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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 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 Case Aspirated thrombus ++ and POBA After thrombus aspiration 1st Angiojet Run with 5Fr catheter Final result, after 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
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