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  1. 1. Diagnosis of ST Elevation MI and chest pain support. Charlie Bloe Clinical Ward Manager, CCU.
  2. 2. Acute CHD Presentations <ul><li>Unstable Angina </li></ul><ul><li>“ Wee heart attack!” </li></ul><ul><ul><ul><li>(subendocardial or partial thickness MI) </li></ul></ul></ul><ul><ul><ul><li>non-ST elevation MI </li></ul></ul></ul><ul><li>“ Big heart attack!” </li></ul><ul><ul><ul><li>(transmural or full thickness MI) </li></ul></ul></ul><ul><ul><ul><li>ST elevation MI </li></ul></ul></ul>
  3. 3. Acute Coronary Syndromes ST elevation MI Unstable Angina Non ST elevation MI
  4. 4. Atherosclerotic Plaque in Coronary Artery Lipid core Fibrous cap > Artery lumen Plaque rupture and thrombus formation
  5. 6. <ul><li>Early diagnosis and reperfusion in STEMI is essential. </li></ul><ul><li>GREAT study (1992) demonstrating that in early stages every one minute delay to reperfusion (by thrombolysis) reduces life expectancy by 11 days . </li></ul><ul><li>“ Treating patients with thrombolysis should be given the same degree of urgency as managing cardiac arrest” (Rawles 1992) </li></ul><ul><li>12-Lead ECG essential diagnostic tool. </li></ul>
  6. 8. The 12-lead ECG <ul><li>6 Limb Leads </li></ul><ul><ul><ul><li>Look at the heart on a vertical (coronal) plane </li></ul></ul></ul><ul><li>6 Chest Leads (precordial leads) </li></ul><ul><ul><ul><li>Look at the heart on a horizontal (sagittal) plane </li></ul></ul></ul>
  7. 9. limb chest
  8. 10. The Six Limb Leads aVR aVL aVF N
  9. 11. The Six Limb Leads aVR aVL aVF Lead I Lead II Lead III N
  10. 12. Use the thoracic skeleton for landmarks The Chest Leads
  11. 13. Correct chest lead placement V1-V6 or C1-C6 V1 V2 V3 V4 V5 V6
  12. 14. 6 + 4 = 12! <ul><li>The 6 limb leads </li></ul><ul><ul><ul><li>aVR, aVL, aVF, </li></ul></ul></ul><ul><ul><ul><li>I, II, III </li></ul></ul></ul><ul><li>The 6 chest leads </li></ul><ul><ul><ul><li>V1, V2, V3, V4, V5 & V6 </li></ul></ul></ul>
  13. 15. <ul><li>Inferior MI: </li></ul><ul><li>Lead II, III & aVF </li></ul>Anterior - septal MI: V1 – V4 Lateral MI: Lead I, aVL, V5, V6
  14. 16. Diagnosis of Acute Coronary Syndromes <ul><li>Presenting History </li></ul><ul><li>Cardiac Enzymes </li></ul><ul><li>12 Lead ECG </li></ul>
  15. 17. Normal ECG complex <ul><li>ST segment. </li></ul><ul><li>End of QRS complex to beginning of T wave. </li></ul><ul><li>QRS ends and ST begins at the J point. May be up to 1mm above base line in normal individuals. </li></ul>
  16. 18. ECG evolution in acute STEMI <ul><li>Normal ECG complex </li></ul><ul><li>Isoelectric ST segment & J point </li></ul><ul><li>Upright T wave </li></ul><ul><li>Note QRS configuration </li></ul><ul><li>Non pathological Q wave </li></ul>
  17. 19. <ul><li>Hyperacute phase </li></ul><ul><li>Very early stages </li></ul><ul><li>ST segment elevation </li></ul><ul><li>1mm or > limb leads </li></ul><ul><li>2mm or > chest leads </li></ul>ECG evolution in acute STEMI
  18. 20. ECG evolution in acute STEMI <ul><li>Fully evolved phase </li></ul><ul><li>During first day </li></ul><ul><li>ST elevation reduces </li></ul><ul><li>T wave inversion </li></ul><ul><li>Pathological Q wave </li></ul>
  19. 21. ECG evolution in acute STEMI <ul><li>Chronic stabilized phase </li></ul><ul><li>Days then stabilized long term </li></ul><ul><li>Isoelectric ST segment </li></ul><ul><li>Upright T wave </li></ul><ul><li>Pathological Q wave </li></ul>
