All About STEMIs. Presented By: Brittney Urvand, RN, BSN, CCCC. Essentia Health Fargo Cardiovascular Program Manager.
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1 All About STEMIs Presented By: Brittney Urvand, RN, BSN, CCCC Essentia Health Fargo Cardiovascular Program Manager Updated 10/2/2018
2 None Disclosures
3 Objectives Identify signs and symptoms of a heart attack Identify risk factors associated with having a heart attack Review and interpret ECGs and STEMI mimics Review and discuss elements of STEMI guidelines with rationales.
4
5 Einthoven s Triangle
6 12-lead ECG Placement
7 12-Lead ECG Waveform Review Ventricular Depolarization Atrial Depolarization Ventricular Repolarization
8 Isoelectric line Baseline tracing without electrical activity Resting phase of myocardium Waveforms and intervals are measured at the point of deviation from the isoelectric line
9 Normal ECG
10 Anatomical view of heart and corresponding leads I II III avr avl avf V1 V2 V3 V4 V5 V6 Inferior: II, III, AVF (RCA) Septal: V1, V2 (LAD) Anterior: V3, V4 (LAD) Lateral: I, AVL, V5, V6 (Circ)
11 Assessing a 12-lead I SEE ALL Inferior Leads II, III, AVF Septal Leads V1, V2 Anterior Leads V3, V4 LEADS I V1 V4 avr Lateral Septal Anterior II avl V2 V5 Inferior Lateral Septal Lateral III avf V3 V6 Inferior Inferior Anterior Lateral Lateral Leads V5, V6, I, AVL
12 J-Point
13 ST Segment
14 How to Measure ST Elevation
15 Measuring the ST Segment Compare ST segment to the TP segment
16 T-wave abnormalities
17 STEMI Definition STEMIs are characterized by the presence of both criteria: ECG evidence of STEMI: ST-segment elevation at the J-point in two contiguous leads with the cut-off points: 2 mm in men or 1.5 mm in women in leads V2-V3 or 1 mm in other leads. Cardiac biomarkers (CKMB, Troponin) exceed the upper limit of normal according to the individual hospital's laboratory parameters with a clinical presentation which is consistent or suggestive of ischemia. J-point = Intersection of end of QRS complex with beginning of ST segment
18 Evolution of a STEMI
19 The wave of necrosis STEMI ST-Elevation Myocardial Infarction Complete occlusion of a coronary artery that eventually produces elevation of the ST segment in the ECG of most patients. Cardiac muscle death begins and proceeds rapidly through the various layers of the heart supplied by that artery unless flow is reestablished.
20 STEMI
21 ACUTE CORONARY SYNDROME Treatment in cath lab
22 Anterior STEMI ECG Characteristics» ST elevation in leads V1-V6. Maximum elevation in V3, maximum depression in III» Later: pathological Q-wave in the precordial leads V2 to V4-V5. Complications» Heart failure» VT/VF» Ventricular septal defect» Complete heart block» Myocardial rupture I II III avr avl avf V1 V2 V3 V4 V5 V6 Anterior: V3, V4 (LAD)
23 I avr V1 V4 Anterior STEMI II avl V2 V5 III avf V3 V6 Anterior: V3, V4 (LAD)
24 STEMI Treatment in cath lab I avr V1 V4 II III avl avf V2 V3 V5 V6 Anterior: V3, V4 (LAD)
25 AnteroSeptal STEMI I avr V1 V4 II avl V2 V5 III avf V3 V6 Anterior: V3, V4 (LAD) Septal: V1, V2 (LAD)
26 Inferior STEMI ST elevation in II, III and avf» This part of the heart muscle lies on the diaphragm and is supplied of blood by the right coronary artery (RCA) in 80% of patients. [In the remaining 20% the inferior wall is supplied by circumflex artery (LCx).] Complications» Sinus bradycardia, sinus arrest, heart block» Papillary muscle rupture» RV failure with RV involvement I II III avr avl avf V1 V2 V3 V4 V5 V6 Inferior: II, III, AVF (RCA)
