1. Risk stratification and Medical management of STEMI Dr . Ranjith MP 14-11-2011

2. OUTLINE Definition of MI Risk stratification Medical management

3. REVISED DEFINITION MI (Myocardial infarction redefined�a consensus document of The Joint European Society of Cardiology/American College of Cardiology committee for the redefinition of myocardial infarction:. J. Am. Coll. Cardiol. 2000;36;959-969) Criteria for Acute, Evolving, or Recent MI Either of the following criteria satisfies Typical rise &/or fall of biochemical markers of myocardial necrosis with at least one of the following: Ischemic symptoms ECG changes indicative of new ischemia (new ST elevation or new/presumed to be new LBBB) Development of pathological Q waves in the ECG Imaging e/o new loss of viable myocardium or new RWMA Pathologic findings of an acute MI

4. REVISED DEFINITION MI (Myocardial infarction redefined�a consensus document of The Joint European Society of Cardiology/American College of Cardiology committee for the redefinition of myocardial infarction:. J. Am. Coll. Cardiol. 2000;36;959-969) PCI periprocedural MI: increases of biomarkers >3 x 99th percentile URL CABG-related MI Increases of biomarkers >5 x 99th percentile URL plus either new pathological Q waves or new LBBB, or angiographically documented new graft or native coronary artery occlusion, or imaging evidence of new loss of viable myocardium.

5. REVISED DEFINITION MI (Myocardial infarction redefined�a consensus document of The Joint European Society of Cardiology/American College of Cardiology committee for the redefinition of myocardial infarction:. J. Am. Coll. Cardiol. 2000;36;959-969) Criteria for established MI. Either of the following criteria satisfies Development of new pathologic Q waves on serial ECGs. The patient may or may not remember previous symptoms. Biochemical markers of myocardial necrosis may have normalized, depending on the length of time that has passed since the infarct developed. Pathologic findings of a healed or healing MI.

6. Risk stratification of STEMI

7. Risk stratification of STEMI There is risk stratification within STEMI, but in general, STEMI is high-risk Important to select greater-risk patients who warrant more aggressive strategies for prevention of future serious events such as reinfarction or sudden death

8. Risk Stratification Occurs in several stages Initial presentation In-hospital course (CCU, intermediate CU) At the time of hospital discharge

9. Acute Phase Risk Stratification: Prior angina pectoris Prior MI Female gender Hypertension History of CHF Hyperlipidemia Diabetes ECG Criteria Markedly elevated cardiac enzymes Elevated BUN Complications VSR/PMD-rupture Myocardial rupture

10. Acute Phase Risk Stratification:Electrocardiographic features Anterior MI/ Persisting ST elevation Q waves in multiple leads RVMI + IWMI High sum of ST elevation Reciprocal ( anterior ) ST depression Persisting ST depression Prolonged QT Conduction defects/ heart block Sinus tachycardia/atrial fibrillation

11. Acute Phase Risk Stratification:Importance of LV dysfunction