pain for > 16 hours 
ECG inferior leads- STEMI 
Complete AV block 
LV failure + shock (Killip IV) 
In the Emergency Department- Still has chest 
pain, ECG ST’s are still raised, echocardiogram 
LVEF 40% 
Indications for PCI of an Infarct Artery in Patients Who Were 
Managed With Fibrinolytic Therapy or Who Did Not Receive 
Reperfusion Therapy 
*Although individual circumstances will vary, clinical stability is defined by the absence of low output, 
hypotension, persistent tachycardia, apparent shock, high-grade ventricular or symptomatic 
supraventricular tachyarrhythmias, and spontaneous recurrent ischemia. 
Why is PCI in ‘latecomers’ different? 
-Thrombus 
- Microvascular injury (reperfusion injury) 
- Slow flow-no-reflow 
-Arrhythmia 
-Shock-LV dysfunction** 
-Elderly/Multiple co-morbidities** 
Thrombus 
•direct stenting 
•deferred stenting (after TIMI III) 
•thrombus aspiration in selected patients? 
•anticoagulation 
•anti platelets (?Ticagrelor) 
•catheters (7Fr for all?) 
•GP IIIbIIa inhibitors in selected patients 
•temporary pacing in RCA’s 
Slow-flow/no-reflow 
•related to thrombus/microemboli 
•previous slide 
•intracoronary Adenosine/Verapamil/nitroprusside 
•avoidance, treatment of shock (vicious cycle) 
• Inferior STEMI 
• Complete AV block 
• Previous admission for unstable angina 
• Shock- IV fluids and single ionotropic support 
• Slow-flow post stent deployment/post 
dilatation with NC balloon 
• Catheter thrombus 
• Operator (co-operator) must focus on 
everything else 
Patient 2 
• 54, male- Inferior STEMI (presented 10 hours 
after initial symptoms) 
• DM/HT/hyperlipidemia 
• previous admissions- ACS + LVFailure- medical 
therapy only 
Case 3 
Aspirated thrombus ++ and POBA 
After thrombus aspiration 
1st Angiojet Run with 5Fr catheter 
Final result, after 4 Angiojet runs 
Next Day 
Post PCI 3.5-4.5x17mm (self-expanding coronary 
stent) 
summary 
• recognise difficulties, potential complications 
• multidisciplinary approach 
• some evidence to guide us—> no clear 
answers 
• multiple tools/equipment may be used 
• thrombosis,no-reflow, shock 
• defer invasive therapy in selected patients