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A CASE OF “TYPICAL” STEMI IN INDIAN SCENARIO
Dr Arindam PandeConsultant Cardiologist,
Apollo Gleneagles Hospital, Kolkata
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CASE HISTORY
• 55 year male• T2DM – 12 years, poor glycemic control• Smoker• Chest pain since 2 o’clock at night• Admitted in local hospital, diagnosed as ASMI• Thrombolysed with Streptokinase with prior loading
of Aspirin and Clopidogrel (300 mg each) plus Atorvastatin 80 mg
• No resolution of ST segment in ECG• Chest pain persisted• Patient was referred to higher center
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COURSE AT OUR HOSPITAL• We received the patient at 1 o’clock in ER• Ongoing chest pain• No resolution of ST segment in ECG• SBP 96 mm Hg, HR 110, SpO2 – 92% (O2 in nasal
canola)• Fine bi-basal crepitations
• Decision for rescue PCI was made and patient shifted to cathlab
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WHAT’S NEXT?• Whether to intervene at this point?• Anti-platelet loading regime?• Use of thrombus aspiration catheter?• Use of intracoronary GP 2B/3A inhibitors?• Use of intracoronary Adenosine, Nikorandil,
Nitropruside?• Whether to stent in this sitting?• Which stent: bare metal, DES or bioabsorbable?
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OPINION OF THE HOUSE…
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FURTHER MANAGEMENT…
• Ongoing chest pain prompted us to proceed for PCI without viability study
• Early hemodynamic instability was another factor for choosing intervention
• Patient was not reloaded with antiplatelets• Low dose Dopamine infusion was initiated to
stabilize BP • UFH was given 70 U/kg body weight IV bolus
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RESCUE PCI: LEVEL OF EVIDENCE
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RELOADING ANTIPLATELETS: CURRENT RECOMMENDATION
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EVIDENCE FOR THROMBUS ASPIRATION
Aspiration thrombectomy was associated with a small but nonsignificant increase in the risk of stroke
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EVIDENCE FOR IC GP2B/3A INHIBITORS
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WHICH STENT ?...CURRENT EVIDENCE
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WHICH STENT ?...Cont.
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TAKE HOME MESSAGE• In cases of failed thrombolysis, we should refer to
PCI-enabled center in an urgent basis• Thrombus aspiration, though not backed by
evidence beyond doubt, is effective in selective practical situations
• Intracoronary GP 2B/3A, Adenosine, Nikorandil: all are effective in real life scenario
• Though bioabsorbable scaffolds are non-inferior to metal stents in ACS, we should wait for further evidences before advocating widespread use