STEMI in SPECIAL

CONDITION
( YOUNG AGE,
PREGNANCY, RENAL
FAILURE )
RUKMA JUSLIM
 CRI at baseline approximately
25% of the primary PCI patients.
 Myocardial infarction
uncommon disease in young
individuals ( 2% and 10% ). INTRODUCTION
 AMI in women during
childbearing age is rare, increase
the risk of AMI 3- to 4-fold.
 Metabolic syndrome have
roles in atherosclerosis Acute ST-
and coronary heart segment
disease development elevation
 Clinical Presentation myocardial
more likely to have typical infarction in
angina and less young adults
cardiogenic shock.
 Single-vessel disease

premature ACS

ANGIOGRAPHY
rapid disease progression,
such as thrombogenesis or
plaque rupture, rather than a
gradually evolving process,
such as atherosclerosis.
 Young patients more often
underwent PCI with
higher initial success rate
and relatively few
complications.
 Both young and older ANGIOGRAPHY
patients had a similar
frequency of undergoing
primary PCI with a similar
initial success rate.
1. Glycoprotein IIb/IIIa
inhibitors.
2. Antiplatelet
3. Angiotensin-converting
enzyme inhibitors or Medical
angiotensin receptor Treatment for
blockers STEMI in Young
4. Statin therapy Patients
5. β –blockers
6. Thrombolytic therapy or
performance of primary
PCI
 Young patients, who had a higher
prevalence of smoking than older
patients, had less extensive coronary
artery disease and better clinical
outcomes.

Thrombogenicity, Coronary
obstruction, less atherosclerotic. PROGNOSIS

PCI or Antithrombotic agent

Approach to
patients with
impaired
renal
function
 Dyslipidemia
 Hyperhomocystinemia
 Cardiovascular stress of
ESRD
 Endothelin/NO balance
disrupted
 Oxidative stress Oxidized VASCULAR
LDL C PATHOLOGY
 Inflamation
 Platelet dysfuncyion
 Coagulopathy
 Fibrinolysis
Chronic troponin elevations
in clinically stable patients
with renal failure (and likely
represent nonischemic
myocardial injury), this
REMEMBER FOR
biomarker should be used
CKD
for the diagnosis of MI in
CKD patients.
When primary PCI is not
available, fibrinolytic
therapy should be
considered a treatment
strategy.
REMEMBER FOR
CKD

Increasing rates of
intracerebral hemorrhage
are seen with worsening
renal
 Although clopidogrel
should be considered as a
treatment option in ACS
patients with CKD,
REMEMBER FOR
prasugrel and ticagrelor
may also be considered in CKD
those patients not
considered to be at high
risk of bleeding.
Stage 4 and 5 CKD patients,
Enoxaparin should be used
cautiously in this population.
REMEMBER FOR
CKD
Fondaparinux and bivalirudin
are options that may be
associated with lower rates of
bleeding in patients with stage
3 and 4 CKD.
1. Charateristic chest pain DIAGNOSIS OF
2. Cardiac enzym ACS IN
3. Electroardiographic PATIENTS
changes RENAL FAILURE
4. Angiography.
CARDIAC ENZYM :
Troponin I biomarker based
on its kinetic profile in
patients with renal failure.
DIAGNOSIS OF
ACS IN
The skeletal myopathy of PATIENTS
renal failure patients
elevate creatinine kinase
RENAL FAILURE
myoglobin and some
troponin T assays, making
these tests less desirable.
 Angiographic features of
patients with CRI
frequently include
multivessel CAD, more
complex lesions. Angiographic in
 The identification of Renal Failure
culprit lesion on
angiography.
 Aspirin, beta blockers,
ACEI, ARB and statins.

 Therapies that require

dose adjustment on the MEDICAL
basis of Creatinine TREATMENT
Clearance include LMWH,
Bivalirudin, and GPIIbIIIa
antagonists.
 In-hospital mortality and
bleeding rates were highest in
patients with advanced renal
MEDICAL
failure, who were least likely to
receive guideline- TREATMENT
recommended therapy
(including revascularization)
Approach to
the end-stage
renal
disease(ESRD)
patient with
coronary
artery disease.
Prevention of CIN :
1. Ensure optimal pre and
post-procedure
hydration
2. Acetylcysteine Contrast-
(Mucomyst) Induced
3. Nephrotoxic drugs Nephropathy
4. Selected contrast
Management
STEMI in
pregnancy
Coronary thrombosis

Hypercoagulable state of
pregnancy (coagulation and
fibrinolytic systems)
Physiology
releasable t PA STEMI in
fast-acting tPA inhibitor, pregnancy

Change in the level of

coagulation factors and
reduction in functional
protein S levels .
Increase in blood volume
and cardiac output may
magnify shear forces of
the blood column in large
vessels, propensity for
dissection. Physiology
STEMI in
Coronary dissection
pregnancy
occurs in more than 1
vessel points toward
generalized rather than
localized disease.
Cigarette smoking

increase risk of thrombosis

due to enhanced platelet
aggregability
 Symptoms
ECG changes
cardiac markers.
DIAGNOSIS
Echocardiogram
Exercise testing
 The treatment plan by
both the cardiologist and
obstetrician.
 Revascularization
 Percutaneous Coronary TREATMENT
Intervention (PCI)
 Thrombolytic Therapy (TT)
 relatively contraindicated in
pregnancy
1. Morphine sulfate;
2. Beta-blockers;
3. Nitroglycerin;
4. Calcium channel
blockers; Drug therapy
5. Heparin;
6. Antiplatelet therapy
including aspirin,
clopidogrel, and
glycoprotein IIb/IIIa
receptor inhibitors
 obstetric considerations
and the clinical status of
the mother.
 Prevention or treatment
of myocardial ischemia
during labor:
IV nitroglycerin LABOUR
beta-blockers
Calcium antagonists
( nitroglycerin and calcium
antagonists have some
tocolytic effects and may
prolong labor ).
 Estimation of creatinine
clearance of GFR should
be an essential part of the
pre-PCI patients
evaluation.
 Patients with impaired
renal function are
increased risk of CIN. CONCLUSION
 Chronic troponin
elevations in clinically
stable patients with renal
failure have been
observed (and likely
represent nonischemic
myocardial injury).
 Killip class III or IV during
hospitalization could
predict the in-hospital
morbidity and mortality in
young patients with
STEMI.
 Premature ACS in young CONCLUSION
patients resulted from
rapid disease progression,
such as thrombogenesis
or plaque rupture.
 hypercoagulable state of
pregnancy due to alterations in
the coagulation and fibrinolytic
systems.
 The mode of delivery in a CONCLUSION
patient with gestational MI
should be determined by
obstetric considerations and
the clinical status of the mother