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NON-STEMI THAT NEED THE CATH LAB NOW
Stephen W. SmithAssociate Professor of EM
Hennepin County Med CenterUniversity of MN
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4 days ago
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4 days ago presenting ECG - pain free
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46 yo male
2.5, 420 ,2 = 27.11
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25 min later
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Side by Side
Missed, ruled in with max trop I = 130 ng/ml. Cath next day.
Proximal LAD occlusion, convalescent anterior WMA
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42 yo with chest pain
Computerized QTc = 388
QTc = 388, STE60V3 = 4 mm, RAV4 = 32 mm: formula = 17.24 (<< 23.4)
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Lateral AMI confirmed by reciprocal depression in lead IIIFirst Diagonal occlusion — NOT “inferior ischemia”
47 yo woman with CP
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RCA occlusion, but not STEMI
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60 yo woman with Chest Pain
Prehospital ECG: STE at 60 ms after the J-point in lead V3 = 2.0 mm, QTc = 422 ms, R-wave amplitude in lead V4 = 4mm: formula = 25.99 (> 23.4)
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Referred for STEMI from clinic
First is outside ECG, 2nd is ED: QTc = 392. 392, 2, 12 = 21.61
390, 2, 11 = 21.8
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Male in 60s with chest pain
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Chest pain, resolved
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Still no chest pain, but trop slightly positive, repeat ECG
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Young woman, crushing and stabbing CP
Initial trop 6.1 (+), serial ecgs unchanged, no WMA, dx myocarditis. No MRI, no rub, no effusion, so diagnosis not certain
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24 yo woman, heavy EtOH and vomiting night before, now CP
After Cath
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Saw this in a pile of ECGs
First trop neg. 2nd trop I returns at 4 hours = 3.8 ng/ml. Repeat ECG:
Formula = 24.5, peak trop 100, 40% LVEF
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“Heartburn”
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25 yo male with chest pain
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Texted to me during meeting
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50 yo male with refractory chest pressure
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Down-Up T-waves
K = 2.3
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61 yo with chest pain
Right sided ECG: (V1-V6 are really V1R through V6R, on the right chest):
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Chest pain
Isolated Posterior STEMI
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51 yo woman with 1 hr of typical Chest Pain.
Old ECG
No emergent PCINext day Troponin 72, CK 3200. Cath next day: culprit lesion 2nd OM. Stented. Convalescent echo: posterior akinesis, 55%
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65 year-old with 2 hours of CP. No h/o MI.
previous
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V3
V6
V5
V4
RVLVRA
A
RVLV
ADIAPHRAGM
V9 V8V7
5th intercostal space
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56 yo male with 2 hours of typical CP
Given tPA. Reperfused, troponin 5.4, posterior WMA. Later angio with 99%
OM-1, stented.
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50 yo m with chest pain
Formula, with QTc 418, = 25.85. 4 hours later:
Becoming hypotensive. To cath lab. Proximal LAD occlusion. Much myocardial loss, but survived.
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Elderly woman with CP
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Elderly woman with chest pain--12 min later
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Chest Pain
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75 yo with chest pain
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60 yo with chest pain uncontrolled by medical Rx
First trop I 0.063. Repeat unchanged, but pain not controlled. Taken for immediate PCI: 95% LAD proximal to large D1 with
thrombus/TIMI-II
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Contrast
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Chest Pain
Early repol, 2.5, 401, 21 = 19.8
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Woman in 40’s with chest pain
Formula (but Q wave V3): 2, 442, 8.5 = 25.64
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Previous 2 cases, compare and contrast
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58 yo with 1 hour of Chest pain
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SyncopeCath lab activated
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Subtle Inferior MI?
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40 yo diagnosed with GERD 5d ago
ClinicECG
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Bedside Ultrasound
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32 yo male with CP, cough, ST (cont’d next slide)
37 minutes
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1st ECG that you just saw
After Cath and PCI
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Same case: 24 hour ECG