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Acute Coronary Syndromes: ST Elevation MI (ACS: STEMI)
Vidya S. Banka, MD, is director of interventional cardiology at Pennsylvania Hospital, and clinical professor of medicine at the University of Pennsylvania School of Medicine. John Edavettal, MD, is interventional cardiology fellow at Pennsylvania Hospital. Here, they discuss ST elevation in myocardial infarction, its causes - mainly plaque rupture, and thrombus formation resulting in total coronary occlusion and complete obstruction of blood flow. The author has no relationships with commercial interests related to the content of this lecture. The authors discuss EKG identification of the infarct related artery in the presence of an inferior wall myocardial infarction... and of the location of the LAD occlusion in the presence of anterior wall myocardial infarction. More than 90% of patients present with acute MI related to thrombotic coronary occlusion secondary to atherosclerotic coronary disease, but other causes include vasospasm, coronary embolic phenomenon, vasculitis, spontaneous coronary dissection, use of cocaine, non-atherosclerotic thrombotic disease, severe hypotension, and aortic dissection. The lecture includes a discussion of unfractionated versus low molecular weight heparin and so-called "heparin rebound." Low molecular weight heparin has, say the authors, greater bioavailability and much longer plasma half-life. Both Dalteperin and Enoxaparin, the most studied preparations, have one third the molecular weight of conventional unfractionated heparin. The authors discuss several acronymic trials, including the ESSENCE (efficacy and safety of subcutaneous Enoxaparin in non-Q coronary events) trial, and the PURSUIT (platelet glycoprotein in unstable angina receptor suppression using Integrilin therapy) trial. Doctors Banka and Edavettal state that there is strong evidence that aspirin reduces the risk of myocardial infarction. They also discuss Clopidigrel... and the factors that weigh heavily in decision making for reperfusion. Management of myocardial infarction, they conclude, continues to evolve. Early intervention includes the primary goals of early recanalization of the infarct related artery and preventing or minimizing microvascular injury. The introduction of IIb/IIIa receptor antagonists has offered a major advance in the management of acute coronary syndrome. There are 80 slides accompanying this lecture. |
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