STEMI

Question 1

What is involved in the management of a STEMI?

Answer 1

1. ECG
2. IV access and bloods
3. Brief assessment
4. Aspirin and ticagrelor
5. Morphine
6. Consider reperfusion therapy

Question 2

What bloods should be done in STEMI?

Answer 2

• FBC
• U&Es
• Glucose
• Lipids
• Troponin

Question 3

What should be included in brief assessment in STEMI?

Answer 3

• History of CVS disease
• Risk factors for IHD
• Pulse, BP, JVP, murmurs, signs of CCF, upper limb pulses
• CXR if won’t delay management
• Contraindications to PCI or fibrinolysis

Question 4

What dose of aspirin should be given in STEMI?

Answer 4

300mg

Question 5

What dose of ticagrelor should be given in STEMI?

Answer 5

180mg

Question 6

If clopidogrel is used instead of ticagrelor, what dose should be used?

Answer 6

300mg

Question 7

What dose of morphine should be given in STEMI?

Answer 7

5-10mg IV

Question 8

What should be given with morphine in STEMI?

Answer 8

Metaclopramide 10mg IV

Question 9

Should GTN be used in STEMI?

Answer 9

Routine use not recommended in acute setting unless patient is hypertensive or in acute LVF

Question 10

When should oxygen be used in STEMI?

Answer 10

• Sats <95%
• Breathless
• Acute LVF

Question 11

What are the ECG criteria for reperfusion therapy?

Answer 11

One of;

• ST elevation >1mm in 2+ adjacent leads, or >2mm in 2+ adjacent leads
• LBBB
• Posterior changes (deep ST depression and tall R waves in leads V1-3)

Question 12

What are the options for reperfusion therapy in STEMI?

Answer 12

• Primary PCI

- Thrombolysis

Question 13

Who should be offered primary PCI in STEMI?

Answer 13

Patients presenting within 12 hours of symptom onset, who are either at or can be transferred to a primary PCI centre within 120 mins of first medical contact.

Question 14

When should primary PCI be used beyond 12 hours of symptom onset?

Answer 14

Evidence of ongoing ischaemia or in stable patients presenting after 12-24 hours - seek specialist advice

Question 15

What is the target time for thrombolysis?

Answer 15

Within 30 min from admission

Question 16

When does the use of thrombolysis require specialist advice?

Answer 16

> 12 hours from symptom onset

Question 17

What agent is used for thrombolysis in STEMI?

Answer 17

Tenecteplase

Question 18

What are the contraindications to thrombolysis?

Answer 18

• Previous intracranial haemorrhage
• Ischaemic stroke <6 months
• Cerebral malignancy or AVM
• Recent major trauma/surgery/head injury (<3 weeks)
• GI bleeding in last month
• Known bleeding disorder
• Aortic dissection
• Non-compressible punctures <24hours, e.g. liver biopsy. LP

Question 19

What are the relative contraindications to thrombolysis?

Answer 19

• TIA <6 months
• Anticoagulant therapy
• Pregnancy/ >1week post-partum
• Refractory hypertension
• Advanced liver disease
• Infective endocarditis
• Active peptic ulcer
• Prolonged/traumatic resuscitation

Question 20

What should happen if thrombolysis?

Answer 20

Patients should be transferred to primary PCI centre for rescue PCI (if residual ST elevation) or angiography (if successful)

Question 21

What should be done in patients with STEMI who do not receive reperfusion therapy?

Answer 21

Treated with fondaparinux