amy gutman md ems medication director [email protected]
TRANSCRIPT
STEMI & PCI Overviews
3 Case Reviews
All cases occurred between 2007 & 2010 (blinded)
STEMI responsible for 500,000 hospital admissions & 75,000 deaths annually
Thrombosis (clots form coronary artery plaques) is most common cause of STEMI
Early reperfusion reduces mortality and morbidity by “rescuing” heart muscle from ischemia and necrosis
Door-to-balloon time for primary PCI of <90 mins
Annual operative volumes of >400 procedures
Recommendation that elective PCI not be performed at facilities without onsite cardiac surgery facilities to perform “rescue” CABG
Acute Coronary Syndrome (ACS)Acute Coronary Syndrome (ACS)
STEMISTEMI NSTEMI NSTEMI
Cardiac MarkersCardiac Markers ((Troponin, CKMB))
Myocardial InfarctionMyocardial Infarction
STEMISTEMI Non-STEMINon-STEMI PCI vs Fibrinolysis Stress Test, Delayed Cath Lab
Unstable AnginaUnstable Angina--
++
STEMIs due to blockage of a coronary artery If treated within 90 mins, >25% of STEMIs regain
complete function of the heart muscle
NSTEMIs due to sudden narrowing of a coronary artery with preserved but diminished cardiac blood flow Pts with NSTEMI presumed to have unstable angina, &
do not necessarily require acute opening of a vessel
Anticoagulation & antiplatelet agents prevent narrowed artery from occluding, followed by stress testing & possibly delayed (1-3 days) coronary angiography
If NSTEMI with continued CP, will proceed to catherization lab
Fibrinolysis (“Clot Busters”)Fibrinolysis (“Clot Busters”) 50-60% achieve normal arterial flow 30% recurrence of ischemia 3-5% re-infarction 1-4% hemorrhagic CVA 20-30% contraindications for thrombolytics
Active internal bleeding, recent stroke, uncontrolled HTN
PCIPCI 95% normal arterial flow (TIMI 3) 10-15% recurrence of ischemia 1-3% re-infarction <1% hemorrhagic CVA Few contraindications
1. Patient Brought To Cath Lab2. Cath wire threaded through
femoral or brachial artery3. Wire passes through aorta &
guided into coronary arteries
RCA Blockage Before Stenting
RCA Opened After Stenting
Wall Affected ST Segment Elevation Artery Septal V1, V2 LADAnterior V3, V4 LAD Anteroseptal V1, V2, V3, V4 LAD Anterolateral V3, V4, V5, V6, I, aVL LAD, Circumflex Inferior II, III, aVF RCA, Circumflex Lateral I, aVL, V5, V6 Circumflex
Wall Affected ST Segment Elevation Artery Septal V1, V2 LADAnterior V3, V4 LAD Anteroseptal V1, V2, V3, V4 LAD Anterolateral V3, V4, V5, V6, I, aVL LAD, Circumflex Inferior II, III, aVF RCA, Circumflex Lateral I, aVL, V5, V6 Circumflex
EMTs & Paramedics Recognized for Outstanding Patient Care
42 yo WM with CC of “Chest Pain”PMH: CADAllergies: PercocetTX: IV, O2, Monitor; ASA, NTG
Outstanding documentation & performance of ACLS protocols!
Admitted 7/14 with V2–V6 STEMI & VFib arrest
<30 mins to cath lab from prehospital callAnterior – lateral STEMI progressed to
inferior – anterior – lateral ischemia just prior to cardiac cath
100% LAD occlusion opened up with stent
Discharged on 7/17 with normal heart function
55 yo Black MaleCC: Chest pain, generalized weakness,
fatiguePMH: NoneMedications: NoneAllergies: NoneRX: IV, O2, Monitor, ASA
Right ventricular infarction complicates 40% of I-STEMIs Isolated RV infarction
extremely uncommon
Preload sensitive due to poor RV contractility Develop rapid & severe
hypotension from nitrates or preload-sensitive agents
Hypotension in right STEMI treated with fluids Nitrates contraindicated
ST elevation V1 (only standard lead looking directly at RV)
ST elevation in lead III > II Lead III more “right facing” than lead II & more sensitive to injury
current
Magnitude of ST elevation in V1 > ST elevation in V2
ST segment in V1 isoelectric & ST segment in V2 depressed Combination of ST elevation in V1 & ST depression in V2
highly specific for RV MI
Right ventricular infarction confirmed by ST elevation in right-sided leads (V3R-V6R)
Place leads V1-6 in a mirror-image position on the right side of the chest
Leave V1 & V2 in usual positions & transfer leads V3-6 to right side of chest (i.e. V3R to V6R).
Most useful lead is V4R, obtained by placing V4 lead in 5th RICS MCL
ST elevation in V4R has sensitivity of 88%, specificity of 78% in diagnosis of RV MI
•Good Documentation of HPI & treatment
•Excellent justification of why NTG appropriately not given
•Followed ALS Protocols
3 Vessel Disease:CircumflexLeft Anterior DescendingRight Coronary Artery
Important Point:This young patient with no prior disease
was a walking “time bomb” who likely would have died or had severely decreased quality of life if he had not gotten to a cath lab immediately
Admitted on 12/14
Prehospital notification of anterior STEMIDoor to Balloon 22 mins (4 mins in ED for
CXR EKG to r/o aortic dissection)RCA and proximal LAD stents
Discharged 12/17 with normal heart function
43 yo W MaleCC: Chest pain that “started 20 minutes
ago”PMH: HTN, NIDDM• Great documentation of HPI, Exam, EKG
findings, & Treatment & Change in Symptoms post Treatment
• Hypotension post NTG makes you think of what type of
infarction?
• What is the immediate treatment?
Stent of 100% occluded RCA
Discharged from hospital 3 days post catherizationDiagnosed with
inferior MIPost cath echo
showed minimal heart damage
Recognition, pre-notification, & early cardiac catherization are keys to improving survival in STEMI patients
These patients walked out of the hospital who would have otherwise died due to outstanding care provided by the EMTs & paramedics