“STEMI” Without the STE:

Non-Traditional Predictors of Acute Coronary Occlusion

Amal Mattu, MD, FAAEM, FACEP

Professor and Vice Chair of Academic Affairs

Department of Emergency Medicine

University of Maryland School of Medicine

amalmattu@comcast.net

ACO Without the STE:

Non-Traditional Predictors of Acute Coronary Occlusion

Amal Mattu, MD, FAAEM, FACEP

Professor and Vice Chair of Academic Affairs

Department of Emergency Medicine

University of Maryland School of Medicine

amalmattu@comcast.net

Case

• 45 yo M presents with chest pain

– Pain associated with nausea and sweats

– Hx/o DM, htn, smokes 1 ppd

– ECG...

Case

Case

• Emergency physician is residency trained, ABEM-certified

Case

• Emergency physician is residency trained, ABEM-certified

– 1:10 am: Patient treated with ASA, SL NTG, morphine

Case

• Emergency physician is residency trained, ABEM-certified

– 1:10 am: Patient treated with ASA, SL NTG, morphine

– 2:15 am: pain persists, SL NTG #3

Case

• Emergency physician is residency trained, ABEM-certified

– 1:10 am: Patient treated with ASA, SL NTG, morphine

– 2:15 am: pain persists, SL NTG #3

– 3:30 am: pain persists, TN mildly elevated

• Repeat ECG ~ unchanged

• NTG drip

• Hospitalist paged to admit

Case

• Emergency physician is residency trained, ABEM-certified

– 4:30 am: pain persists, repeat ECG unchanged

• Hospitalist (by phone) recommends cardiology consult

Case

• 5:00 am: patient develops hypotension

– Cardiology consulted

Case

• 5:00 am: patient develops hypotension

– Cardiology consulted

• Cardiology arrives at 6:05 am...

Case

• 5:00 am: patient develops hypotension

– Cardiology consulted

• Cardiology arrives at 6:05 am...as the patient loses pulses

Case

• 5:00 am: patient develops hypotension

– Cardiology consulted

• Cardiology arrives at 6:05 am...as the patient loses pulses

• Resuscitation attempts are unsuccessful

– Pronounced dead at 6:45 am

Case• Lawsuit filed

Case

• Was this a missed “STEMI”?

Case

• Was this a missed “STEMI”?

• Was this a missed ACO?

ACO, OMI, NOMI

• We are mainly interested in identifying ACOs in order to initiate acute reperfusion therapy (PCI or lytics)

ACO, OMI, NOMI

• We are mainly interested in identifying ACOs in order to initiate acute reperfusion therapy (PCI or lytics)

• Problem: STE is just a surrogate marker for ACO

ACO, OMI, NOMI

• STEMI vs. Non-STE-ACS is a flawed concept

ACO, OMI, NOMI

• STEMI vs. Non-STE-ACS is a flawed concept

– 10-15% of patients with ACS Sx’s and STE rule OUT for ACO

ACO, OMI, NOMI

• STEMI vs. Non-STE-ACS is a flawed concept

– 10-15% of patients with ACS Sx’s and STE rule OUT for ACO

– Up to 40% of patients with ACS Sx’s and ACOs do NOT have STE

• These patients typically get cath/PCI after significant delay

ACO, OMI, NOMI

• Increasing support to replace STEMI vs. Non-STE-ACS with OMI vs. NOMI

• OMI (ACO) needs emergent cath

• NOMI does not

ACO, OMI, NOMI

• Increasing support to replace STEMI vs. Non-STE-ACS with OMI vs. NOMI

• OMI (ACO) needs emergent cath

• NOMI does not

• Are there ECG findings beyond STE that predict ACO?

What are the ECG indications for emergent reperfusion?

What are the ECG indications for emergent reperfusion?

• Concerning Sx’s plus...

– STE in contiguous leads (usual guidelines)

What are the ECG indications for emergent reperfusion?

• Concerning Sx’s plus...

– STE in contiguous leads (usual guidelines)

– Posterior STEMI

Isolated PMI

Anteroseptal ischemia or posterior MI?

Isolated PMI — Posterior Leads

Isolated PMI — Posterior Leads

Isolated PMI

Isolated PMI

What are the ECG indications for emergent reperfusion?

• Concerning Sx’s plus...

