Stemi vs Nstemi

8/10/2019 Stemi vs Nstemi

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Treatment Guidelines for ST-segment

Elevation Myocardial Infarction(STEMI) and Non ST-segment Elevation

Myocardial Infarction (NSTEMI)

Brady Helmink

University of Nebraska Medical Center

College of Pharmacy

Class of 2013 Pharm.D. candidate


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Objectives

Understand which conditions classify as Acute

Coronary Syndromes (ACS)

Identify the difference between the presentation ofNSTEMI vs. STEMI

Know how to stratify patients with NSTEMI using the

TIMI risk score

Compare and contrast treatment algorithms for high

and low-risk patients with NSTEMI


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Objectives

Explain how the pathophysiology of STEMI differs

from NSTEMI

Understand the importance of PCI and time torevascularization in both NSTEMI and STEMI

Recognize the significance of fibrinolytic agents and

their place in therapy Discuss similarities and differences between the

treatment of STEMI and NSTEMI


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Acute Coronary Syndrome (ACS)

Refers to anginal symptoms at rest for > 20 minutes;may or may not be relieved by SL NTG

Three categories ST-segment Elevation Myocardial Infarction (STEMI)

Non ST-segment Elevation Myocardial Infarction (NSTEMI)

Unstable Angina (UA)

Management focused on rapid diagnosis, riskstratification, and therapies to restore coronary bloodflow and reduce myocardial ischemia

DiPiro, Joseph T. "Chapter 24. Acute Coronary Syndromes." Pharmacotherapy: A Pathophysiologic Approach. New

York, N.Y: McGraw-Hill Medical, 2011. Access Pharmacy.http://www.accesspharmacy.com/content.aspx?aID=7972196
http://www.accesspharmacy.com/content.aspx?aID=7972196http://www.accesspharmacy.com/content.aspx?aID=7972196


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Patient Case

BC, a 61 year-old female presents to the Onawa

ER with progressive substernal chest pain radiating

up into her neck and jaw over the past four days Initial EKG showed non-specific T wave changes and

cardiac troponin levels were elevated at 1.3

Coronary arteriography showed 90% stenosis ofthe LAD


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Patient Case (cont.)

Past medical history of DM 2, HTN, HLD, depression

and recurrent bronchitis. Patient is a long-standing

and ongoing tobacco user, and also has a positivefamily history of CAD

Home medications include ASA 81mg daily,

metoprolol XL 25mg daily, HCTZ 12.5mg daily,

lisinopril 20mg daily, cymbalta 60mg daily, apidra

on sliding scale, and lantus 25 units QHS


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NSTEMI

Defined as angina at rest for > 20 min without ST-

segment elevation, but with a rise in cardiac

markers

Pathophysiology

Abrupt in myocardial oxygen supply

Thrombus formation on an atherosclerotic plaque

Management depends on risk stratification

TIMI (Thrombolysis in Myocardial Infarction) risk score




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Risk Stratification for NSTEMI

One point is assigned for each of the following riskfactors1. Age 65 years

2. 3 or more CHD risk factors: smoking, hypercholesterolemia,hypertension, diabetes mellitus, family history of prematureCHD death/events

3. Known CAD (50% stenosis of at least one major coronaryartery on coronary angiogram)

4. Aspirin use within the past 7 days5. 2 or more episodes of chest discomfort within the past 24 hrs

6. ST-segment depression 0.5 mm

7. Positive biochemical marker for infarction

Antman, EM, et al. The TIMI risk score for unstable angina/non-ST elevation MI: A method for prognostication andtherapeutic decision making. JAMA. 2000 Aug 16; 284(7):835-42


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Patient Case

BC, a 61 year-old female presents to the Onawa

ER with progressive substernal chest pain radiating

up into her neck and jaw over the past four daysMultiple episodes of chest pain

Initial EKG showed non-specific T wave changes and

troponin levels were elevated at 1.3Positive

cardiac markers

Coronary arteriography showed 90% stenosis of

the LADKnown CAD


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Patient Case (cont.)

