Disclosures. STEMI:To Call or Not to Call. Disclosures 9/18/2017. Alternate Title: Hey Doc, If you re not doing anything Saturday Night

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1 STEMI:To Call or Not to Call Disclosures No financial disclosures September, 2017 Frederick James Trip Meine III MD, FACC, FSCAI Cape Fear Heart Associates, Wilmington, NC Disclosures Alternate Title: Hey Doc, If you re not doing anything Saturday Night 1

2 Interventional Cardiologist On Call Interventional Cardiologist On Call 5 6 Interventional Cardiologist On Call Complications of Cardiac Cath Increased 40% during emergent procedures J Invasive Card

3 Complications of Cardiac Cath Complications of Cardiac Cath 9 10 Complications of Cardiac Cath Complications of Cardiac Cath

4 Complications of Cardiac Cath We don t know what the H$%& we are doing? 13 STEMI Care Here in the Land of Sand 4

5 The Beach The Beach B I IIa IIb III PCI in Specific Clinical Situations: STEMI Primary PCI of the Infarct Artery Primary PCI should be performed in patients with STEMI presenting to a hospital with PCI capability within 90 minutes of first medical contact as a systems goal. Does Time Really Matter? B I IIa IIb III Primary PCI should be performed in patients with STEMI presenting to a hospital without PCI capability within 120 minutes of first medical contact as a systems goal. 5

6 Death by guideline goal 7% 6.7% Local Reperfusion Strategy Is Primary PCI < 120 mins achievable throughout the region? In hospital death 2.4% Beyond goal Seven Primary Counties 9 Referral hospitals Within goal 1 PCI Center 0% EMS Agencies 1 Critical Care Transfer Agency ~ 350 STEMI Patients per year NC RACE, Circulation.2012;126: The Clock is Ticking... Pre-hospital Activation of STEMI Team 1: EMS 2:ED 3: Cath Lab/ STEMI MD 6

7 Recognizing a STEMI When It Just Doesn t Make Sense STEMI Imitators Bundle Branch Block Left ventricular hypertrophy Benign Early Repolarization Pericarditis Paced Rhythm 28 7

8 Physiology of BBB Bundle Branch Blocks Left Bundle Branch Block (LBBB) & Right Bundle Branch Block (RBBB) Normal electric pathway blocked Impulse takes an alternate route Time to reach base and apex increases QRS Complex widens Bundle Branch Blocks Diagnostic criteria QRS >0.12 wide Supra ventricular Diagnosed in V1 Turn Signal Method LBBB: How to Identify QRS > 0.12 sec (in sinus or supraventricular rhythms) LBBB: To the left of the J Point is down in V1 RBBB: To the left of the J Point is up in V1 (STEMI can be identified in presence of RBBB) V 1 left of the J point is down 8

9 LBBB: How to Identify LBBB Downward deflection to the left of the j point in V1 => LBBB Wide QRS Appears as ST elevation, however is not a STEMI Right Bundle Branch Block Identification Wide QRS > 0.12 Classic triphasic rsr ( M or rabbit ears ) V 1 left of the J point is up Right Bundle Branch Block 9

10 Early Repolarization Early Repolarization The patient Healthy, asymptomatic patients, often young males, does not indicate pathology The waveform J point elevation, may have notch/slur at end of QRS fish hook shape Concave upward toward t wave Tall T waves, symmetrical ST Elevation Seen throughout EKG, not just in contiguous leads No reciprocal changes Sep BER Acute Pericarditis Notice ST elevation everywhere, not just in contiguous leads. 10

11 Pericarditis Pericarditis Revisited ST segments elevated diffusely because entire pericardium is usually irritated. Irritation causes net positivity of epicardium expressed as ST elevation. 12 LEAD ECG: The Art of Interpretation Ch 12 Acute Pericarditis Chest Pain sharp, affected by movement, respiration, position Pain may decrease leaning forward Diffuse, generalized ST elevation throughout EKG PR depression in all leads except avr and V1 PR elevation in avr PR depression No reciprocal changes STE is usually concave Low voltage Pericarditis: PR Depression and Notching ST Elevation 12 LEAD ECG: The Art of Interpretation Ch 12 11

12 Pericarditis Left Ventricular Hypertrophy Left Ventricular Hypertrophy Impact Electrical impulses travel through excess tissue Increased time required for contraction ECG implication Increased height and depth of QRS elevates ST Segment, especially V1 V6 Identification Find the larger S wave in V1 & V2, count the boxes Find the larger R wave in V5 & V6, count the boxes Add the sum, if > than 35, suspect LVH S wave V1 or V2 R wave V5 or V6 Sum > 35? LVH: How to Identify Increased amplitude height and depth of QRS LVH can cause ST elevation, especially in V1 V6 To identify: 1. Find the larger S wave in V1 & V2, count the boxes 2. Find the larger R wave in V5 & V6, count the boxes 3. Add the sum, if > than 35, suspect LVH Note: LVH QRS complexes are discordant S wave V1 or V2 R wave V5 or V6 Sum > 35? 12

13 LVH Lots of ink on the page, start looking for LVH. Find the larger S wave in V1 & V2, add it to the larger R wave in V5 or V6. Greater than 35? If so => LVH Other Tips ST segment: Concave Up is usually benign Concave Up: if you can draw a smiley face, usually benign ST segment: Convex Down is usually Pathological Paced Rhythm Paced Rhythm 13

14 Ventricular Paced Rhythm Regular and Wide Complex like a BBB Paced Rhythm: Additional Rules Look for pacing spikes Ventricular paced is uninterpretable Atrial paced is interpretable 14