ST-segment elevation myocardial infarction: Difference between revisions
No edit summary
Line 8: Line 8:
{{ACS anatomical correlation}}
{{ACS anatomical correlation}}


==Prehospital==
===Prehospital===
Patients with a STEMI on the prehospital ECG but resolution of ST elevations on arrival require activation of the cath team or transfer for primary catheterization even though there has been resolution of the ST-elevations. There is a high likelihood of a significant coronary occlusion.<ref>Ownbey M, Suffoletto B, Firsch A, et al. Prevalence and interventional outcomes of patients with resolution of ST-segment elevation between prehospital and in-hospital ECG. Prehosp Emerg Care. 2014. Apr-Jun;18(2):174-9</ref>
Patients with a STEMI on the prehospital ECG but resolution of ST elevations on arrival require activation of the cath team or transfer for primary catheterization even though there has been resolution of the ST-elevations. There is a high likelihood of a significant coronary occlusion.<ref>Ownbey M, Suffoletto B, Firsch A, et al. Prevalence and interventional outcomes of patients with resolution of ST-segment elevation between prehospital and in-hospital ECG. Prehosp Emerg Care. 2014. Apr-Jun;18(2):174-9</ref>


==Cardiac Arrest and STEMI==
===Cardiac Arrest and STEMI===
*Consider hypothermia cooling protocol for patients with documented cardiac arrest felt to be caused by lethal cardiac rhythm (e.g. [[ventricular fibrillation]]
*Consider hypothermia cooling protocol for patients with documented cardiac arrest felt to be caused by lethal cardiac rhythm (e.g. [[ventricular fibrillation]]
*Patients with cardiac arrest and ST elevation at any point, even if resolved, should still under go emergent coronary angiography<ref>2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science [http://circ.ahajournals.org/content/122/18_suppl_3/S768.full PDF]</ref>
*Patients with cardiac arrest and ST elevation at any point, even if resolved, should still under go emergent coronary angiography<ref>2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science [http://circ.ahajournals.org/content/122/18_suppl_3/S768.full PDF]</ref>


==Diagnosis==
==Diagnosis==
When possible, particularly in questionable presentations, comparison to old ekg's should be performed.
When possible, particularly in questionable presentations, comparison to old ekg's should be performed.


Line 27: Line 26:
≥1.5 mm in V2-V3 and 1 mm (0.1mV) in all other leads
≥1.5 mm in V2-V3 and 1 mm (0.1mV) in all other leads


===New LBBB===
===New [[LBBB]]===
*New Left Bundle Branch Block is no longer a STEMI criteria for activation of the cath lab as of 2013<ref>Am Heart J 2013;166:409-13</ref>
*New Left Bundle Branch Block is no longer a STEMI criteria for activation of the cath lab as of 2013<ref>Am Heart J 2013;166:409-13</ref>
*Sick patients with a new LBBB should be discussed with a cardiologist for possible coronary angiography
*Sick patients with a new LBBB should be discussed with a cardiologist for possible coronary angiography
Line 35: Line 34:


==Differential Diagnosis==
==Differential Diagnosis==
#Myocardial ischemia or infarction
#Noninfarction, transmural ischemia (Prinzmetal's angina pattern or acute takotsubo cardiomyopathy)
#Post-MI (ventricular aneurysm pattern)
#Previous MI with recurrent ischemia in same area
#[[Pericarditis]]
#Early repolarization
#LVH or [[LBBB]] (only V1-V2 or V3)
#[[Myocarditis]] (may look like myocardial infarction or pericarditis)
#[[Brugada Syndrome]]
#Myocardial tumor
#Aortic dissection
#Myocardial trauma
#[[Hyperkalemia]] (only leads V1 and V2)
#[[Hypothermia]] (J wave/Osborn wave)
{{ST elevation DDX}}
{{ST elevation DDX}}