Past medical history of DM 2, HTN, HLD, depressionand recurrent bronchitis. Patient is a long-standingand ongoing tobacco user, and also has a positive

family history of CAD 3 CHD riskequivalents

Home medications include ASA 81mg daily,metoprolol XL 25mg daily, HCTZ 12.5mg daily,lisinopril 20mg daily, cymbalta 60mg daily, apidraon sliding scale, and lantus 25 units QHSASAuse in the past 7 days


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TIMI risk score for NSTEMI

High-risk Medium-risk Low-risk

TIMI risk score TIMI risk Score TIMI risk score

57 points 34 points 02 points

TIMI risk scoreMortality, MI, or severe recurrent ischemic requiring urgent

target vessel revascularization

0/1 4.7%

2 8.3%

3 13.2%

4 19.9%5 26.2%

6/7 40.9%


York, N.Y: McGraw-Hill Medical, 2011. Access Pharmacy.

http://www.accesspharmacy.com/content.aspx?aID=7972196


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Invasive vs. Conservative strategy

Invasive (high-risk patients)

Antiplatelet and Anticoagulation therapies followed by

revascularization

Percutaneous Coronary Intervention (PCI)OR Coronary Artery Bypass Grafting (CABG)

Conservative (low-risk patients)

Antiplatelet and Anticoagulation therapies followed bywatchful waiting

Hoenig MR, Aroney CN, Scott IA. Early invasive versus conservative strategies for unstable angina and non-ST elevation

myocardial infarction in the stent era. Corchrane Database Syst review 2010; Mar 17; 3:CD004815.

Mahoney M, Jurkovitz CT, Chu H, et al. Cost and cost-effectiveness of an early invasive vs conservative strategy for the

treatment of unstable angina and non-ST-segment elevation myocardial infarction. JAMA2002; 288: 1851

8185.

Kushner FG, Hand M, Smith SC Jr, et al. 2009 Focused Updates: ACC/AHA Guidelines for the Management of Patientswith ST-Elevation Myocardial Infarction and ACC/AHA/SCAI Guidelines on Percutaneous Coronary

Intervention. 2009; 120: 22712306.


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Pharmacologic Management of

NSTEMI

Antiplatelet therapy

Aspirin162-325mg chewed immediately and 81-162mg

continued indefinitely

Clopidogrel600mg load for pts undergoing PCI and 75mgdaily continued for at least 12 months

+/- GP IIb/IIIa inhibitor (only for high risk patients who are

likely to undergo invasive strategy: elevated troponin or ST-

segment depression)o Eptifibatide (Integrilin) Two180mcg/kg boluses 10min apart,

followed by a 2mcg/kg/minute infusion for 72-96 hours

Quantitative comparison of clopidogrel 600 mg, prasugrel and ticagrelor, against clopidogrel 300 mg on major

adverse cardiovascular events and bleeding in coronary stenting: synthesis of CURRENT-OASIS-7, TRITON-

TIMI-38 and PLATO. Int J Cardiol.2012 Jul 12; 158(2): 181-5. Epub 2012 Jan 10.

Giugliano, Robert P. et al. Early versus Delayed, Provisional Eptifibatide in Acute Coronary Syndromes. N Engl J Med

2009; 360: 2176-2190


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NSTEMI

Anticoagulation

Heparin60-70 units/kg IV bolus, followed by 12-15units/kg/hr continuous IV infusiono

DC Heparin when going to PCIOR

Enoxaparin1mg/kg Q12hrs

OR

Bivalirudinwith PCI, give 0.75mg/kg IV bolus,followed by continuous IV infusion 1.75mg/kg/hr. DC atend of procedure or continue for up to 4 hours

Enoxaparin vs Unfractionated Heparin in High-Risk Patients With NonST-Segment Elevation Acute Coronary

Syndromes Managed With an Intended Early Invasive Strategy. JAMA. 2004; 292(1): 45-54.

Stone GW, McLaurin BT, Cox DA, et al. Bivalirudin for patients with acute coronary syndromes. N Engl J Med2006;

355: 2203-2216.


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NSTEMI

Beta blockers

Metoprolol IV 5mg given over 1-2 minutes Q5min X 3 doses;convert to PO 25-50mg Q6hrs

Nitrates

SL NTG Q5min X 3 doses

IV NTG for pts with refractory angina

o 5-10mcg/min IV; by 10mcg/min Q5min to a max of 100mcg/min

Morphine Sulfate

2-5mg IV Q5-30min PRN pain




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NSTEMI

ACE inhibitors

HOPE trialo Attenuates the ventricular remodeling process

o Early administration mortality in AMI patients

Statins

Helps with long-term atherosclerotic plaque stabilizationo High doses most beneficial (treat to LDL < 70 mg/dL)

Effects of an Angiotensin-ConvertingEnzyme Inhibitor, Ramipril, on Cardiovascular Events in High-Risk Patients. N Engl

J Med 2000; 342: 145-153

Daga, Lal C., Upendra Kaul, and Aijaz Mansoor. "Approach to STEMI and NSTEMI." J Assoc Physicians India. 2011

