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Tuesday, January 22, 2013
STEMI and Acute Coronary Syndromes
STEMI and Acute Coronary Syndromes
STEMI and Acute Coronary Syndromes
STEMI and Acute Coronary Syndromes
STEMI and Acute Coronary Syndromes
STEMI and Acute Coronary Syndromes
STEMI and Acute Coronary Syndromes
STEMI and Acute Coronary Syndromes
STEMI and Acute Coronary Syndromes
STEMI and Acute Coronary Syndromes
STEMI and Acute Coronary Syndromes
STEMI and Acute Coronary Syndromes
STEMI and Acute Coronary Syndromes
STEMI and Acute Coronary Syndromes
STEMI and Acute Coronary Syndromes
STEMI and Acute Coronary Syndromes
From the AHA/ACC STEMI guidelines




    NSTEMI                          STEMI
Stenotic Lesion
  Fibrotic
  Thick Cap
  Stable
  Less Enlargement
  + Sx
  BAD!


Non-Stenotic
  Lipid Rich
  Thin Cap
  Unstable
  Enlargement
  Catastrophic
  WORSE!!!
  Detectible?
STEMI and Acute Coronary Syndromes
STEMI and Acute Coronary Syndromes
vs
     FMC TO DEV: 90 MIN.
STEMI and Acute Coronary Syndromes
STEMI and Acute Coronary Syndromes
STEMI and Acute Coronary Syndromes
STEMI and Acute Coronary Syndromes
STEMI and Acute Coronary Syndromes
Early Recognition of ACS (red flags)

Dispatch Resources & Pre-Arrival ASA

EMS Recognition & Stabilization

Initial Care & Comfort
12 Lead – STEMI identification.

MONA+ Medications

Triage & Pre-notify ED

Education & Prevention
STEMI and Acute Coronary Syndromes
Central Anterior Chest Pain

Pressure, Tightness, Dull, Crush

Radiating to Arms, Neck, Back

Approx. 50% ACS Patients
Musculoskeletal or Positional

Sharp or Stabbing

Epigastric Discomfort

Many Elderly, Female, Diabetic
Dyspnea

Palpitations

Syncope

Diaphoresis

Nausea / Vomiting

General Weakness
Over 65 y/o

Known CHD

HTN

DM

High Cholesterol

Sedentary Lifestyle
Over 45 y/o

Obese

Black

Cocaine Abuse

Smoking

Being a character in “Pulp Fiction”
STEMI and Acute Coronary Syndromes
1. Ischemia (Angina or NSTEMI)
 a) lack of oxygenation
 b) ST depression or T inversion
2. Injury (STEMI)
 a) prolonged ischemia
 b) ST elevation
3. Infarct (DEAD)
 a) dead tissue
 b) may or may not show in Q wave
STEMI and Acute Coronary Syndromes
ST segment elevation (STEMI)
• Limb leads [I, II, III, AVL, AVF] >one mm (1 small box)
• Precordial leads [V1-V6] >two mm (2 small boxes)

New or presumed new LBBB = ST elevation (STEMI)

ST segment depression (Angina or NSTEMI)
• One mm or more (one small box)

T Wave Inversion (Angina or NSTEMI)

Q Wave (MI)?
• One mm or more (1 small box)
STEMI and Acute Coronary Syndromes
STEMI and Acute Coronary Syndromes
STEMI and Acute Coronary Syndromes
STEMI and Acute Coronary Syndromes
STEMI and Acute Coronary Syndromes
STEMI and Acute Coronary Syndromes
STEMI and Acute Coronary Syndromes
STEMI and Acute Coronary Syndromes
A “normal” ECG does NOT rule out ACS. “Non-Diagnostic”

ST segment depression or T wave inversion represents ischemia (Angina, NSTEMI).

ST segment elevation is evidence of injury (STEMI).

Q wave indicative of MI. Not all MI=Q wave

Indicators can come in any combination.

Process may go forwards or backwards.

There are always exceptions to the rules.


Look for reciprocal changes

Evaluate Rate and Rhythm (DEFIB)

Evaluate for Axis Deviation

Evaluate QRS Duration and more…
STEMI and Acute Coronary Syndromes
• Morphine (class I, level C)
     • Analgesia
     • Reduce pain/anxiety—decrease sympathetic tone,
       peripheral vascular resistance and oxygen demand.
     • Careful with hypotension, hypovolemia, respiratory
       depression, RVI

• Oxygen (> 94% sPO2) (class I, level C)
     • Up to 70% of ACS patient demonstrate hypoxemia
     • May limit ischemic myocardial damage by increasing
       oxygen delivery/reduce ST elevation
     • Shown to have limited benefit, possible harm if >100%
• Nitroglycerin (class I, level B)
     •   Analgesia—titrate infusion to keep patient pain free
     •   Dilates coronary vessels—increase blood flow
     •   Reduces systemic vascular resistance and preload
     •   Careful with recent ED meds, hypotension, bradycardia, tachycardia,
         RVI

