Non-STEMI that need cath lab now; Smith at SMACC.

1. Stephen W. Smith
Associate Professor of EM
Hennepin County Med Center
University of MN

5. 2.5, 420 ,2 = 27.11

7. Missed, ruled in with max trop I = 130 ng/ml. Cath next day.
Proximal LAD occlusion, convalescent anterior WMA

8. Computerized QTc = 388
QTc = 388, STE60V3 = 4 mm, RAV4 = 32 mm: formula = 17.24 (<< 23.4)

9. 47 yo woman with CP

11. 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)

12. First is outside ECG, 2nd is ED: QTc = 392. 392, 2, 12 = 21.61
390, 2, 11 = 21.8

16. Initial trop 6.1 (+), serial ecgs unchanged, no WMA, dx myocarditis. No
MRI, no rub, no effusion, so diagnosis not certain

17. After
Cath

18. Formula = 24.5, peak trop 100, 40% LVEF
First trop neg. 2nd trop I returns at 4 hours = 3.8 ng/ml. Repeat ECG:

23. K = 2.3

24. Right sided ECG: (V1-V6 are really V1R through V6R, on the right chest):

25. Isolated Posterior STEMI

26. Old ECG
No emergent PCI
Next day Troponin 72, CK 3200.
Cath next day: culprit lesion 2nd OM.
Stented. Convalescent echo:
posterior akinesis, 55%

27. previous

28. V3
V5
V6
V4
RV
RA LV
A
RV
LV
A
DIAPHRAGM
V9 V8
V7
5th intercostal space

30. Formula, with QTc 418, = 25.85. 4 hours later:
Becoming hypotensive. To cath lab. Proximal LAD
occlusion. Much myocardial loss, but survived.

35. 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

37. Early repol, 2.5, 401, 21 = 19.8

38. Formula (but Q wave V3): 2, 442, 8.5 = 25.64

39. Previous 2 cases, compare and contrast

43. Clinic
ECG

45. 37 minutes

46. After Cath and PCI