Line 55: Line 39:
=== Adjunctive ===
=== Adjunctive ===
#O2
#O2
##esp for SpO2 <90%
#*esp for SpO2 <90%
#ASA 162-325mg chewable or 600mg PR
#ASA 162-325mg chewable or 600mg PR
#NTG
#NTG
#Morphine
#Morphine
#Beta-Blocker:
#Beta-Blocker:
##PO within 24 hours
#*PO within 24 hours
##IV beta-blocker is reasonable for patients who are hypertensive in the absence of:
#*IV beta-blocker is reasonable for patients who are hypertensive in the absence of:
###Heart failure
#**Heart failure
###Low cardiac output state
#**Low cardiac output state
###Cardiogenic shock risk factors
#**Cardiogenic shock risk factors
####Age > 70yr, sys BP < 120, HR > 110 or <60,  
#***Age > 70yr, sys BP < 120, HR > 110 or <60,  
###Conduction block (PR interval > 0.24s, 2nd or 3rd block
#**Conduction block (PR interval > 0.24s, 2nd or 3rd block
###Active asthma
#**Active asthma


===Antiplatelets===
===Antiplatelets===
Line 84: Line 68:
===Anticoagulation===
===Anticoagulation===
#[[Heparin]] (UFH)
#[[Heparin]] (UFH)
##Bolus 60U/kg (max: 4000U) followed by 12U/kg/h (max: 1000U/h)
#*Bolus 60U/kg (max: 4000U) followed by 12U/kg/h (max: 1000U/h)
##Titrate to PTT 1.5-2.5 x control
#*Titrate to PTT 1.5-2.5 x control
#LMWH
#LMWH
##<75yo with serum Cr < 2.5 mg/dL (men) or < 2.0 mg/dL (women):
#*<75yo with serum Cr < 2.5 mg/dL (men) or < 2.0 mg/dL (women):
###30mg IV bolus followed by 1mg/kg SC q12h
#**30mg IV bolus followed by 1mg/kg SC q12h
##≥ 75yo
#*≥ 75yo
###0.75mg/kg SC q12h
#**0.75mg/kg SC q12h
##CrCl < 30 mL/min
#*CrCl < 30 mL/min
###1mg/kg SC qd
#**1mg/kg SC qd
#Fondaparinux
#Fondaparinux
##Cr < 3.0 mg/dL:
#*Cr < 3.0 mg/dL:
###2.5mg IV bolus then 2.5mg SC qd started 24hr after bolus
#**2.5mg IV bolus then 2.5mg SC qd started 24hr after bolus
##Monitor anti-Xa levels
#*Monitor anti-Xa levels
#Bivalirudin
#Bivalirudin
##0.75mg/kg IV bolus followed by 1.75 mg/kg/h
#*0.75mg/kg IV bolus followed by 1.75 mg/kg/h
##CrCl < 30 mL/min
#*CrCl < 30 mL/min
###0.75mg/kg IV bolus followed by 1.0 mg/kg/h
#**0.75mg/kg IV bolus followed by 1.0 mg/kg/h


===Definitive===
===Definitive===
The most critical aspect of care is to ensure systems are in place to minimize time taken for reperfusion. Anyone presenting within 12 hours of symptoms onset should have attempted reperfusion for STEMI. Options include fibrinolytic therapy or PCI. PCI is preferred if possible and had been demonstrated to result in superior outcomes.  
The most critical aspect of care is to ensure systems are in place to minimize time taken for reperfusion. Anyone presenting within 12 hours of symptoms onset should have attempted reperfusion for STEMI. Options include fibrinolytic therapy or PCI. PCI is preferred if possible and had been demonstrated to result in superior outcomes.  


#PCI
#PCI
##Goal: PCI should be attempted if the procedure can be started within 120 minutes (faster than 90 minutes is the goal, the faster the better)
#*Goal: PCI should be attempted if the procedure can be started within 120 minutes (faster than 90 minutes is the goal, the faster the better)
## if the PCI can't be commenced within 120 minutes then fibrinolysis should be given to suitable candidates
#*if the PCI can't be commenced within 120 minutes then fibrinolysis should be given to suitable candidates


