STEMI CARE THE RIGHT

REPERFUSION STRATEGY
Dr. Eka Ginanjar, SpPD, KKV, FINASIM, FACP, FICA
Division of Cardiology, Department of Internal Medicine, Universitas Indonesia
Pelayanan Jantung Terpadu, RSCM
 The Cardiovascular Continuum of Events
ACS
Coronary
Secondary Arrhythmia and
prevention
Thrombosis Stroke Loss of Muscle

Myocardial Remodeling
Ischemia

Ventricular
CAD Dilatation

Atherosclerosis Congestive
Heart Failure
Primary
prevention Risk Factors End-stage
( Dyslipidemia,  BP, , Heart Disease
Insulin Resistance, Platelets,
Adapted from
Fibrinogen, etc)
Dzau et al. Am Heart J. 1991;121:1244-1263
Initial Assessment for ACS patients

10 minutes

No need to
wait the result
Ischemic Heart Disease
SUPPLY vs DEMAND
 Spectrum of Pathology and Clinical IHD

Stable angina NSTEMI STEMI

IHD= Ischaemic heart disease

ACS
NSTEMI= Non ST segment elevation myocardial infarction
STEMI= ST segment elevation acute myocardial infarction
ACS= Acute coronary syndrome

Adapted from Morrow DA, et al. N Engl J Med 2017;376:2053-64.

REVASCULARIZATION
 Important To Identify Symptom Onset in STEMI
to choose the right reperfusion strategy

In early stage of AMI , ECG

may be normal or near normal

5- 30 min after onset of

infarction

Changes
< 1 mm - > 10 mm

1-2 hours of onset

symptoms

• ST resolves - anterior up to 2 weeks;

posterior > 2 weeks
• T wave : many months

9
• Morris F, Brady WJ. BMJ 2002 Apr 6;;324(7341) :831-4
TIME and Myocardial Salvage
Component Time Delay

In Hospital and EMS

Diagnose capabilities

Improve Public
Awareness ACS Network
CODE STEMI
 Importance for Early Reperfusion

• Reperfusion is a key strategy in Acute STEMI care and it

time dependent
• Shortening the time from symptom to reperfusion and
choosing the optimal reperfusion strategy for STEMI
patients are a great challenges in practice.
• The infarction related artery (IRA) must be opened
early, consistently, and thoroughly in order to
effectively restore myocardial perfusion

1. Zhang et al. J Zhejiang Univ-Sci B (Biomed & Biotechnol). 2011; 12(8):629-632; 2. Ibanez B et al. Eur Heart J. 2017; 00: 1–66
2017

A primary PCI strategy is

recommended over fibrinolysis
within indicated Timeframes
1A
Ibanez B et al. Eur Heart J 2017. https://academic.oup.com/eurheartj/article/4095042
 Recommended / Should be Not
indicated considered recommended

Ibanez B et al. Eur Heart J 2017. https://academic.oup.com/eurheartj/article/4095042

 Mortality benefit with fibrinolytics is
greatest with shortest delay to treatment

Proportional effect of fibrinolytic therapy on

35-day mortality according to treatment delay1
22 trials were
reported between Time to Fibrinolytic Control/placebo
treatment (h) better better
1983 and 1993 and P=0.001 vs
0–1
indexed in the other
timepoints ≥1–2
MEDLINE
≥2–3
information
≥3–6
system.
≥6–12
≥12–24

0 0.5 1.0 40
Odds ratio
Benefit shown for treatment delays up to 12 hours

1. Boersma E et al. Lancet 1996;348:771–775;

 Recommended / Should be Not
indicated considered recommended
Ibanez B et al. Eur Heart J 2017. https://academic.oup.com/eurheartj/article/4095042
 Timing and logistical factors influence choice of
reperfusion strategy

Time to reperfusion Healthcare resource

• Patient ability to recognize • PCI vs non-PCI capable hospitals1–3

symptoms1,2 • Dependence on operator
• Mode of transportation to the hospital expertise/volume3
(self-presentation vs EMS)1,2 • Availability of a 24/7 service1,3*
• Inter-hospital transfer challenges • Availability of a pre-hospital system for
(distance, traffic patterns, climatic diagnosis and treatment3,4,5
conditions etc)2,3
*Patients treated during non-working hours (6 PM to 8 AM) have
a greater delay to therapy, twice the failure rate of PPCI, and a
>2-fold increased 30-day mortality rate3,6

• 1. Ibanez B et al. Eur Heart J 2017. https://academic.oup.com/eurheartj/article/4095042. Accessed November 6, 2017; 2. O’Gara PT et al. Circulation 2013;127:e362–e425; 3. Armstrong PW et al.
Circulation 2009;119:1293–1303; 4. Welsh RC et al. Am Heart J 2006;152:1007–1014; 5. Danchin N et al. Circulation 2004;110:1909–1915; 6. Henriques JPS et al. J Am Coll Cardiol 2003;41:2138–2142
Contraindications to fibrinolytic therapy1–3