– STE in contiguous leads (usual guidelines)

– Posterior STEMI

– Non-STE-ACS with...

• Refractory ischemia (frequent litigation)

• Developing acute heart failure

• Electrical instability

• Hemodynamic instability

(2014 ACC/AHA guidelines-–cath w/i 2 hrs, Class IA)

Courtesy Haney Mallemat, MD

What are the ECG indications for emergent reperfusion?

• Increasing literature but not yet in the U.S. guidelines

What are the ECG indications for emergent reperfusion?

• Increasing literature but not yet in the U.S. guidelines

– LBBB with Sgarbossa criteria (& modified)

– Pacers with Sgarbossa criteria (& modified)

– de Winter T-waves

– STE in aVR with diffuse STD

Normal LBBB

Normal LBBBRule of appropriate discordance

(true for pacemakers also)

AMI in LBBBSgarbossa, et al. NEJM 1996

A B C

A -- Concordant ST elevation > 1 mm in any lead (very specific)

B -- Concordant ST depression > 1 mm in V1, V2, or V3 (very specific)

C -- Discordant ST elevation > 5 mm (less specific)

AMI in LBBBSgarbossa, et al. NEJM 1996

A B C

A -- Concordant ST elevation > 1 mm in any lead (very specific)

B -- Concordant ST depression > 1 mm in V1, V2, or V3 (very specific)

C -- Discordant ST elevation > 5 mm (less specific)

LBBB with ACO

Courtesy Bill Brady, MD

Courtesy Bill Brady, MD

“Sgarbossa A”

LBBB with ACO

“Sgarbossa B”

85 yo woman with CPCourtesy Dr. Eric Klotz

“Sgarbossa A & B”Courtesy Dr. Eric Klotz

Revised Sgarbossa “C”(

• Sgarbossa criteria “C” is not specific enough

C

Revised Sgarbossa “C”(Smith, et al. Ann Emerg Med 2012)

• Maybe the ratio of the ST deviation : size of the QRS is more important (> 25%)

C

Cai, et al. Amer Heart J 2013

Revised Sgarbossa “C”(Smith, et al. Ann Emerg Med 2012)

Cai, et al. Amer Heart J 2013

Revised Sgarbossa “C”(Validation: Am Heart J 2015)

Pt. with LBBB & CPIIIIII

aVRaVLaVF

V1V2V3

V4V5V6

V1

SANCHEZ, CAMILAID:005665334

20-AUG-2014 12:50:36LAC-USC MEDICAL CENTER

Sinus bradycardiaLeft bundle branch blockAbnormal ECGNo previous ECGs available

25mm/s10mm/mV

40Hz8.0.1

12SL241 HDCID: 0

Referred by:Unconfirmed

BPM58

Vent. ratems

178PR interval

ms148

QRS durationms

QT/QTc480/471

1428

82P-R-T axes

12-NOV-1937 (76 yr)Female

Caucasian

Room:RESUSLoc:29

Option:1Technician: BOYCETest ind:

Page 1 of 1

SID: 82489 EID: EDT: ORDER:

Courtesy Dr. Paul Jhun

Pt. with LBBB & CPIIIIII

aVRaVLaVF

V1V2V3

V4V5V6

V1

SANCHEZ, CAMILAID:005665334

20-AUG-2014 12:50:36LAC-USC MEDICAL CENTER

Sinus bradycardiaLeft bundle branch blockAbnormal ECGNo previous ECGs available

25mm/s10mm/mV

40Hz8.0.1

12SL241 HDCID: 0

Referred by:Unconfirmed

BPM58

Vent. ratems

178PR interval

ms148

QRS durationms

QT/QTc480/471

1428

82P-R-T axes

12-NOV-1937 (76 yr)Female

Caucasian

Room:RESUSLoc:29

Option:1Technician: BOYCETest ind:

Page 1 of 1

SID: 82489 EID: EDT: ORDER:

Pt. with LBBB & CP

IIIIII

aVRaVLaVF

V1V2V3

V4V5V6

V1

SANCHEZ, CAMILAID:005665334

20-AUG-2014 12:50:36LAC-USC MEDICAL CENTER

Sinus bradycardiaLeft bundle branch blockAbnormal ECGNo previous ECGs available

25mm/s10mm/mV

40Hz8.0.1

12SL241 HDCID: 0

Referred by:Unconfirmed

BPM58

Vent. ratems

178PR interval

ms148

QRS durationms

QT/QTc480/471

1428

82P-R-T axes

12-NOV-1937 (76 yr)Female

Caucasian

Room:RESUSLoc:29

Option:1Technician: BOYCETest ind:

