“STEMI Guidelines for the ED Physician and ECG

Review”

December 2, 2014

Gagan D. Singh M.D.

Division of Cardiovascular MedicineUC Davis Medical Center

Sacramento CA

STEMI Definition

STEMI Definition

In the absence of LBBB or LVH New ST elevation at the J point in at

least 2 contiguous leads of: 2 mm (0.2 mV) in men or 1.5 mm (0.15

mV) in women in leads V2–V3 and/or of 1 mm (0.1 mV) in other contiguous

chest leads or the limb leads ST depression in 2 precordial leads (V1–

V4) may indicate transmural posterior injury

STEMI Definition

Caveats Most cases of LBBB at time of

presentation are “not known to be old” because of ECG is not available for comparison.

New or presumably new LBBB at presentation occurs infrequently Interfere with ST-elevation analysis, and Should not be considered diagnostic of

acute MI in isolation Baseline ECG abnormalities other than

LBBB (LVH, Brugadda, V paced) obscure STEMI assessment

Jain et al. Am J Cardiol 2011;107: 1111–1116

7

Hospitalizations in the U.S. Due to Acute Coronary Syndromes (ACS)

Acute Coronary Syndromes*

1.57 Million Hospital Admissions - ACS

UA/NSTEMI† STEMI

1.24 million Admissions per year

.33 million Admissions per year

Heart Disease and Stroke Statistics – 2007 Update. Circulation 2007; 115:69-171. *Primary and secondary diagnoses. †About 0.57 million

NSTEMI and 0.67 million UA.

STEMI Epidemiology

STEMI Facts

In hospital and 1 year mortality continue to decline Reperfusion therapy Earlier recognition “Time is myocardium”

Target Areas For Improvement Women, Non-whites, Diabetics, Elderly,

CKD/ESRD

STEMI Timeline

STEMI Guidelines – Cath Activation

STEMI Guidelines

Platelets Role in Thrombosis

Reproduced with permission from Cannon CP. Atherothrombosis slide compendium. Available at: www.theheart.org.

Aggregation31

Activation2

Adhesion

Pathways to Clot Formation

White HD. AM J Cardiol 1997; 80:2B-10BSchafer A. J Clin Invest 1986; 78:73-79DeJong MJ, et al. Critical Care Nursing Clin of N Am 1999; 11:355-371

STEMI Guidelines - Fibrinolytic

STEMI Guidelines - Fibrinolytic

STEMI Guidelines - Fibrinolytic

STEMI Guidelines - Fibrinolytic

STEMI Guidelines - Hypothermia

STEMI Guidelines - Anticoagulation

ECG Review

An Electrical Beat

Many faces of normal ST segments

Pathologic ST segments

ECG

ECG

ECG

ECG

ECG

ECG

ECG

ECG

THANK YOU

University of California Davis Medical Center