ABSOLUTE RELATIVE

• Previous intracranial hemorrhage or stroke of • Transient ischemic attack in the preceding 6

unknown origin at any time month
• Ischemic stroke in the preceding 6 months • Oral anticoagulant therapy
• Central nervous system damage or neoplasms or • Pregnancy or within 1 week postpartum
arteriovenous malformation • Refractory hypertension
• Recent major trauma/surgery/head injury (within • Advanced liver disease
the preceding 3 weeks) • Infective endocarditis
• Gastrointestinal bleeding within the past mo • Active peptic ulcer
• Known bleeding disorder (excluding menses) • Prolonged or traumatic resuscitation
• Aortic dissection
• Non-compressible punctures in the past 24 h
(e.g. liver biopsy, lumbar puncture)
• Ischemic stroke more than 6 months ago

1. Ibanez B et al. Eur Heart J 2017. https://academic.oup.com/eurheartj/article/4095042; Accessed November 6, 2017; 2. O’Gara PT et al. Circulation 2013;127:e362–e425; 3.
Morse MA et al. Drugs 009;69:1945–1966
21

Preparation Fibrinolytic therapy

1. Prepare Patients (Provide informed concent )
2. Drug and Equipment preparation

Streptokinase 1.5 jt Trolley Emergency Defibrilator Monitor ECG

unit

3. Administered Drug
• IV line – 2 ways if hemodynamic is not stabil
Fibrin Non-Specific Fibrin Specific

Prourokinase Tenecteplase
Urokinase Alteplase
Streptokinase Reteplase
4. Monitoring every 10 minutes
Vital check, Symptoms, Heart Rhythm
Reference : iSTEMI Indonesia Video
 Fibrinolytic Therapy
Specific
Drugs Dosage & Administration
Contraindication
Streptokinase 1.5 Million units over 30-60 min i.v. Previous treatment
with streptokinase or
anistreplase
Alteplase 15 mg i.v. bolus
0.75 mg/kg i.v. over 30 min (up to 50 mg)
Then 0.5 mg/kg i.v. over 60 min (up to 35 mg)
Reteplase 10 units + 10 units i.v. bolus given 30 min apart
Tenecteplase Single i.v. bolus:
(TNK-tPA) 30 mg (6000 IU) if <60 kg
35 mg (7000 IU) if <70 kg
40 mg (8000 IU) if <80 kg
45 mg (9000 IU) if <90 kg
50 mg (10000 IU) if ≥90 kg
It is recommended to reduce to half-dose in
patients ≥75 years old
ESC Guideline. Ibanez B et al. Eur Heart J 2017. https://academic.oup.com/eurheartj/article/4095042
 Fibrinolytic Complication and it’s
management
Hypotention Allergic reaction Bleeding Arythmia
• Patient position – Mild allergic Minor Bleeding • Refer to ACLS
supine Antihistamin injection Pressure to bleeding guidelines
• Reduce or stop (difenhidramin 10 mg area
streptokinase i.v) Major Bleeding – eg • Reperfusion sign
drops Severe allergic ICH • Premature
• Provide Ringer Dexamethasone Stop streptokinase and Ventricular
Lactate / NaCL 100 injection 5 mg refer patient for further Contraction
ml (10 minutes) bleeding management • Idiophatic
• Stop vasodilator Ventricular
drug (eg. Nitrate) Rhytm
• Streptokinase
drop continue if
systolic pressure >
90 mmHg Parameter Successful Fibrinolytic Therapy

1. Reduction of chest pain

2. Decrease ST elevation > 50%
3. Arrhythmia reperfusion
Reference : iSTEMI Indonesia Video
 Early Reperfusion Strategy in STEMI
Symptom Primary PCI Fibrinolytic
Onset
0 – 3 hours
 
3 – 12 hours
 
> 12 hours
 

Presented to PCI Routine

Hospital Angiography ± PCI
Maximum Wire crossing 60 Successful Thrombolytic
minutes Within 2-24 Hours
target
Presented to Non Rescue PCI
time from PCI Hospital If Failed Thrombolytic
diagnosis Wire crossing 90 (60 -90 min after start
minutes thrombolytic)

Ibanez B et al. Eur Heart J 2017. https://academic.oup.com/eurheartj/article/4095042. Accessed November 6, 2017.

 The success of reperfusion in STEMI is dependent on the
time of administration

 Time delays are central in the decision-making process

 Registry data show that the 30-min DTN and 90-min DTB
time goals are extremely difficult to achieve

 Analysis of the NRMI (National Registry of Myocardial

Infarction) 3/4 data demonstrated that only 4.2% of
patients undergoing PPCI achieve a DB time 90 min

 Time delays are also crucial to determine the best

reperfusion strategy

Danchin N. J Am Coll Cardiol Intv. 2009; 2: 901– 908.