#Fibrinolytics
#Fibrinolytics
##Goal: if it is determined that PCI can't be performed within 120 minutes then fibrinolytics should be given, and they should be given within 30 minutes  
#*Goal: if it is determined that PCI can't be performed within 120 minutes then fibrinolytics should be given, and they should be given within 30 minutes  
##If receive fibrinolytics also give anticoagulants for minimum of 48hr, and preferable the length of the hospitalization
#*If receive fibrinolytics also give anticoagulants for minimum of 48hr, and preferable the length of the hospitalization
##Fibrinolytic tx w/in 3hr resulted in >30 lives saved per 1000 pts
#*Fibrinolytic tx w/in 3hr resulted in >30 lives saved per 1000 pts
##0.5-1% of pts suffer ICH
#*0.5-1% of pts suffer ICH


== Fibrinolysis  ==
== Fibrinolysis  ==


=== Indications  ===
=== Indications  ===
#&lt;12hr from onset of CP AND:  
#&lt;12hr from onset of CP AND:  
##ST elevation of ≥1mm in 2 contiguous limb or precordial leads OR new LBBB
#*ST elevation of ≥1mm in 2 contiguous limb or precordial leads OR new LBBB


=== Contraindications  ===
=== Contraindications  ===
====Absolute contraindications====
#Any prior ICH
#Known structural cerebral vascular lesion (AVM)
#Known intracranial neoplasm
#Ischemic stroke w/in 3 mo
#Active internal bleeding (excluding menses)
#Suspected aortic dissection or pericarditis


#Absolute contraindications
====Relative contraindications====
##Any prior ICH
#Severe uncontrolled BP (&gt;180/100)  
##Known structural cerebral vascular lesion (AVM)
#History of chronic severe poorly controlled HTN  
##Known intracranial neoplasm
#History of prior ischemic stroke &gt;3 mo  
##Ischemic stroke w/in 3 mo
#Known intracranial pathology not covered in absolute contraindications  
##Active internal bleeding (excluding menses)
#Current use of anticoagulants with known INR &gt;2–3  
##Suspected aortic dissection or pericarditis
#Known bleeding diathesis  
#Relative contraindications  
#Recent trauma (past 2 wk)  
##Severe uncontrolled BP (&gt;180/100)  
#Prolonged CPR (&gt;10 min)  
##History of chronic severe poorly controlled HTN  
#Major surgery (&lt;3 wk)  
##History of prior ischemic stroke &gt;3 mo  
#Noncompressible vascular punctures (e.g. IJ, subclavian)  
##Known intracranial pathology not covered in absolute contraindications  
#Recent internal bleeding (within 2–4 wk)  
##Current use of anticoagulants with known INR &gt;2–3  
#Pts treated previously with streptokinase should not receive streptokinase a 2nd time  
##Known bleeding diathesis  
#Pregnancy  
##Recent trauma (past 2 wk)  
#Active peptic ulcer disease  
##Prolonged CPR (&gt;10 min)  
#Other medical conditions likely to increase risk of bleeding (diabetic retinopathy, etc)
##Major surgery (&lt;3 wk)  
##Noncompressible vascular punctures (e.g. IJ, subclavian)  
##Recent internal bleeding (within 2–4 wk)  
##Pts treated previously with streptokinase should not receive streptokinase a 2nd time  
##Pregnancy  
##Active peptic ulcer disease  
##Other medical conditions likely to increase risk of bleeding (diabetic retinopathy, etc)<br>


=== Dosing (Alteplase)  ===
=== Dosing (Alteplase)  ===
*&gt;67kg pt:  
*&gt;67kg pt:  
**Infuse 15mg IV over 1-2min; then 50mg over 30min; then 35mg over next 60min (i.e. 100mg over 1.5hr)
**Infuse 15mg IV over 1-2min; then 50mg over 30min; then 35mg over next 60min (i.e. 100mg over 1.5hr)
Line 157: Line 138:


=== Dosing (Tenecteplase-TNKase) ===
=== Dosing (Tenecteplase-TNKase) ===
*Reconstitute 50 mg vial in 10 mL sterile water (5 mg/mL)
*Reconstitute 50 mg vial in 10 mL sterile water (5 mg/mL)
*&lt; 60 kg = 30 mg IV push over 5 seconds
*&lt; 60 kg = 30 mg IV push over 5 seconds
Line 166: Line 146:


=== Rescue PCI ===
=== Rescue PCI ===
*Failed reperfusion: consider if repeat EKG 90 minutes after infusion fails to show reduction of elevated ST segments by 50%
*Failed reperfusion: consider if repeat EKG 90 minutes after infusion fails to show reduction of elevated ST segments by 50%
*Recurrent significant ST elevation following successful lysis
*Recurrent significant ST elevation following successful lysis
Line 174: Line 153:


== Consideration of Mechanical Complications  ==
== Consideration of Mechanical Complications  ==
There should always be consideration of mechanical complications of MI particularly in those presenting in shock. These include papillary muscle rupture and severe mitral regurgitation, LV rupture, ventricular septal rupture with defect, cardiac tamponade. Although it should not delay transition to cardiac catheterization, rapid bedside echocardiography is useful in assessing for these.
There should always be consideration of mechanical complications of MI particularly in those presenting in shock. These include papillary muscle rupture and severe mitral regurgitation, LV rupture, ventricular septal rupture with defect, cardiac tamponade. Although it should not delay transition to cardiac catheterization, rapid bedside echocardiography is useful in assessing for these.


Revision as of 17:59, 8 March 2015

Background

  • RV infarction accompanies ~25% of inferior STEMIs
    • Hemodynamically significant only 10% of the time
  • Posterior infarction is rarely isolated (~3-8% of all AMIs)
    • Usually will see changes in V6 OR II, III, aVF

Anatomical Correlation

ACS Anatomical Correlation Chart

Ischemic Changes Location Coronary Artery
STE V1-V3, TWI

Q waves in V1-V3 over time

Septal Septal branch
STE V2-V4 Anterior LAD
STE I, aVL, V5, V6

STD inf leads

Lateral Circumflex
STE I, aVL, V2-6 Anterolateral LAD + circumflex = Left main or 2 critical lesions
STE II, III, aVF

STD in aVL (most common lead to see reciprocal change)

Inferior RCA

STE V1 (only lead looking at RV)
STE III > II (III more R facing)
STE V1 > V2, STE V1 + STD V2

Right ventricle RCA

STD in V1, V2, V3;
R>S in V1
Tall R waves in V1-V3 (Q waves on back of heart) w/ upright TWs

Posterior aka Inferolateral RCA (90%), LCA (10%)
STE avR>V1

Doesn't apply in SVT

Anterolateral Left Main

Prehospital

Patients with a STEMI on the prehospital ECG but resolution of ST elevations on arrival require activation of the cath team or transfer for primary catheterization even though there has been resolution of the ST-elevations. There is a high likelihood of a significant coronary occlusion.[1]

Cardiac Arrest and STEMI

  • Consider hypothermia cooling protocol for patients with documented cardiac arrest felt to be caused by lethal cardiac rhythm (e.g. ventricular fibrillation
  • Patients with cardiac arrest and ST elevation at any point, even if resolved, should still under go emergent coronary angiography[2]

Diagnosis

When possible, particularly in questionable presentations, comparison to old ekg's should be performed.

Use the J-point for measurement in 2 contiguous leads:[3]

Men

  • In males ≥ 40 years old 2mm in V2-V3 and 1mm in all other leads.
  • In males < 40 years old 2.5mm in V2-V3 and 1mm in all other leads.

Women

≥1.5 mm in V2-V3 and 1 mm (0.1mV) in all other leads

New LBBB

  • New Left Bundle Branch Block is no longer a STEMI criteria for activation of the cath lab as of 2013[4]
  • Sick patients with a new LBBB should be discussed with a cardiologist for possible coronary angiography

Sgarbossa's Criteria in LBBB

Original Criteria

Sgarbossa's Original Criteria

≥3 points = 98% probability of STEMI[5]

  • ST elevation ≥1 mm in a lead with upward QRS complex (concordant) - 5 points
  • ST depression ≥1 mm in lead V1, V2, or V3 - 3 points
  • ST elevation ≥5 mm in a lead with downward QRS complex (discordant) - 2 points

