Initial Management of Patients with STEMI

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Heart Disease is the leading cause of death in adults in the United States. Recent advances in the treatment of acute myocardial infarction have significantly reduced rates of morbidity and mortality. However, these treatments are time-sensitive and necessitate rapid initiation for desirable outcomes. It is an essential part of the initiation process for patients to recognize signs and symptoms of STEMI and seek help immediately. The healthcare providers’ role is to accurately diagnose an MI, regardless of their presentation, and to initiate appropriate treatment. Initial Management of Patients with STEMI will cover timing, protocol, checklists, and more to help improve patient outcomes and reduce morbidity and mortality. 

Introduction 

Heart Disease is the leading cause of death in adults in the United States. Recent advances in the treatment of acute myocardial infarction have significantly reduced rates of morbidity and mortality. However, these treatments are time–sensitive and necessitate rapid initiation for desirable outcomes. It is an essential part of the initiation process for patients to recognize signs and symptoms of STEMI and seek help immediately. The healthcare provider’s role is to accurately diagnose an MI, regardless of their presentation-typical or atypical, to initiate appropriate treatment. Initial Management of Patients with STEMI will cover timing, protocol, checklists, and more to help improve patient outcomes and reduce morbidity and mortality. 

Delay in Treatment 

There are several concerns relating to the delay in the treatment and diagnosis of STEMI. The first area of concern is related to the delay in patient access to medical care. Many patients wait a significant amount of time after the onset of symptoms before seeking care (1). The initial management of patients with STEMI is the most crucial part of treatment and delays in treatment can result in worsening outcomes. 

Timing is Everything. 

• The median delay from chest pain onset until the patient arrives in the ED is greater than 2 hours. 
• The average delay is significantly longer due to a small number of people who wait up to 24 hours or longer before seeking care (1).  

Studies show that if a patient with acute myocardial infarction is treated within 70 minutes, the damage to the left ventricle can be minimized. If therapy is delivered after this amount of time the rates of morbidity and mortality rise dramatically as irreversible damage has already occurred (1). The first step in the initial management of patients with STEMI is in the patients’ control, which is why patient education is vital to help patients recognize the symptoms. 

The second area of concern relates to delays that may occur before the healthcare provider makes an AMI diagnosis and definitive care is implemented. Chest pain is a frequent complaint among patients presenting to the ED which include 5% of ED visits. Despite this, only 10-15 % of these patients presenting with chest pain have an AMI (1).  

The third area of concern is the healthcare providers’ failure to diagnose AMI in patients with typical or atypical systems correctly. Correct diagnosis is pivotal in the initial management of patients with STEMI. Based on research from the American College of Emergency Physicians (ACEPS), “4-13% of patients with AMI are released from the ED with false reassurance that they do not have coronary artery disease as a cause of their symptoms (1).” Many of these patients later suffer complications from their MI, with 11-25 % of these patients dying (1).  

As a result of these astonishing numbers and failure in the traditional approach, many Emergency Departments have developed specialized protocol, personnel, space, and equipment for the patient presenting with chest pain. Along with these protocols, prehospital chest pain evaluation should be made by 911 dispatchers and EMS providers to begin the process of diagnosis and treatment in a timely manner to improve patient outcomes.  

In patients with ECG evidence of STEMI, paramedics should review a reperfusion checklist and relay ECG checklist findings to a predetermined medical facility (2). This checklist is designed to determine any potential comorbidities and underlying conditions in which fibrinolytic therapy could be harmful to the patient.  

Reperfusion Checklist for Evaluation of the Patient with STEMI 

The following checklist covers the process for evaluating a patient to determine if fibrinolysis is indicated in the initial management of patients with STEMI (3).

STEP 1:

Has the patient experienced chest discomfort for greater than 15 minutes and less than 12 hours?

• No -> STOP
• Yes -> Are there any contraindications to fibrinolysis?

STEP 2:

Are any of the following true for the patient?

