MI + Bradycardia

Question 1

A 62 year old man presents to ED with chest pain for 3 hours in a tertiary hospital. His ECG shoes Inferior STEMI. His BP is 108/66mmHg and a heart rate of 45bpm. He is in pain. How will you assess and manage him?

Answer 1

Impression
Inferior STEMI as per ECG findings. This is a medical emergency demanding urgent assessment and management. The Bradycardia is likely due to infarction of vascular supply to conduction system of heart /SA node

Complications concerned about;
- Re-infarction
- Arrhythmias
- acute cardiac failure
- heart block and cardiac arrest

Goals
- Rapid assessment and emergent treatment, with priority for reperfusion treatment with either PCI or tPA.
- referral for ongoing/ long-term CVD risk factor optimisation and management

Question 2

STEMI - Assessment

Answer 2

Assessment
Take A to E approach, call for senior help (MERT)
A - patent, maintaining, tube pending GCS
B - RR/SP02, supplemental 02
C - ECG monitoring (serial). BP/HR. 2xIVC access for bloods (Trops, BNP, FBC, UEC, LFT, CRP). Put pads on for transcutaneous pacing given bradycardia, ?vascular access for transvenous (be prepared for unless improves with reperfusion therapy).
D - GCS, PEARL

Initial/definitive acute management
- DAPT: Aspirin 300mg loading dose then 100-150, Clopidogrel 600mg loading dose then 75
- Reperfusion: Thrombolysis (tenecteplase) if not CI, or straight for PCI if available in acute setting (90-120 minutes)
Other
- Atropine for bradycardia
- UHF 5000units as pre-preparation for PCI in theatres
- defib and prepare for transcutaneous pacing in setting of acute deterioration
- GTN patch for pain +/- morphine

Question 3

STEMI - History

Answer 3

History
- collateral/from patient
- sx: chest pain (Socrates), SOB, dyspnoea, diaphoresis, timing, progression,
- HPI: past angina, CVD risk factors and pharmacological management,
- Medications, allergies, last meal
- SNAP

Question 4

STEMI - Examination

Answer 4

Examination
as per A to E
- general appearance + vitals
- Cardiac examination: PR, murmurs, BP monitoring

Question 5

STEMI - Investigations

Answer 5

Investigations
Key/diagnostic
- serial ECG
- serial trops

• bedside: trops, ECG, VBG
• bloods: FBC, UEC, LFT, CRP, lipid panel,
• imaging: CXR (ddx list), ECHO, Coronary angiography

Question 6

STEMI - Management

Answer 6

Management
Acute
- as per in A to E assessment: goal is reperfusion ASAP
- cardio consult/ referral for PCI if available/appropriate

otherwise
- Pain medication
- documentation
- inform family

Longterm
- optimise CVD risk factors with non-pharm and pharmacological
o SABA