Smith's modification[6]

Smith's Modified Sgarbossa 3rd Rule
  • Changes the 3rd rule of original Sgarbossa's Criteria to be ST depression OR elevation discordant with the QRS complex and with a magnitude of at least 25% of the QRS
    • Increases Sn from 52% → 91% at the expense of reducing Sp from 98% → 90%

Differential Diagnosis

ST Elevation

Treatment

Adjunctive

  1. O2
    • esp for SpO2 <90%
  2. ASA 162-325mg chewable or 600mg PR
  3. NTG
  4. Morphine
  5. Beta-Blocker:
    • PO within 24 hours
    • IV beta-blocker is reasonable for patients who are hypertensive in the absence of:
      • Heart failure
      • Low cardiac output state
      • Cardiogenic shock risk factors
        • Age > 70yr, sys BP < 120, HR > 110 or <60,
      • Conduction block (PR interval > 0.24s, 2nd or 3rd block
      • Active asthma

Antiplatelets

Clopidogrel

  • Loading dose of 600mg if PCI anticipated (otherwise give 300mg)
  • No loading dose if >75yr receiving fibrinolytics

Ticagrelor

  • May significantly reduce mortality as compared to clopidogrel[7]
  • 180 mg loading dose, followed by 90 mg BID
  • Ticagrelor offers no added benefit in STEMI when given pre-hospital vs. in-hospital (ambulance vs. cath lab)[8]

GPIIB/IIIa Inhibitors

  • Abciximab, Eptifibatide
  • Defer to cardiologist
  • Given right before PCI depending on specific institutional protocols

Anticoagulation

  1. Heparin (UFH)
    • Bolus 60U/kg (max: 4000U) followed by 12U/kg/h (max: 1000U/h)
    • Titrate to PTT 1.5-2.5 x control
  2. LMWH
    • <75yo with serum Cr < 2.5 mg/dL (men) or < 2.0 mg/dL (women):
      • 30mg IV bolus followed by 1mg/kg SC q12h
    • ≥ 75yo
      • 0.75mg/kg SC q12h
    • CrCl < 30 mL/min
      • 1mg/kg SC qd
  3. Fondaparinux
    • Cr < 3.0 mg/dL:
      • 2.5mg IV bolus then 2.5mg SC qd started 24hr after bolus
    • Monitor anti-Xa levels
  4. Bivalirudin
    • 0.75mg/kg IV bolus followed by 1.75 mg/kg/h
    • CrCl < 30 mL/min
      • 0.75mg/kg IV bolus followed by 1.0 mg/kg/h

Definitive

The most critical aspect of care is to ensure systems are in place to minimize time taken for reperfusion. Anyone presenting within 12 hours of symptoms onset should have attempted reperfusion for STEMI. Options include fibrinolytic therapy or PCI. PCI is preferred if possible and had been demonstrated to result in superior outcomes.

  1. PCI
    • Goal: PCI should be attempted if the procedure can be started within 120 minutes (faster than 90 minutes is the goal, the faster the better)
    • if the PCI can't be commenced within 120 minutes then fibrinolysis should be given to suitable candidates
  1. Fibrinolytics
    • Goal: if it is determined that PCI can't be performed within 120 minutes then fibrinolytics should be given, and they should be given within 30 minutes
    • If receive fibrinolytics also give anticoagulants for minimum of 48hr, and preferable the length of the hospitalization
    • Fibrinolytic tx w/in 3hr resulted in >30 lives saved per 1000 pts
    • 0.5-1% of pts suffer ICH

Fibrinolysis

Indications

  1. <12hr from onset of CP AND:
    • ST elevation of ≥1mm in 2 contiguous limb or precordial leads OR new LBBB

Contraindications

Absolute contraindications

  1. Any prior ICH
  2. Known structural cerebral vascular lesion (AVM)
  3. Known intracranial neoplasm
  4. Ischemic stroke w/in 3 mo
  5. Active internal bleeding (excluding menses)
  6. Suspected aortic dissection or pericarditis