• Diastolic BP > 100 mmHg
• Right vs left arm systolic BP difference greater than 15 mmHg
• History of structural central nervous system disease
• Significant closed head/facial trauma within the last three months
• Recent major trauma, surgery, or GI bleed (6 weeks)
• Bleeding or clotting problem OR on blood thinners
• Pregnant female
• Serious systematic disease

If ANY are true, fibrinolysis may be contraindicated.

STEP 3:

Does the patient have severe heart failure or cardiogenic shock such that PCI is preferable?

• Pulmonary edema
• Systemic hypoperfusion

Example of Interventional Protocol from the American College of Cardiology

A Door-to-Balloon “STEMI Alert” Checklist has been created by the American College of Cardiology as a standard for intervention among patients experiencing STEMI. Below are steps and processes, and protocols for a patient receiving timely treatment. The goal for door to balloon time of ≤90 minutes if patients arrive directly to ED without EMS transport (4). The informational checklist below is based on information from the American College of Cardiology and the American Heart Association as a guideline to follow for a patient with STEMI (2,4). 

Initial Patient Contact to Confirmed STEMI Diagnosis
Goal Time: 5 Minutes

If patient arrives by ambulance:  

• ECG obtained and assessment conducted in ambulance.  
• ECG transmitted from ambulance to ED along with physical assessment to confirm STEMI.  

If patient arrives at hospital in personal car or ambulance without ECG:  

• Triage nurse should preform rapid assessment, history of paint and obtain ECG with patient of complaints of chest pain and less typical signs of MI. 
• ECG and assessment findings communicated to advanced provider or physician to confirm STEMI.  

For ALL patients: 

• 2L of oxygen should be administered per nasal cannula.  
• Asa 81 mg. x 4 chewed and administered in ambulance unless already taken by the patient or contraindicated.  
• Consider morphine sulfate administered for pain. 
• IV fluids at KVO  
• Lab work including cardiac markers, CVC, INR, BMP, and Lipid Profile  

STEMI Diagnosis to Initiation of Cardiac Cath Lab
Goal Time: 5 Minutes

• ED physician or advanced provider notified hospital operator to send group page to Interventional Cardiologist and Cardiac Cath Lab Team. 
• The Interventional Cardiologist as well as the Cardiac Cath lab team responded to the page within 5 minutes.  
• ED physician or advanced provider verified with hospital operator that pages are confirmed.  

Activation of Cardiac Cath Lab Team to Arrival
Goal Time: 30 Minutes

• ED physician or advanced provider explained diagnosis, coronary angiography, and PCI to patient and family prior to Interventional Cardiologist arrival. 
• Informed consent obtained for diagnostic cath and PCI from patient or next of kin.  
• Data collected included VS, height and weight, pulmonary assessment, cardiac auscultation, peripheral pulse assessment, time of symptom onset, allergies, prior cardiac procedure history, time of last meal, description of chest discomfort.  
• Heparin administered.  
• Glycoprotein IIB/IIA Inhibitors administered (block platelet aggregation). 
• Beta–blockers administered unless contraindicated.  
• The admitting team notified of critical care or step-down bed.  
• Staff prepare catheterization site.  
• Staff communicate regarding transport to cath lab.  

Cardiac Cath Lab Team Arrival to Intervention
Goal Time: 35 Minutes

• Pre-mixed medications readily accessible to cath lab (e.g., dopamine, dobutamine, nitroglycerine, heparin). 
• ED nurse and cath lab nurse complete nursing hand-off. 
• Family sent to waiting area and pastoral care notified by ED nurse.  
• Patient lab results called to cath lab.  
• Interventional Cardiologist scrubbed in while patient positioned on the table.  
• Nurse and tech staff position patient on table monitors connected patient prepped and drape, ongoing assessment provided of patient. 
• Angiography of infarct–related artery performed to allow selection and preparation of interventional equipment.  
• Guide catheter and interventional guidewire prepped and ready for a decision to proceed with PCI (passing of guidewire to re-establish blood flow). 
• Angioplasty balloon and coronary stents prepped and ready.  
• Heparin administered.