• Aspirin (160-325mg chewed &
  swallowed) (class IIa, level B)
     •   Irreversible inhibition of platelet aggregation
     •   Stabilize plaque and arrest thrombus
     •   Reduce mortality in patients with STEMI
     •   Careful with active ulcers, hypersensitivity, bleeding disorders
        In AMI, ASA reduced the risk of death by 20-25%
        In UA, ASA reduced the risk of fatal or nonfatal MI by 71% during the
         acute phase.
• Thienopyridines (Prasugrel, Plavix)
   (class I, level A)
     • Irreversible inhibition of platelet aggregation
     • Used in support of cath / PCI intervention or if
       unable to take aspirin
     • 3 to 12 month duration depending on scenario

• Glycoprotein IIb/IIIa inhibitors (Integrilin)
     (class IIa, level B)
     • Inhibition of platelet aggregation at final common
       pathway
     • In support of PCI intervention as early as possible
       prior to PCI.
• Proton Pump Inhibitors (Prilosec, Pepcid)
     • Given to reduce ulcers and increase compliance
     • May reduce blood thinning mechanisms of Plavix.


• Hyperglycemia control in STEMI (Insulin)
     (class IIa, level B)
     • Control of hyperglycenia (180 mg/dl) recommended.
     • May reduce inflammation and increase LV Ejection
       Fraction.
• Beta-Blockers (class I, level A)
     • 14% reduction in mortality risk at 7 days at 23% long
       term mortality reduction in STEMI
     • Approximate 13% reduction in risk of progression to MI
       in patients with threatening or evolving MI symptoms
     • Be aware of contraindications (CHF, Heart block,
       Hypotension)
     • Reassess for therapy as contraindications resolve.
• ACE-Inhibitors (class I, level A)
     • Start in patients with anterior MI, pulmonary
       congestion, LVEF < 40% in absence of
       contraindication/hypotension
     • Start in first 24 hours
• Unfractionated Heparin (class I, level A)
   – Concurrent with reperfusion therapies of all types.
      • Reduces clotting during acute in-hospital treatment.


• Aldosterone blockers (class I, level A)
   – Post-STEMI patients
      •   no significant renal failure (cr < 2.5 men or 2.0 for women)
      •   No hyperkalemis > 5.0
      •   LVEF < 40%
      •   Symptomatic CHF or DM
STEMI and Acute Coronary Syndromes
STEMI and Acute Coronary Syndromes
STEMI and Acute Coronary Syndromes
STEMI and Acute Coronary Syndromes
STEMI and Acute Coronary Syndromes
Education/
    Thrombolytics        Prevention
     / Angioplasty
                                          Pre Arrival
                                      Instructions / ASA




 Triage
Hospital                                 Focused
                                        Assessment




                                       Patient
    MONA+                              Comfort
                     Pre-Hospital
                       12 Lead
Education/
    Thrombolytics        Prevention
     / Angioplasty
                                          Pre Arrival
                                      Instructions / ASA




 Triage
Hospital                                 Focused
                                        Assessment




                                       Patient
    MONA+                              Comfort
                     Pre-Hospital
                       12 Lead
STEMI and Acute Coronary Syndromes
STEMI and Acute Coronary Syndromes

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STEMI and Acute Coronary Syndromes