Relative contraindications

  1. Severe uncontrolled BP (>180/100)
  2. History of chronic severe poorly controlled HTN
  3. History of prior ischemic stroke >3 mo
  4. Known intracranial pathology not covered in absolute contraindications
  5. Current use of anticoagulants with known INR >2–3
  6. Known bleeding diathesis
  7. Recent trauma (past 2 wk)
  8. Prolonged CPR (>10 min)
  9. Major surgery (<3 wk)
  10. Noncompressible vascular punctures (e.g. IJ, subclavian)
  11. Recent internal bleeding (within 2–4 wk)
  12. Pts treated previously with streptokinase should not receive streptokinase a 2nd time
  13. Pregnancy
  14. Active peptic ulcer disease
  15. Other medical conditions likely to increase risk of bleeding (diabetic retinopathy, etc)

Dosing (Alteplase)

  • >67kg pt:
    • Infuse 15mg IV over 1-2min; then 50mg over 30min; then 35mg over next 60min (i.e. 100mg over 1.5hr)
  • ≤67kg pt:
    • Infuse 15mg IV over 1-2min; then 0.75 mg/kg (max 50mg) over 30 min; then 0.5 mg/kg over 60min (max 35 mg)

Dosing (Tenecteplase-TNKase)

  • Reconstitute 50 mg vial in 10 mL sterile water (5 mg/mL)
  • < 60 kg = 30 mg IV push over 5 seconds
  • 60-69 kg = 35 mg IV push over 5 seconds
  • 70-79 kg = 40 mg IV push over 5 seconds
  • 80-89 kg = 45 mg IV push over 5 seconds
  • > 90 kg = 50 mg IV push over 5 seconds

Rescue PCI

  • Failed reperfusion: consider if repeat EKG 90 minutes after infusion fails to show reduction of elevated ST segments by 50%
  • Recurrent significant ST elevation following successful lysis
  • Persistent hemodynamically unstable arrythmias, persistent ischemic symptoms, or worsened cardiogenic shock
  • Even in those with successful reperfusion, its reasonable to do angiography within the index hospitalization, although this should not be done within 2-3 hours of thrombolytic therapy.

Consideration of Mechanical Complications

There should always be consideration of mechanical complications of MI particularly in those presenting in shock. These include papillary muscle rupture and severe mitral regurgitation, LV rupture, ventricular septal rupture with defect, cardiac tamponade. Although it should not delay transition to cardiac catheterization, rapid bedside echocardiography is useful in assessing for these.

See Also

External Links

Source

  • Electrocardiography in Emergency Medicine. ACEP Textbook
  1. ↑ Ownbey M, Suffoletto B, Firsch A, et al. Prevalence and interventional outcomes of patients with resolution of ST-segment elevation between prehospital and in-hospital ECG. Prehosp Emerg Care. 2014. Apr-Jun;18(2):174-9
  2. ↑ 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science PDF
  3. ↑ ACCF/AHA 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013 Jan 29;61(4):e78-140. PDF
  4. ↑ Am Heart J 2013;166:409-13
  5. ↑ Sgarbossa E. et al.. "Electrocardiographic diagnosis of evolving acute myocardial infarction in the presence of left bundle-branch block. GUSTO-1 (Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries) Investigators". NEJM. 1996. 334(8):481-7
  6. ↑ Smith, S. et al. Diagnosis of ST-Elevation Myocardial Infarction in the Presence of Left Bundle Branch Block With the ST-Elevation to S-Wave Ratio in a Modified Sgarbossa Rule. 60(6). 766-776
  7. ↑ Wallentin et Al. Ticagrelor versus Clopidogrel in Patients with Acute Coronary Syndromes. N Engl J Med 2009; 361:1045-1057.
  8. ↑ Montalescot G et al. Prehospital ticagrelor in ST-segment elevation myocardial infarction. N Engl J Med 2014 Sep 1.
Retrieved from "https://www.wikem.org/w/index.php?title=ST-segment_elevation_myocardial_infarction&oldid=33321"