  20. 22. Case Study (March 2010) <ul><li>History of presenting complaint </li></ul><ul><li>68 year-old male living in Nairn. </li></ul><ul><li>Smoker, overweight. </li></ul><ul><li>Sudden onset of heavy anterior chest pain 1 hour previously. </li></ul><ul><li>Radiating to throat and down arms. </li></ul><ul><li>Vomiting and sweaty. </li></ul><ul><li>Paramedics send ECG to CCU via telemetry link. </li></ul><ul><li>Thrombolysis nurse calls back within 2 mins. with diagnostic support. </li></ul>
  21. 24. Raigmore ‘clot busters’ support team <ul><li>12 CCU thrombolysis support nurses trained. </li></ul><ul><li>Lifenet station in CCU to accept ECG transmissions from SAS. </li></ul><ul><li>Diagnostic support. </li></ul><ul><li>Objective to increase pre hospital thrombolysis rates. Historically <20% in NHSH. </li></ul><ul><li>Aim also to triage non STEMI ACS and high risk arrhythmia patients more appropriately. </li></ul><ul><li>System live February 2009. </li></ul><ul><li>Paramedics and CCU nurses key to success. </li></ul>
  22. 25. Impact on pre hospital thrombolysis (% of STEMI patients receiving PHT) Lots of myocardium saved!
  23. 26. Case study – Sept. 2010 <ul><li>59 yr old man. </li></ul><ul><li>Recent bad cold & cough. Required antibiotic. Chest x-ray clear. </li></ul><ul><li>Ischaemic chest pain at 6:50am </li></ul><ul><li>Called ambulance at 08:10am. </li></ul><ul><li>ECG sent to CCU at 08:24am. </li></ul><ul><li>Analysed by Laura. </li></ul>
  24. 28. Case study <ul><li>Discussed with Jamie Smith. </li></ul><ul><li>SAS advised to take patient straight to cath lab. </li></ul><ul><li>Arrived 09:10am. </li></ul><ul><li>Completely occluded LAD. </li></ul><ul><li>PCI / stent: complete success. </li></ul><ul><li>Open artery and radial sheath out at 09:35am. </li></ul><ul><li>ECG transmission to sheath out 1 hr.10 mins. </li></ul><ul><li>This is the Gold Standard!!! </li></ul>
  25. 29. Optimal Reperfusion Therapy. <ul><li>Aspiration is for PPCI to be the mainstay therapy. </li></ul><ul><li>Barriers: </li></ul><ul><li>Geography >40% of population out with drive time. </li></ul><ul><li>Smith & Leslie only willing to do a 90 hour week! </li></ul><ul><li>Cash! Need to expand cath lab capacity. (£250K from swear box so far) </li></ul><ul><li>Thrombolysis will be mainstay for some considerable time. It is still a very good therapy - especially for Highlanders! </li></ul>
  26. 30. QIS standard for RACP (less acute chest pain) <ul><li>Patients will be seen at RACP service within 5 working days of GP consultation. </li></ul><ul><li>Historical model of patients being seen at cardiac OPD by consultants - against a backdrop of increasing waiting lists. Weeks to consultation. </li></ul><ul><li>Nurse led service provided from within CCU live in August 2009. </li></ul><ul><li>Team of three nurses (Rhona, Jayne & Andrew) plus a doctor (Pushan) working collaboratively to provide 16 clinic slots weekly with immediate ETT access. </li></ul><ul><li>Consultants on hand for advice and management guidance. </li></ul>
  27. 31. RACP clinic to date. <ul><li>First year over 500 patients seen. (80% of slots taken) </li></ul><ul><li>95% of patients seen within 5 days of referral. (usually 48 hours) </li></ul><ul><li>Single point of referral via CCU. </li></ul><ul><li>Same day ETT etc </li></ul><ul><li>Collaborative working between cardiologists and RACP nurses. </li></ul><ul><li>Over 125 referred for angiography. </li></ul><ul><li>Very high degree of diagnostic accuracy! </li></ul>
  28. 32. Thank you.