Initial Management of Patient with STEMI Symptoms 

Physical Exam

“Physical examination should be performed to aid in the diagnosis and assessment of the extent, location, and presence of complications of STEMI (2).” A brief limited neurological exam to assess for evidence of stroke should be performed prior to the administration of fibrinolytic therapy (2). These exams enable rapid triage of patients to expedite the treatment process.  

• Brief Physical Exam  
• Airway, Breathing Circulation (ABC)  
• Vital Signs 
• Presence or absence of jugular venous distension 
• Pulmonary auscultation  
• Cardiac auscultation 
• Presence or absence of stroke  
• Presence or absence of pulses  
• Presence or absence of systemic hypoperfusion (cool, clammy, pale, ashen)  

According to the American Heart Association guidelines in the treatment of patient with a STEMI, the choice of STEMI treatment should be made by the emergency medicine physician or advanced practitioner on–call based on the predetermined, institution-specific protocol. The protocol should be a collaborative approach involving cardiologists, emergency physicians/practitioners, nurses, and other appropriate personnel. For patient satiations where the diagnosis and treatment plan are unclear to the provider or not covered explicitly by the institution’s written protocol, immediate cardiology consultation is advisable (2).  

Laboratory Findings and Biomarkers

Laboratory exams should be performed as a part of management for STEMI patients; however, the process should not delay reperfusion therapy initiation (2). 

• Cardiac-specific troponins should be used as the ideal biomarker for the evaluation of patients with STEMI who have a coexistent skeletal muscle injury.  
• For patients with ST–elevation along with symptoms of STEMI, reperfusion therapy should be initiated as soon as possible and should not be contingent on biomarker assay (2).  
• Serial biomarkers can provide supportive evidence of reperfusion after fibrinolytic therapy patients who are not undergoing angiography within the first 24 hours after receiving fibrinolytic therapy. They should not be relied upon to diagnose reinfarction within the first 18 hours after the onset of STEMI (2). 

Nitroglycerine

The use of Nitroglycerine is indicated for the relief of ongoing ischemic discomfort as well as the control of hypertension or the management of pulmonary congestion (2). 

• Patients with ongoing discomfort should receive sublingual nitroglycerin (0.4 mg) every 5 minutes for a total of 3 doses. After this, an assessment should be made about the need for intravenous nitroglycerine.  
• Should not be administered to patients with systolic blood pressure less than 90 mmHg or greater than or equal to 30 mmHg below baseline, severe bradycardia, tachycardia, or suspected RV infarction.  
• Should not be administered to patients who have received phosphodiesterase inhibitor for erectile dysfunction within the last 24 hours (2).  

Pain Management

Pain management is a crucial element in the initial management of patients with STEMI. The control of cardiac pain is usually accomplished with a combination of nitrates, opiate analgesics, oxygen, and beta-adrenergic blockers.  

Facts to keep in mind upon assessment of a patient presenting with possible STEMI: 

• Elderly patients are more likely to complain of shortness of breath as well as other atypical symptoms such as syncope or unexplained nausea (2). 
• People with diabetes may have impaired angina (pain) recognition, especially in the presents of autonomic neuropathy. Diabetic patients may misinterpret dyspnea, nausea, vomiting, fatigue, and diaphoresis as a disturbance of their diabetic control (2).  
• Only 40-50% of patients with AMI have clear evidence of ECG infarction on their initial presentation to the ED (1). Therefore, protocol and observational data are extremely important tools for the response team to keep in mind when caring for and diagnosing a patient with STEMI.  
• If the initial ECG is not diagnostic of STEMI, but the patient remains symptomatic, and there is high clinical suspicion for STEMI, serial ECGs at 5–10-minute intervals or continuous 12-lead ST-segment monitoring should be performed to detect potential development of ST elevation.

Conclusion

The initial management of patients with STEMI is the most crucial part of treatment. With implementation of quality protocols and team management, the healthcare team can evolve and implement strategies to improve patient outcomes and reduce morbidity and mortality. It is essential for healthcare providers working in the environments of Emergency Departments, Cath Labs, ICU’s, and step-down units to understand the importance of timely intervention among the patients that they are caring for.  

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