Dilemma:

STEMIs and Reperfusion Timing


Time is Muscle:

Patients with persistent symptoms and STEMIs need to receive mechanical or pharmacological treatments. In general, the faster they can get these treatments the better. With a PCI capable facility we want these patients to have treatment within 90 min of entering the hospital.

  • If you don’t have a cath lab they need to be transferred appropriately to STEMI facility to undergo treatment within 120 min.

  • If your patient is going to undergoing fibrinolytic therapy with such as tPA you ideally want to start within 30 min of arrival

The data shows that PCI has better outcomes than Fibrinolytics. PCI is more effective in establishing flow and reducing reocclusion in the infarct-related artery than fibrinolytic therapy and is associated with a decreased incidence of short- and long-term death, reinfarction, and intracranial hemorrhage compared with fibrinolytic therapy.

PCI is even beneficial after fibrinolytic therapy; in the TRANSFER-AMI study, high-risk patients treated with fibrinolytics for STEMI at non–PCI-capable centers were randomized to standard care or immediate transfer for PCI within 6 hours after fibrinolysis. The patients who underwent the pharmacoinvasive strategy had a 6.2% absolute reduction in death, reinfarction, recurrent ischemia, new or worsening heart failure, or cardiogenic shock at 30 days.


TLDR:

1) Reperfuse STEMI’s ASAP!

2) PCI > Fibrinolytics

What’s in the future?

Out with STEMI

In with OMI (Occlusive Myocardial Infarction)!

In 2020, Dr. Myers published in JEM, “Comparison of the ST-Elevation Myocardial Infarction (STEMI) vs. NSTEMI and Occlusion MI (OMI) vs. NOMI Paradigms of Acute MI”. It looked at what differences exist between STEMI(+) OMI patients and STEMI(-) OMI patients in terms of time to catheterization and outcomes.

He found that STEMI(+)OMI went to catheterization (~40min) while STEMI(-) OMI went to catheterization in >400min. Not good!

These results support that OMI-NOMI (rather than STEMI-NSTEMI) criteria can identify more patients with ACS that have emergently salvageable myocardium and benefit from emergent therapy and intervention. It could be within our practice that we see the term STEMI disappear and OMI take it place!



Reference:

Meyers HP, Bracey A, Lee D, Lichtenheld A, Li WJ, Singer DD, Kane JA, Dodd KW, Meyers KE, Thode HC, Shroff GR, Singer AJ, Smith SW. Comparison of the ST-Elevation Myocardial Infarction (STEMI) vs. NSTEMI and Occlusion MI (OMI) vs. NOMI Paradigms of Acute MI. J Emerg Med. 2021 Mar;60(3):273-284. doi: 10.1016/j.jemermed.2020.10.026. Epub 2020 Dec 9. PMID: 33308915.


Cantor WJ, Fitchett D, Borgundvaag B, Ducas J, Heffernan M, Cohen EA, Morrison LJ, Langer A, Dzavik V, Mehta SR, Lazzam C, Schwartz B, Casanova A, Goodman SG; TRANSFER-AMI Trial Investigators. Routine early angioplasty after fibrinolysis for acute myocardial infarction. N Engl J Med. 2009 Jun 25;360(26):2705-18. doi: 10.1056/NEJMoa0808276. PMID: 19553646.


Key Terms:

ST-Elevation Myocardial Infarction (STEMI), Occlusive Myocardial Infarction (OMI), Non ST-Elevation Myocardial Infarction (NSTEMI), Non-Occlusion Myocardial Infarction (NOMI), Percutaneous Coronary Intervention (PCI), Tissue Plasminogen Activator (tPA)