27 Inferior STEMI I II III avr avl avf V1 V2 V3 V4 V5 V6 Inferior: II, III, AVF (RCA)
28 STEMI Treatment in cath lab I avr V1 V4 II III avl avf V2 V3 V5 V6 Inferior: II, III, AVF (RCA)
29 Lateral STEMI Lateral wall of the left ventricle ST elevation in leads I, avl, V5 and V6» Supplied by the LCx, LAD, or a branch of the RCA» Usually accompanies an anterior or inferior MI Complications» VT» HF» HB I II III avr avl avf V1 V2 V3 V4 V5 V6 Lateral: I, AVL, V5, V6 (Circ)
30 I avr V1 V4 Lateral STEMI II avl V2 V5 III avf V3 V6 Lateral: I, AVL, V5, V6 (Circ)
31 STEMI Treatment in cath lab I II avr avl V1 V2 V4 V5 Lateral: I, AVL, V5, V6 (Circ) III avf V3 V6
32 Reciprocal Changes» ST depression in leads opposite the infarction» Strengthen suspicion for AMI, but are not necessary to identify STEMI
33 DIFFERENTIATE STEMI FROM STEMI IMPOSTERS
34 ST Segment Morphology STEMI
35 ST Segment Morphology The various faces of STEMI
36 ST Segment Morphology ST elevation in other conditions
37 Left Ventricular Hypertrophy (LVH)» Increases height of QRS» Voltage criteria formula for determining if LVH: 1. Compare V1 and V2 and decide which one has the deepest negative deflection 2. Compare V5 and V6, deciding which one has the tallest positive deflection 3. Add the numbers, and if the sum is 35 mm or more, suspect LVH. V1 V5 20 mm 23 mm 43 mm
38 Left Ventricular Hypertrophy (LVH)
39 Ken Horrocks, 2017 Left Bundle Branch Block
40 Left Bundle Branch Block» It is difficult to distinguish an acute from a chronic left bundle branch block without access to a previous 12-lead EKG» A left bundle branch block without other signs of symptoms of MI is not considered a STEMI
41 Ken Horrocks, 2017 Left Bundle Branch Block
42 Ken Horrocks, 2017 Left Bundle Branch Block
43 Ken Horrocks, 2017 Paced Rhythm
44 Paced Rhythm
45 Paced Rhythm with a STEMI
46 Pericarditis» ST elevation is concave in STEMI it is typically convex or flat» ST elevation is diffuse in STEMI it is usually confined to one distribution» PR depression occurs in pericarditis
47 Pericarditis
48 Pericarditis
49 Benign Early Repolarization (BER)
50 Benign Early Repolarization (BER)
51 » RBBB pattern Brugada Syndrome» ST elevation only in the right precordial leads V1-V2» Saddle-shaped or coved-shaped ST elevation» Syndrome has been linked to mutations in the cardiac sodium channel gene» Much more common in men
52 Brugada Syndrome
53 Brugada Syndrome
54 Brugada Syndrome
55 Tako-Tsubo Cardiomyopathy a.k.a. Broken Heart Syndrome» Almost always affects women» Presentation: chest pain and shortness of breath after severe emotional or physical stress» ECG can mimic STEMI» Rise in biomarkers can occur» Normal coronary arteries or nonobstructive CAD» LV apical ballooning» Temporary condition usually resolves within one month»
56 Tako-Tsubo Cardiomyopathy a.k.a. Broken Heart Syndrome
57 IMPORTANT!» The presence of an imposter does not rule out AMI» If you suspect infarct BEFORE the 12-lead you must still suspect infarct AFTER the 12-lead!
58 LETS PRACTICE!!!!
59 Where s the STEMI???
60 Where s the STEMI???
61 Where s the STEMI???
62 Where s the STEMI???
63 Where s the STEMI???
64 Where s the STEMI???
65 Where s the STEMI???
66 Questions? Thank you for your commitment to providing excellent cardiac care!
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