Page 1 of 1

SID: 82489 EID: EDT: ORDER:

Pt. with LBBB & CP

IIIIII

aVRaVLaVF

V1V2V3

V4V5V6

V1

SANCHEZ, CAMILAID:005665334

20-AUG-2014 12:50:36LAC-USC MEDICAL CENTER

Sinus bradycardiaLeft bundle branch blockAbnormal ECGNo previous ECGs available

25mm/s10mm/mV

40Hz8.0.1

12SL241 HDCID: 0

Referred by:Unconfirmed

BPM58

Vent. ratems

178PR interval

ms148

QRS durationms

QT/QTc480/471

1428

82P-R-T axes

12-NOV-1937 (76 yr)Female

Caucasian

Room:RESUSLoc:29

Option:1Technician: BOYCETest ind:

Page 1 of 1

SID: 82489 EID: EDT: ORDER:

S wave = 16 mm

Pt. with LBBB & CP

IIIIII

aVRaVLaVF

V1V2V3

V4V5V6

V1

SANCHEZ, CAMILAID:005665334

20-AUG-2014 12:50:36LAC-USC MEDICAL CENTER

Sinus bradycardiaLeft bundle branch blockAbnormal ECGNo previous ECGs available

25mm/s10mm/mV

40Hz8.0.1

12SL241 HDCID: 0

Referred by:Unconfirmed

BPM58

Vent. ratems

178PR interval

ms148

QRS durationms

QT/QTc480/471

1428

82P-R-T axes

12-NOV-1937 (76 yr)Female

Caucasian

Room:RESUSLoc:29

Option:1Technician: BOYCETest ind:

Page 1 of 1

SID: 82489 EID: EDT: ORDER:

S wave = 16 mm

ST deviation = 5 mm

Pt. with LBBB & CP

IIIIII

aVRaVLaVF

V1V2V3

V4V5V6

V1

SANCHEZ, CAMILAID:005665334

20-AUG-2014 12:50:36LAC-USC MEDICAL CENTER

Sinus bradycardiaLeft bundle branch blockAbnormal ECGNo previous ECGs available

25mm/s10mm/mV

40Hz8.0.1

12SL241 HDCID: 0

Referred by:Unconfirmed

BPM58

Vent. ratems

178PR interval

ms148

QRS durationms

QT/QTc480/471

1428

82P-R-T axes

12-NOV-1937 (76 yr)Female

Caucasian

Room:RESUSLoc:29

Option:1Technician: BOYCETest ind:

Page 1 of 1

SID: 82489 EID: EDT: ORDER:

S wave = 16 mm

ST deviation = 5 mm

ST deviation > 25% of the size of the S wave (5/16 > 25%)

LBBB…anything more?Courtesy Dr. Kristin McKee

LBBB…anything more?Courtesy Dr. Kristin McKee

LBBB…anything more?

Is the ST:S > 25%?

LBBB…anything more?

S wave = 20 mm

LBBB…anything more?

S wave = 20 mm

ST deviation = 9 mm

LBBB…anything more?

S wave = 20 mm

ST deviation = 9 mm

ST deviation > 25% of the size of the S wave (9/20 > 25%)

Case

Courtesy Adam Thompson, EMT-P

Case

Courtesy Adam Thompson, EMT-P

Case

Courtesy Adam Thompson, EMT-P

Case

S wave = 7 mm

Case

S wave = 7 mm

STE = 5 mm

Case

S wave = 7 mm

STE = 5 mm

STE > 25% of the size of the S wave (5/7 > 25%)

AMI with Pacers

Normal Pacemaker

“Sgarbossa A”Courtesy Dr. Jim Campagna

(New York)

“Sgarbossa B”Courtesy Dr. Santiago Harris

Handy Scanner for Android

Courtesy Dr. Patrick Bruss

Modified “Sgarbossa C”

Modified “Sgarbossa C”

Modified “Sgarbossa C”

S wave =22 mm

STE = 7 mm

ST deviation > 25% of the size of the S wave (7/22 > 25%)

