STEMI

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DEFINITION
See acute coronary syndromes.
Only management of this stratification will be discussed here.
- see additional perioperative MI notes also.

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MANAGEMENT
Initial Management
Refer ACS iCARD.

Interpret the ECG:
Anterior: V1-V4 elevated
Inferior: II,III,aVF elevated
Posterior: isolated ST depression in V1,V2

Post-Stratification Management
Aspirin (ISIS II trial - 27% RRR of death).
Thrombolysis (Huge trials - 25% RRR of death).
NB that these two are complimentary, target different parts of the thrombus (see ACS iCARD).
Overall 48% RRR of death.
Can thrombolyse with strep or tPA, tPA better but 10x price.
B-blocker - see below

Contraindications
>12 hours since onset of pain.
(Cardiologists may choose to otherwises, as they can make up evidence on the spot).
Active GI bleeding or PUD.
Major surgery / trauma last 1/12.
Prior haemorrhagic stroke.
Pregnancy.
Recent head injury, however minor
Prolonged traumatic CPR
- Risk of haemorrhagic stroke is 0.39%.

Further Management
Proceed to invasive methods if no success with strep.

Secondary Prevention
Beta-blocker
Metoprolol is agent of choice.
20% reduction in sudden death (VF and cardiac rupture).
Also decreases myocardial O2 demand and decreased BP)
--> give early but not in CHF, bradycardia or hypotension

ACEi
(HOPE Trial).
Independent vessel protection and prevents remodelling.

Aspirin
Low dose.

Statin
If high lipids.
Target <4.00 (AVERT trial).
Low 3s ideal.
RRR 28% of death over 5 yrs (4S trial).

Blood Pressure
If needed further to the above agents.
Want target of 125/85 (be vigorous - WHOISH recommendations).
Benefit down to 120/80.
Beware J-shaped curve of increasing mortality below this.
NB - Thiazides are losing favour as they leach K+, and have no independent advantage, unlike ACEi, Beta-blockers.

Diet
Accounts 10-15% of cholesterol levels.
Increase fruit and vegetable intake - NHF recommends 7+ a day in those with cardiac disease.
Antioxidants (anthracidins in grapes, strawberries, cruesetin in tomatoes).
Vegetables bind to fat in the gut decreasing absorption.
Decrease saturated fats.

Exercise
30-40 minutes 3-4 times per week - bare minimum.
Slight further benefit 1 hr.
Excessive exercise beyond this, especially vigorous sports should be avoided because of the risk of intimal tears.
Sex ok if pt can get heart rate above 115bpm/ walk 20mins and then swiftly climb a decent flight of stairs.

Other
Modify other risk factors.
Don't smoke or you're a death waiting to happen.
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