  • 18. From the AHA/ACC STEMI guidelines NSTEMI STEMI
  • 19. Stenotic Lesion Fibrotic Thick Cap Stable Less Enlargement + Sx BAD! Non-Stenotic Lipid Rich Thin Cap Unstable Enlargement Catastrophic WORSE!!! Detectible?
  • 22. vs FMC TO DEV: 90 MIN.
  • 28. Early Recognition of ACS (red flags) Dispatch Resources & Pre-Arrival ASA EMS Recognition & Stabilization Initial Care & Comfort
  • 29. 12 Lead – STEMI identification. MONA+ Medications Triage & Pre-notify ED Education & Prevention
  • 31. Central Anterior Chest Pain Pressure, Tightness, Dull, Crush Radiating to Arms, Neck, Back Approx. 50% ACS Patients
  • 32. Musculoskeletal or Positional Sharp or Stabbing Epigastric Discomfort Many Elderly, Female, Diabetic
  • 34. Over 65 y/o Known CHD HTN DM High Cholesterol Sedentary Lifestyle
  • 35. Over 45 y/o Obese Black Cocaine Abuse Smoking Being a character in “Pulp Fiction”
  • 37. 1. Ischemia (Angina or NSTEMI) a) lack of oxygenation b) ST depression or T inversion 2. Injury (STEMI) a) prolonged ischemia b) ST elevation 3. Infarct (DEAD) a) dead tissue b) may or may not show in Q wave
  • 39. ST segment elevation (STEMI) • Limb leads [I, II, III, AVL, AVF] >one mm (1 small box) • Precordial leads [V1-V6] >two mm (2 small boxes) New or presumed new LBBB = ST elevation (STEMI) ST segment depression (Angina or NSTEMI) • One mm or more (one small box) T Wave Inversion (Angina or NSTEMI) Q Wave (MI)? • One mm or more (1 small box)
  • 48. A “normal” ECG does NOT rule out ACS. “Non-Diagnostic” ST segment depression or T wave inversion represents ischemia (Angina, NSTEMI). ST segment elevation is evidence of injury (STEMI). Q wave indicative of MI. Not all MI=Q wave Indicators can come in any combination. Process may go forwards or backwards. There are always exceptions to the rules. Look for reciprocal changes Evaluate Rate and Rhythm (DEFIB) Evaluate for Axis Deviation Evaluate QRS Duration and more…
  • 50. • Morphine (class I, level C) • Analgesia • Reduce pain/anxiety—decrease sympathetic tone, peripheral vascular resistance and oxygen demand. • Careful with hypotension, hypovolemia, respiratory depression, RVI • Oxygen (> 94% sPO2) (class I, level C) • Up to 70% of ACS patient demonstrate hypoxemia • May limit ischemic myocardial damage by increasing oxygen delivery/reduce ST elevation • Shown to have limited benefit, possible harm if >100%
  • 51. • Nitroglycerin (class I, level B) • Analgesia—titrate infusion to keep patient pain free • Dilates coronary vessels—increase blood flow • Reduces systemic vascular resistance and preload • Careful with recent ED meds, hypotension, bradycardia, tachycardia, RVI • Aspirin (160-325mg chewed & swallowed) (class IIa, level B) • Irreversible inhibition of platelet aggregation • Stabilize plaque and arrest thrombus • Reduce mortality in patients with STEMI • Careful with active ulcers, hypersensitivity, bleeding disorders  In AMI, ASA reduced the risk of death by 20-25%  In UA, ASA reduced the risk of fatal or nonfatal MI by 71% during the acute phase.
  • 52. • Thienopyridines (Prasugrel, Plavix) (class I, level A) • Irreversible inhibition of platelet aggregation • Used in support of cath / PCI intervention or if unable to take aspirin • 3 to 12 month duration depending on scenario • Glycoprotein IIb/IIIa inhibitors (Integrilin) (class IIa, level B) • Inhibition of platelet aggregation at final common pathway • In support of PCI intervention as early as possible prior to PCI.
  • 53. • Proton Pump Inhibitors (Prilosec, Pepcid) • Given to reduce ulcers and increase compliance • May reduce blood thinning mechanisms of Plavix. • Hyperglycemia control in STEMI (Insulin) (class IIa, level B) • Control of hyperglycenia (180 mg/dl) recommended. • May reduce inflammation and increase LV Ejection Fraction.
  • 54. • Beta-Blockers (class I, level A) • 14% reduction in mortality risk at 7 days at 23% long term mortality reduction in STEMI • Approximate 13% reduction in risk of progression to MI in patients with threatening or evolving MI symptoms • Be aware of contraindications (CHF, Heart block, Hypotension) • Reassess for therapy as contraindications resolve. • ACE-Inhibitors (class I, level A) • Start in patients with anterior MI, pulmonary congestion, LVEF < 40% in absence of contraindication/hypotension • Start in first 24 hours
  • 55. • Unfractionated Heparin (class I, level A) – Concurrent with reperfusion therapies of all types. • Reduces clotting during acute in-hospital treatment. • Aldosterone blockers (class I, level A) – Post-STEMI patients • no significant renal failure (cr < 2.5 men or 2.0 for women) • No hyperkalemis > 5.0 • LVEF < 40% • Symptomatic CHF or DM
  • 61. Education/ Thrombolytics Prevention / Angioplasty Pre Arrival Instructions / ASA Triage Hospital Focused Assessment Patient MONA+ Comfort Pre-Hospital 12 Lead
  • 62. Education/ Thrombolytics Prevention / Angioplasty Pre Arrival Instructions / ASA Triage Hospital Focused Assessment Patient MONA+ Comfort Pre-Hospital 12 Lead

Notas del editor

  1. Who has to recognize? Us. Them. Dispatchers.
  2. What causes CP?
  3. Who has to recognize? Us. Them. Dispatchers.