Non-Traditional Predictors of Acute Coronary Occlusion

“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

[email protected]

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

[email protected]

Case

• 45 yo M presents with chest pain

– Pain associated with nausea and sweats

– Hx/o DM, htn, smokes 1 ppd

– ECG...

Case

• Emergency physician is residency trained, ABEM-certified

Case


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

Case



– 2:15 am: pain persists, SL NTG #3

Case



– 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


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

• Hospitalist (by phone) recommends cardiology consult

Case

• 5:00 am: patient develops hypotension

– Cardiology consulted

Case



• Cardiology arrives at 6:05 am...

Case



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

Case



• 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


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

ACO, OMI, NOMI


– 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?


• 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 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


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


• 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)

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




25mm/s10mm/mV

40Hz8.0.1

12SL241 HDCID: 0


BPM58

Vent. ratems

178PR interval

ms148

QRS durationms

QT/QTc480/471

1428

82P-R-T axes


Caucasian

Room:RESUSLoc:29


Page 1 of 1


Pt. with LBBB & CP

IIIIII

aVRaVLaVF

V1V2V3

V4V5V6

V1




25mm/s10mm/mV

40Hz8.0.1

12SL241 HDCID: 0


BPM58

Vent. ratems

178PR interval

ms148

QRS durationms

QT/QTc480/471

1428

82P-R-T axes


Caucasian

Room:RESUSLoc:29


Page 1 of 1


Pt. with LBBB & CP

IIIIII

aVRaVLaVF

V1V2V3

V4V5V6

V1




25mm/s10mm/mV

40Hz8.0.1

12SL241 HDCID: 0


BPM58

Vent. ratems

178PR interval

ms148

QRS durationms

QT/QTc480/471

1428

82P-R-T axes


Caucasian

Room:RESUSLoc:29


Page 1 of 1


S wave = 16 mm

Pt. with LBBB & CP

IIIIII

aVRaVLaVF

V1V2V3

V4V5V6

V1




25mm/s10mm/mV

40Hz8.0.1

12SL241 HDCID: 0


BPM58

Vent. ratems

178PR interval

ms148

QRS durationms

QT/QTc480/471

1428

82P-R-T axes


Caucasian

Room:RESUSLoc:29


Page 1 of 1


S wave = 16 mm

ST deviation = 5 mm

Pt. with LBBB & CP

IIIIII

aVRaVLaVF

V1V2V3

V4V5V6

V1




25mm/s10mm/mV

40Hz8.0.1

12SL241 HDCID: 0


BPM58

Vent. ratems

178PR interval

ms148

QRS durationms

QT/QTc480/471

1428

82P-R-T axes


Caucasian

Room:RESUSLoc:29


Page 1 of 1


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?

Is the ST:S > 25%?


S wave = 20 mm


S wave = 20 mm

ST deviation = 9 mm

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”


S wave =22 mm

STE = 7 mm


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)


• 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)




• 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?




• 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

4th Univ. Definition of MI (2018)

Circulation Nov 13, 2018Also published in JACC and

European Heart Journal

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


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

Takehome Points



• Learn to look for these other ECGs indicators of ACP

Takehome Points



• Learn to look for these other ECGs indicators of ACP

• Get serial ECGs in concerning cases!

[email protected]

Non-Traditional Predictors of Acute Coronary Occlusion

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