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Flashcards in STEMI Deck (37)
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Define Acute coronary syndrome

A collection of syndromes resulting from acute myocardial ischaemia. Includes: Unstable angina, NSTEMI, and STEMI


Describe the presentation of acute coronary syndrome

Acute central crushing chest pain >20 min duration Sweating, nausea, dyspnoea, palpitations


How may presentation of MI differ in elderly and diabetic patients?

They may experience 'Silent' MIs. These may present with syncope, pulmonary oedema, vomiting, acute confusion, stroke, and diabetic hyperglycaemic states.


Name 3 conditions that mimic the pain of acute coronary syndrome

Pericarditis Dissecting aortic aneurysm Pulmonary embolism Oesophageal reflux, spasm, rupture (Boerhavve syndrome) Biliary tract disease Perforated peptic ulcer Pancreatitis


Categorise acute coronary syndrome on treatment

STEMI: requires reperfusion therapy on presentation NSTEMI and UA: not treated with thrombolysis


Differentiate the types of acute coronary syndrome

STEMI: ST-elevation or LBBB on 12-lead ECG, with positive cardiac markers NSTEMI: No ST-elevation, with positive cardiac markers UA: No ST-elevation, with negative cardiac markers *Cardiac markers: Troponin I, CK-MB


Outline the initial emergency management of acute coronary syndrome

Transfer to CCU/HDU for continuous ECG monitoring and access to defibrillator if needed. ABC assessment: exclude hypotension, locate murmurs, identify and treat acute pulmonary oedema IV access 12-lead ECG Diamorphine 2.5-10mg IV PRN + metoclopramide 10mg Oxygen (controlled oxygen therapy 2-5L/min if hypoxic) Nitroglycerine 2 puffs sublingual (unless hypotensive) Aspirin 300mg PO


Outline the initial investigations for acute coronary syndrome

FBC and U&Es: maintain K+ between 4-5 mmol/L LFTs Glucose Lipids CK-MB: abnormal if 2x upper-limit of normal Troponin I* Portable CXR: Cardiomegaly and pulmonary oedema


What is the criteria for prior MI?

Any one of the following: -Pathological Q waves in absence of non-ischaemic cause -Imaging evidence of region loss of myocardium that is thinned and fails to contract, in the absence of non-ischaemic cause -Pathological finds of a prior MI


Describe the presentation of STEMI

Severe chest pain, may radiate to left arm, neck, jaw Not relieved by sublingual GTN >20 min duration Autonomic: Pale, clammy, sweating, weak pulse and hypotensive, brady- or tachycardia Atypical: Dyspnoea, fatigue, epigastric pain, syncope


What ECG changes are seen in STEMI?

ST elevation or new LBBB (V1 and V6) May have T wave inversion or pathological Q waves


Describe the evolution of STEMI on ECG

Mins to hrs: ST elevation and hyperacute T wave Hrs to 1 day: T wave inversion and Q wave 1 week: Coronary T wave Months: Q wave


Which vessel is occluded in the following?

Anteroseptal STEMI: Left anterior descending artery

ST elevation of:

  • 0.2+ mV in leads V1-3
  • 0.1+ mV in all other leads


Which vessel is occluded in the following?

High lateral STEMI: Left diagonal branch of LAD


Which vessel is occluded in the following?

Posterior STEMI: Posterior descending artery

Inverted changes seen in V1-3

Posterior leads V7-9 indicated


Which vessel is occluded in the following?

Inferior MI: Right coronary artery


What vessel is occluded in an anteroseptal STEMI, and which leads would be abnormal?

Left anterior descending artery V1-4


What vessel is occluded in a lateral STEMI, and which leads would be abnormal

Left marginal artery V5-6


What vessel is occluded in a high-lateral STEMI, and which leads would be abnormal?

Left circumflex artery I and aVL


What vessel is occluded in an inferior STEMI, and which leads would be abnormal?

Right coronary artery II, III, aVF


Which lead would be abnormal in a right ventricular STEMI?



Which leads would be abnormal in a posterior STEMI

V7-9 or V1-3 reciprocal ST depression


Outline the medical intervention for STEMI

Diamorphine 2.5-10mg IV PRN + Metoclopramide 10mg Oxygen (controlled oxygen therapy 2-5L/min if hypoxic) Nitroglycerine: 2 puffs sublingual (unless hypotensive) Aspirin 300mg PO Correct electrolyte imbalances: Low K+ and Mg2+ may be arrhthmogenic. Maintain K+ between 4-5 mmol/L Limit infarct size -Beta blockers: give early to all patients unless contraindicated -ACEi: given within 24hr of presentation -Reperfusion: Thrombolysis or PCI


List the absolute contraindications for beta-blockers

HR <60 SBP <100 Moderate to severe heart failure AV conduction defect Severe airway disease


List the relative contraindications for beta-blockers

Asthma CCBs and/or beta-blockers Critical limb ischaemia Large inferior MI involving right ventricle


List 3 complications of STEMI

Sudden death Pump failure/pericarditis Ruptured papillary muscle or septum Embolism Aneurysm/arrhythmias -LV aneurysm: persistent ST elevation with LV failure Dressler's syndrome: secondary autoimmune pericarditis 2-6wk post MI


What are the benefits of reperfusion therapy for MI

Lowers: Mortality* LV dysfunction Heart failure Cardiogenic shock Arrhythmias


What are the indications for Percutaneous coronary intervention?

All patients with chest pain and ST elevation/new LBBB Thrombolysis contraindicated Rescue PCI: if patient symptomatic post-thrombolysis or develops cardiogenic shock ST elevation of > 2mm in 2 or more consecutive anterior leads (V1-V6), or ST elevation of greater than 1mm in greater than 2 consecutive inferior leads (II, III, avF, avL)


Name 3 complications of percutaneous coronary intervention

Bleeding from puncture site Stroke Recurrent infarction Need for emergency CABG Death


What scoring system is used to assess operative mortality in cardiac surgery?