2017 ESC STEMI Guidelines

Indications for Emergent CLA

High-Risk ECG Patterns in ACS—Need for Guideline Revision(Birnbaum, et al. J Electrocardiol 2013)

• Acute occlusion of the proximal LAD or less commonly 1st diagonal or left Cx

• Urgent cath should be “strongly considered”

de Winter T Waves

Courtesy Mat Goebel

de Winter T Waves

Case 1

Upsloping ST depression, tall symmetric Ts

90 min laterCourtesy Mat Goebel

From de Winter, NEJM 2008

De Winter T-waves

•Although no STE, high concern for decompenstation

– Active Sx’s

– Unstable LAD stenosis

– Now → treat aggressively, get

ECGs, may evolve → STEMI

– Future → STEMI equivalent (CLA)?

Key Point

STE in aVR with concurrent diffuse STD

DDx for STE in aVR(with STD in other leads)

• ACS: LMCA, triple vessel, and prox LAD disease

DDx for STE in aVR(with STD in other leads)

• ACS: LMCA, triple vessel, and prox LAD disease

• Any other causes of global cardiac ischemia

– TAD, severe anemia, early post-arrest (w/i 15 min of EPI or shocks)

DDx for STE in aVR (with STD in other leads)

• ACS: LMCA, triple vessel, and prox LAD disease

• Any other causes of global cardiac ischemia

– TAD, severe anemia, early post-arrest (w/i 15 min of EPI or shocks)

• Massive PE

• LVH with strain, esp. with severe htn

• LBBB, pacers

• SVTs (esp. AVRT)

• Severe hypoK+

• Sodium channel pathology (incl. TCAs, hyperK+, Brugada, etc.)

What is the Hx and PE?

• ACS: LMCA, triple vessel, and prox LAD disease

• Any other causes of global cardiac ischemia

– TAD, severe anemia, early post-arrest (w/i 15 min of EPI or shocks)

• Massive PE

• LVH with strain, esp. with severe htn

• LBBB, pacers

• SVTs (esp. AVRT)

• Severe hypoK+

• Sodium channel pathology (incl. TCAs, hyperK+, Brugada, etc.)

• Important points about STE in aVR– Worry about major coronary disease if...

• Patients are actively having symptoms and typically look sick

• STE > 1-1.5 mm• ST depressions are noted in multiple

other leads as well

aVR — The Forgotten

12th Lead

2017 ESC STEMI Guidelines:Indications for Emergent CLA

2017 ESC STEMI Guidelines:Indications for Emergent CLA

4th Univ. Definition of MI (2018)

Circulation Nov 13, 2018Also published in JACC and

European Heart Journal

4th Univ. Definition of MI (2018)

4th Univ. Definition of MI (2018)

• ACS with severe coronary stenoses– Patients are actively having symptoms and

typically look sick– STE > 1-1.5 mm– Multiple other leads with STD– Consider other potential causes

Key Points

Cereal ECG Testing

• Failure to repeat the ECG...

– If the first ECG is poor quality

– If ongoing concerning Sx’s

• ACC/AHA guidelines recommend serial ECGs every 15-30 min for the first hour if there are concerning Sx’s and initial ECG is non-dx’ic

Serial ECG Testing

• Failure to repeat the ECG...

– If the first ECG is poor quality

– If ongoing concerning Sx’s

• ACC/AHA guidelines recommend serial ECGs every 15-30 min for the first hour if there are concerning Sx’s and initial ECG is non-dx’ic

• 15-20% of STEMIs are dx’d on the repeat ECG!

Serial ECG Testing

Takehome Points

Takehome Points

• “STE” as the sole criteria predictor of an ACO is a flawed concept

Takehome Points

• “STE” as the sole criteria predictor of an ACO is a flawed concept

• Don’t forget about refractory ischemia as an indicator (in current guidelines) for cath lab activation

Takehome Points

• “STE” as the sole criteria predictor of an ACO is a flawed concept

• Don’t forget about refractory ischemia as an indicator (in current guidelines) for cath lab activation

• Learn to look for these other ECGs indicators of ACP

Takehome Points

• “STE” as the sole criteria predictor of an ACO is a flawed concept

• Don’t forget about refractory ischemia as an indicator (in current guidelines) for cath lab activation

• Learn to look for these other ECGs indicators of ACP

• Get serial ECGs in concerning cases!

Thanks!amalmattu@comcast.net