STEMI/NONSTEMI Flashcards
cardinal symptoms of CV dx
Cardinal Symptoms of Cardiovascular Disease
- Chest pain or discomfort
- Dyspnea
- orthopnea
- paroxysmal nocturnal dyspnea
- wheezing Cough
- hemoptysis
- Fatigue
- weakness
- Pain in extremities with exertion (claudication)
Epidemiology of the STEMI
- Epidemiology:
- Coronary Heart Disease (CHD) Causes
- One (1) out of six (6) adults in the US (380,000 deaths/year)
- One(1)coronaryeventq30seconds
- STEMI accounts for 30% of all MI’s
- Coronary Heart Disease (CHD) Causes
Clinical history of STEMI patient
- Clinical Manifestations
- History
- – Chest discomfort (more sever than angina)
- – Heavy, pressure, crushing, etc.
- – Retrosternal, left, across chest; neck, jaw,
- Left arm, epigastrium
- – Nausea, vomiting, diaphoresis, dyspnea,
- – Not reliability relieved by Nitro or rest
- – 20% AMI are painless (silent); diabetic elderly woman
clinical manifestation of STEMI patient
- Physical Exam
- Normal
- S4 Gallop
- BP Variable
- Sympathetic hyperactivity (↑ HR, ↑BP) seen in anterior MI
- Parasympathetic hyperactivity (Bradycardia, ↓BP) in inferior MI
- Heart Failure–S3, crackles, ↑JVD, new murmur
ST Segment Elevation = X infarction?
transmural
NSTEMI vs NSTE ACS
- NSTEMI
- ST segment depression, T wave inversion
- Chest pain, elevated cardiac enzymes
- NSTE ACS
- ST segment depression, T wave inversion, chest pain
- Normal cardiac enzymes
ECG
ECG Evolution
- Early Acute Phase
- T wave increase amplitude
- Hyper-acute pattern
- Convex upward ST pattern
Other causes of ST elevation
- Pericarditis
- LVH with J point elevation
- Normal variant early repolarization
Evolved Acute Phase
Evolved Acute Phase
- Chronic Phase
- Resolution of ST elevation is variable (2 weeks inferior wall; later anterior wall)
- Persistent ST elevation (after 2 weeks) think ventricular aneurysm
QRS Complex normally
QRS Complex
- Ventricular depolarization
- .05-.10 sec duration
- Q waves shouldn’t be found more than. 03 sec in width
- Q waves, narrow/small, 1-2mm is normal in 1, AVL, AVF, V5,V6
Normal ST Segment after QRS Complex
• Normally it is isoelectric; sometimes normally elevated not more than 1mm in standard leads and 2mm in chest leads; it is Never normally depressed more than 1/2 mm.
ST depression- sub endocardial/ST elevation – sub epicardial or transmural injury or ischemia.
observe the level (relative to baseline; elevated or depressed) and shape.
Normally it is isoelectric
Sometimes normally elevated not more than 1mm in standard leads and 2mm in chest leads
it is never normally depressed more than 1/2 mm.
ST depression- sub endocardial/ST elevation – sub epicardial or transmural injury or ischemia.
V1-V7
Anterior Wall infarction
II, III, aVF, V3R-V6R
RCA: inferior wall infarction (RV infarction)
I, AvL, V5-V6
circumflex a–> Lateral wall
V1-V3
Posterior descending a. –> posterior wall infarction
Zone of ischemia
Zone of Injury
Zone of infarction
Zone of ischemia: T wave inversion due to altered repolarization
Zone of injury: ST segment elevation
Zone of infarction (muscle death): Q or QS waves
Stages of a transmural infarct: subendocardial stage
- infarct has not occured (no cell death yet)
- R wave is more or less normal
- ST elevation
- T wave is peaked
Transmural infarct: first day
R wave amplitude diminishing
ST elevation marked
Transmural infarct: first and second day
R wave almost gone or gone
Significant Q wave
T wave inversion beginning
Transmural infarct 2-3 days
No R wave, Marked Q wave, deep T wave inversion, ST may be at baseline
transmural infarct After several weeks or months
- Some R wave may return
- significant Q wave persists
- T wave often less inverted
- ST elevation may persist if aneursym develops
STEMI tx
E.D. Standard of Care - STEMI
• 12 lead ECG with continuous cardiac monitoring
- IV lines inserted
- Cardia cenzymes(cTnI),CBC,CMP,PT,PTT
Reperfusion Strategy
Reperfusion Strategy
- Choices
- Primary Percutaneous Coronary Intervention (PCI) with angioplasty and stenting
- Cath lab within 90 minutes (goal)
STEMI tx 30 minutes and 90 minutes
Fibrinolysis (clot busters)
Fibrinolytic or Thrombolytic
Begun in Emergency Dept. within 30 minutes (goal)
Reperfusion Strategy - Choices
- Primary Percutaneous Coronary Intervention (PCI) with angioplasty and stenting
- Cath lab within 90 minutes (goal)
failure of ST segment to normalize by 50-70% in the first hour
Reperfusion Therapy
- Accelerates changes over minutes to hours
- Failure of ST elevation to resolve by > 50-70% within 1-2 hours suggests failure of fibrinolysis
hospital does NOT have a cath lab and your patient has a STEMI: next step
If hospital does not have a catheter lab (non PCI capable) transfer within 120 min (goal)
STEMI with symptoms up to but less than 12 hrs
Primary PCI–preferred for STEMI with symptoms <12 hours
• Lower mortality rate and ICH (intracerebral hemorrhage)
If No
Fibrinolytic Therapy: what two situations is it useful in?
Fibrinolytic Therapy: Useful in two situations
STEMI or new left BBB within 12 hours of onset of symptoms
• Major risk is ICH (.5 to 1.0%)
Initial Medical Management - STEMI
ASA
ASA (162–325mg) po–given on presentation /unless contraindicated
apart from ASA, what other drugs would you give for a stemi initially?
IV Heparin or Enoxaparin
- Adenosine diphosphate receptor (p2Y12) inhibitor
- Antiplatelet agent (clopidogrel prasugrel ticagrelor)
- Use for 1 year after PC1 for STEMI with stenting to prevent stent stenosis
when do you use beta blockers?
when DON’T you use beta blockers?
when do you use an ACEI?
- Nitroglycerin – relieve vasoconstriction; relieve pain, reduce pre and afterload
- Morphine – persistent pain
- Beta blocker – (esp. if ↑BP or ↑HR) Don’t use in decompensated HF ↓HR, ↓BP, MCO2
- ACEI – helpful if EF↓, ↑BP; prevent remodeling statin
AHA diet
Coronary ICU – AHA diet
a variety of fruits and vegetables,
whole grains,
low-fat dairy products,
skinless poultry and fish
nuts and legumes
non-tropical vegetable oils
NSTEMI tx
- Treatment for NSTEMI
- • Assess for high risk patient/NSTEMI
- • Age > 65 y/o, >3 CAD risk factors, prior stenosis, ST deviation, >2 anginal event < 24 hrs., elevated cardiac enzymes
- • Highest risk – cardiac cath with 48 hrs. (consider PCI or CABG if indicated)
- • Anti thrombotic therapy; ASA, Platelet P2Y12receptor antagonist, anticoagulant (UFH, LMWH-enoxaparin)
- • Unstable-IVGP 11b/111a antagonist
Subendocardial infarction
ST Depression
ST depression
subendocardial infarction, digitalis toxicity, stress test
significant Q waves
indicates necrosis