Dec; 59 Suppl: 19-25


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BC received


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Patient Case

Heparin 6000 unit IV bolus (70 units/kg), followed by

1200 units/hr (14 units/kg/hr) continuous IV infusion*

ASA 162mg daily*

Clopidogrel 300mg load, followed by 75mg daily*

Lisinopril 10mg daily

Metoprolol XL 25mg BID

Morphine 2mg IV Q2hrs PRN NTG SL 2 tablets relieved symptoms

NTG IV cont. 250mL bottle titrated to pain free*

Simvastatin 80mg initially, followed by 40mg daily


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Patient Case

Procedure

PCI w/ placement of drug eluting stent in LAD

Medications (given intra-arterial)

Heparin 3000 units

NTG 600mcg initially, 400mcg after 30min

Bivalirudin 65mg, or 13 mL IV bolus (0.75mg/kg),

followed by continuous IV infusion of 30mL/hr

(1.75mg/kg/hr). DCd at end of procedure


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STEMI

Defined as prolonged chest discomfort unrelieved

by SL NTG with ST-segment elevation on EKG and a

rise in cardiac markers

Pathophysiology

Total or near-total thrombotic occlusion of a coronary

artery

Management involves immediate reperfusiontherapy (PCI preferred)

Door-to-balloon time is 90 minutes




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Fibrinolytic therapy in STEMI

If > 90 minutes from nearest cardiac cath lab,fibrinolytic therapy can risk of mortality

Door-to-needle time is 30 minutes

Fibrinolyticsmay be administered if patient presentswithin 12 hrs of symptom onset

t-PA (alteplase)

r-PA (retaplase)

TNK (tenecteplase)

Shown to open occluded artery in 60-90% of pts and mortality by 20%

Single-bolus tenecteplase compared with front-loaded alteplase in acute myocardial infarction: theASSENT-2 double-blind randomised trial. Lancet. 1999 Aug 28; 354(9180): 716-22.


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STEMI

Antiplatelet therapy

Aspirin162-325mg chewed immediately and 81-

162mg continued indefinitely Clopidogrel300mg load for pts undergoing PCI or

receiving fibrinolytic and 75mg daily continued for at

least 14 days and up to12 months

Generally do not use GP IIb/IIIa inhibitors in the settingof STEMI due to no improvement in outcomes and an

increased risk of bleeding


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NSTEMI

Anticoagulation

With fibrinolytic Heparin60 units/kg IV bolus, followed by 12 units/kg

continuous IV infusion

OR

Enoxaparin30mg IV bolus, followed by 1mg/kg Q12hrs

Without fibrinolytic Heparin60-70 units/kg IV bolus, followed by 12-15

units/kg continuous IV infusion

OR

Enoxaparin1mg/kg Q12hrs


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STEMI

Beta blockers

Nitrates

Morphine Sulfate

ACE inhibitors

Statins

Dosing similar to

NSTEMI


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References

1. DiPiro, Joseph T. "Chapter 24. Acute Coronary Syndromes." Pharmacotherapy: APathophysiologic Approach. New York, N.Y: McGraw-Hill Medical, 2011. Access Pharmacy.http://www.accesspharmacy.com/content.aspx?aID=7972196

2. Antman, EM, et al. The TIMI risk score for unstable angina/non-ST elevation MI: A methodfor prognostication and therapeutic decision making. JAMA. 2000 Aug 16; 284(7):835-42.

3. Hoenig MR, Aroney CN, Scott IA. Early invasive versus conservative strategies for unstableangina and non-ST elevation myocardial infarction in the stent era. Corchrane Database Systreview 2010;Mar 17;3:CD004815.

4. Mahoney M, Jurkovitz CT, Chu H, et al. Cost and cost-effectiveness of an early invasive vsconservative strategy for the treatment of unstable angina and non-ST-segment elevationmyocardial infarction. JAMA2002;288:18518185.

5. Kushner FG, Hand M, Smith SC Jr, et al. 2009 Focused Updates: ACC/AHA Guidelines forthe Management of Patients with ST-Elevation Myocardial Infarction and ACC/AHA/SCAIGuidelines on Percutaneous Coronary Intervention. 2009;120:22712306.

6. Quantitative comparison of clopidogrel 600 mg, prasugrel and ticagrelor, againstclopidogrel 300 mg on major adverse cardiovascular events and bleeding in coronarystenting: synthesis of CURRENT-OASIS-7, TRITON-TIMI-38 and PLATO. Int J Cardiol.2012Jul 12;158(2):181-5. Epub 2012 Jan 10.
http://www.accesspharmacy.com/content.aspx?aID=7972196http://www.accesspharmacy.com/content.aspx?aID=7972196http://www.accesspharmacy.com/content.aspx?aID=7972196http://www.accesspharmacy.com/content.aspx?aID=7972196


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