 Impact on Time Delays and 30-Day Mortality of the Number of Medical Parties
Involved Before Hospital Admission in the French FAST-MI Registry

0 or 1 Party 2 Parties ≥3 Parties

Median time from 100 (50–170) 122 (60–201) 155 (80–270)

first call to
reperfusion (range)

30-day mortality 5.5% 7.1% 12.1%

FAST-MI = French registry of Acute ST-segment elevation or non–ST-segment elevation Myocardial Infarction.

Danchin N. J Am Coll Cardiol Intv. 2009; 2: 901– 908.

 Recommendation System of Care in STEMI
based on Mission LIfeLine – AHA

Non-PCI Primary PCI

Hospital/ STEMI EMS Hospital/ STEMI-
Referring Center Receiving Center

• Registered with Mission Lifeline (one platform)

• Routine multidisciplinary team meeting
• Standardized protocol : Prehospital identification and
activation, destination protocol for STEMI receiving centre,
transfer protocol for STEMI referring Center
• Coordinator for recognized system, physician champion, EMS
medical director
• Accreditation for STEMI referring and receiving center

• http://www.heart.org/HEARTORG/Professional/MissionLifelineHomePage 27
 Alur Pasien STEMI tahun 2017
Pasien STEMI

Door Time Triase IGD (PPDS IPD)

Data Anamnesis, Pemeriksaan Fisik, EKG

Decision Dokter Konsulen Kardiologi Intervesi

Konfirmasi Diagnosis STEMI
Persetujuan Primary PCI

Delivery
Transfer Pasien ke cathlab PJT

Persiapan Primary PCI

Definitive
Tindakan Primary PCI
Hasil Capaian Door TO BalloOn Time dan Median TIME
Januari-Desember 2017
PeRSENTASE Inhospital Mortality Pasien
STEMI Post Primary PCI TAHUN 2017

Jumlah Pasien STEMI Post PPCI

Jumlah Mortality Pasien STEMI Post
Tahun 2017 Persentase
PPCI Tahun 2017
(STEMI CODE)

8 87 9%
GUIDELINE STEMI 2017
 Alur Pasien STEMI CODE 2018
Pasien STEMI

Triase IGD
Door

ECG : STEMI Anamnesis, Pemeriksaan Fisik, EKG

Diagnosis Time

Dokter Konsulen Kardiologi

Decision
Jaga dan Intervesi
Konfirmasi Diagnosis STEMI

Persetujuan Primary PCI

Delivery Transfer Pasien ke cathlab PJT

Persiapan Primary PCI

DEFINITIVE :
Wire Crossing Tindakan Primary PCI
Time
 Rata-rata waktu STEMI Diagnosis to wire crossing time
(Januari - Juni 2018)

160

140 141

120
103 Rata-
100 98
98 rata
90
80 87 per
81 79
bulan
60 (menit
40 )

20

0
Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18
CAPAIAN BTP STEMI CODE juni 2018
 CAPAIAN BTP STEMI CODE juni 2018
Selisih waktu Durasi waktu
(Wire crossing STEMI diagnosis - Delivery (IGD) Durasi waktu di
Nama Target
No time - STEMI Penyebab Target tidak tercapai delivery ke cathlab cathlab
Pasien (90 menit)
diagnosis time) (IGD) (menit) (menit)
(menit) (menit)

di IGD pasien dilakukan pemeriksaan CXR pre PPCI, Kesulitan Puncture di cathlab
1 Tn. R.S 104 90 54 5 45
(tindakan diawali oleh dokter fellow intervensi)

Lama di IGD karena masalah administrasi/jaminan (Pasien rujukan dari RS PON,

2 Tn. S.M 237 90 164 25 48
menunggu pembuatan SEP) dan pasien dilakukan pemeriksaan CXR pre PPCI

Lama di IGD karena menunggu Persetujuan pasien (informed consent). Dari RS

3 Ny. N 163 90 98 18 47
Perujuk (RS Carolus) pasien tidak diedukasi mengenai rencana PPCI

Tindakan saat cuti bersama, pasien datang malam hari (diagnosis pukul 23:13
4 Tn. A. R 117 90 67 5 45
WIB), Kesulitan Puncture di cathlab

Lama di IGD karena keputusan PPCI lama (sulit menghubungi konsulen jaga).
5 Tn. I.B 138 90 Tindakan saat cuti bersama, pasien datang malam hari (diagnosis pukul 23:40 85 19 34
WIB)

Tindakan saat cuti bersama, Lama wiring di cathlab, tindakan diawali oleh dokter
6 Tn. A.H 116 90 47 11 58
fellow intervensi

7 Tn. L 115 90 Operator sulit dihubungi. Tindakan dilakukan subuh (diagnosis pukul 02:25 WIB) 70 10 35
 Summary
• Reperfusion is a key strategy in Acute STEMI care and it time
dependent
• PPCI is preferred options for reperfusion strategy for STEMI
patients

• Fibrinolytic therapy is an important reperfusion alternative

when onset chest pain < 3 hours or when primary PCI cannot
be offered in a timely manner

• Important to know capabilities of each hospital before

referring STEMI patients to prevent delay

38
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