A CASE OF “TYPICAL” STEMI IN INDIAN SCENARIO

Dr Arindam PandeConsultant Cardiologist,

Apollo Gleneagles Hospital, Kolkata

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

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

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?

OPINION OF THE HOUSE…

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

RESCUE PCI: LEVEL OF EVIDENCE

RELOADING ANTIPLATELETS: CURRENT RECOMMENDATION

EVIDENCE FOR THROMBUS ASPIRATION

Aspiration thrombectomy was associated with a small but nonsignificant increase in the risk of stroke

EVIDENCE FOR IC GP2B/3A INHIBITORS

WHICH STENT ?...CURRENT EVIDENCE

WHICH STENT ?...Cont.

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