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STEMI
Joshua M. Kosowsky, MD
Brigham & Women’s Hospital
Emergency Medicine Physician
ACS Lecture Overview
• Definition and pathophysiology
• ACS case
– Reperfusion therapy
– Adjunctive medications
• Shock & CHF
• Right Ventricular Infarct
• AHA ACS Prevention Goals
Acute Coronary Syndrome:
Definition & Pathophysiology
• Pathophysiology:
Atherosclerotic plaque disruption
Intracoronary thrombus formation
BMJ 2003;326:1259-1261 (7 June), doi:10.1136/bmj.326.7401.1259
Yeghiazarians et al., NEJM 2000; 342: 101.
Yeghiazarians et al., NEJM 2000; 342: 101.
• 65 yo male with 1 hour
of left sided chest pain
• Diaphoretic
• H/o diabetes and
hyperlipidemia
• T: 98.2 HR: 74
BP: 128/69 RR: 20
How to treat ACS:
Data Goals:
Lytic therapy: 30 minutes
PCI: 90 minutes
Decision
Drug/Balloon
Reperfusion
I IIa IIb III STEMI patients presenting to a hospital with PCI
capability should be treated with primary PCI
within 90 minutes of first medical contact.
40 37 35
30 25
19 18
20
10 8
0
-10
-14
-20
BBB Ant Inf ST Depr 0-1hr 2-3hr 4-6hr 7-12hr
ST ST
ECG Findings Time to Treatment
Lancet 343:311,1994
Fibrinolytic Therapy: Indications
• Recommended in:
– Patients receiving fibrinolytics (not
SK/APSAC)
– All patients undergoing PCI.
• Dosing:
– 60 unit/kg bolus then 12 units/kg/hr (max
4000/1000)
Beta-Blockers
Oral beta-blocker therapy should be initiated in
the first 24 hours for patients who do not have
the following:
Signs of heart failure
Evidence of low output state
I IIa IIb III
Increased risk for cardiogenic shock
Age >70 years
Systolic blood pressure <120 mm Hg
Sinus tachycardia (heart rate >110 or < 60 bpm)
Increased time since onset of symptoms of STEMI
Relative contraindications to beta-blockade
PR interval >0.24 seconds
second- or third-degree heart block
active asthma or reactive airway disease
Beta-Blockers
It is reasonable to administer an IV beta-
blocker at the time of STEMI presentation to
I IIa IIb III patients who are hypertensive and who do not
have any of the following:
Signs of heart failure
Evidence of low output state
Increased risk for cardiogenic shock
Other relative contraindications to beta-blockade
Presentation:
• ST elevation inferiorly (II, III, AVF)
• Hypotension (worse with preload reducing
agents: nitrates, morphine, diuretics)
• Classic triad:
– Jugular venous distention
– Clear lungs
– Hypotension
RV Infarct
• 10-50% of inferior wall MIs (II,III, AVF)
have associated right ventricular infarct
• Contractility of the right ventricle depends
on diastolic pressure and output can
decrease dramatically with decreased
preload (volume)
• Also increased loss of AV synchrony
• ST elevation inferiorly in leads II, III, & AVF
•ST elevation anteriorly in V1
• To do a right sided EKG
place pre-cordial leads
(V1-V6) across the
right side of the chest
in a mirror image of
the standard left-sided
leads (V1R-V6R)
• Lead V4T is placed in the
right 5th intercostal space
at the mid-clavicular line
Diabetes Management:
HbA1c less than 7%.
Influenza Vaccination:
Patients with cardiovascular disease should have
an annual influenza vaccination.