ST-Elevation Myocardial Infarction (STEMI) Pathway

Ahmad Sharadqa¹.

*Correspondence to: Ahmad Sharadqa.

Copyright

© 2023 Ahmad Sharadqa. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Received: 19 June 2023

Published: 01 July 2023

Purpose

Care of the ST-elevation myocardial infarction (STEMI) and cardiogenic shock (CS) patient requires a systematic approach to ensure optimal care. To assist the emergency department (ER), cardiac catheterization laboratory (CCL), and coronary care unit (CCU) to achieve best care possible.

Management of Cardiogenic Shock Complicating MI

Description of Roles and Responsibilities of door to balloon (D2B) Team.

Ideal D2B process, and time record. 

Definition

STEMI: An acute myocardial infarction that generates a specific type of ST-segment elevation on a 12-lead ECG

Cardiogenic Shock (CS): Cardiogenic shock is a life-threatening condition in patients with acute myocardial infarction, caused by severe impairment of myocardial performance that results in diminished cardiac output, end?organ hypoperfusion, and hypoxia

Fibrinolytic therapy: is used to lyse acute blood clots by activating plasminogen. This results in the formation of plasmin, which cleaves the fibrin cross-links causing thrombus breakdown. Administered to patients with J-point ST-segment elevation greater than 2 mm (0.2 Mv) in leads V2 and V3 and 1 mm or more in all other leads or by new or presumed new LBBB without contraindications.

Examples of fibrin-specific drugs are rtPA, reteplase, and Tenecteplase.

• D2B: door to balloon time is a time measurement between the arrival of a patient with STEMI in the ER until the time of balloon inflated in the CCL
• Time entry form: recording the time of patient arrival the ER until the balloon inflated in CCL

• STEMI protocol: guideline form to give high-quality treatment for confirmed STEMI patient
• STEMI Team-A: (cardio specialist, cardio interventional, nursing supervisor, cath lab team, anesthesia, surgeon, and perfusionist)
• STEMI Team-B: (Cardio surgeon, perfusionist, and OR team)

STEMI Protocol

ER Responsibility

Triage ER nurse, Primary ER Nurse, ER Charge Nurse:

Triage nurse respond directly as “first priority” to patients identified as possible STEMI Alert. most common symptoms:

• Chest pain/discomfort, uncomfortable pressure, squeezing
• Upper abdominal pain (epigastric pain)
• Arm, shoulder or jaw pain
• Shortness of breath
• Nausea/vomiting
• Dizziness/ near syncope
• Palpitations

Perform rapid initial assessment with ECG and give to ER physician with the goal of STEMI diagnosed/confirmed within 10 minutes of patient arrival

If STEMI confirmed, institute immediately activate CCL team

• Obtain appropriate laboratories, and preparation
• Keep patient NPO  
• Attach cardiac monitor
• Start 2 IV’s (gages18, 20) at Left arm to KVO
• Remove all clothes and Wear hospital gown (open front)
• Shave right wrist arm, and groin area (right and left)

Emergency Physician/ cardiology specialist:

Perform rapid patient assessment to establish patient appropriateness for STEMI Alert status.

Respond with “first priority” to potential STEMI Alert ECG with STEMI diagnosed/confirmed within 10 minutes of arrival as criteria of STEMI alert:

A- Inclusion criteria for immediate ER activation of STEMI Alert Team:

1. Symptom onset <12 hours
2. ECG evidence of STEMI
3. < 80 years’ old
4. Ongoing pain
5. Mobile and independent

B- Criteria requiring discussion with cardiologist:

1. Symptom onset > 12 hours
2. Borderline ECG changes
3. Left bundle branch block(LBBB)
4. Prior coronary artery bypass graft (CABG)
5. Significant comorbidities (e.g., malignancy, dementia)
6. Out-of-hospital cardiac arrest
7. Pulmonary oedma/Cardiogenic shock
8. Major surgery in past 2 weeks
9. Active bleeding
10. < 80 years’ old
11. Endotracheal intubation

Interventional Cardiologist responsibility:

• Immediately respond to call
• Discuss the case with either the initial ER physician/ cardiology specialist.
• Confirm STEMI case
• Arrive CCL within 20-30 minutes ready to start the procedure 
• Inflation balloon within 20-30 minutes of starting the procedure

CCL Team responsibility:

• Immediately respond to call and arrive within 20-30 minutes including preparation the procedure room, materials, medications, activate the cath lab machine and Call ER to transfer the patient
• Final check and proper hand-off
• Prepare the patient on cath lab table to be ready for catheterization within 10 minutes

References                                                                                                                 

1. ACC/AHA Guidelines for the Management of Patients with ST-Elevation Myocardial Infarction.

2. American College of Cardiology: Primary Percutaneous Coronary Intervention for Patients with ST-Elevation Myocardial Infarction (Focused Update): An Update of the Guideline for Percutaneous Coronary Intervention and the Guideline for the Management of ST-Elevation Myocardial Infarction.

3. 2017 ESC Guidelines for the Management of STEMI

4. Reynolds HR, Hochman JS. Cardiogenic shock. Current concepts and improving outcomes. Circulation 2008;117:686–697.

5. Medical Clinic II (Cardiology/Angiology/Intensive Care Medicine), University Heart Centre Luebeck, University Hospital Schleswig-Holstein, Ratzeburger Allee 160, Luebeck 23538, Germany; and 2 Duke University Medical Centre, Durham, NC, USA Received 30 December 2014; revised 4 February 2015; accepted 11 February 2015; online publish-ahead-of-print 2 March 2015

6. Abrams D, Combes A, Brodie D. Extracorporeal membrane oxygenation in cardiopulmonary disease in adults. J Am Coll Card 2014;63:2769–2778.

7. Wong GC, Welsford M, Ainsworth C, et al. 2019 Canadian Cardiovascular Society/Canadian Association of Interventional Cardiology Guidelines on the Acute Management of ST-Elevation Myocardial Infarction: Focused Update on Regionalization and Reperfusion. Can J Cardiol. 2019;35(2):107-132
8. Promes S, Glauser J, Smith M, Torbati S, Brown M. Clinical Policy: Emergency Department Management of Patients Needing Reperfusion Therapy for Acute ST-Segment Elevation Myocardial Infarction. Ann Emerg Med. 2017;70(5):724-73