Myocardial infarction

1. MYOCARDIAL INFARCTION

2. ACS :4rth
UDMI

3. Universal 4rth
definition
,2020
Type 1: Atherosclerotic plaque
disruption
Type 2: mismatch between oxygen
supply and demand
• Coronary dissection
• Vasospasm
• Emboli
• Microvascular dysfunction
• Increases in demand :HCM/HTN/HOCM
Type 3 : MI resulting in death when
biomarker values are unavailable

4. Type 4a: Periprocedural AMI(PCI)
• coronary dissection, occlusion of a major epicardial artery or a
side branch occlusion/thrombus, disruption of collateral flow,
slow flow or no-reflow, or distal embolization
Type 4b: PCI-related MI is stent/scaffold thrombosis
Type 5: CABG : cTn values >10 times the 99th
percentile URL in patients with normal baseline cTn
values
• new pathological Q waves
• new graft occlusion or new native coronary artery occlusion
• new loss of viable myocardium or new RWMA

5. WHEN TO SUSPECT
ACUTE MI
• CHEST PAIN
• SHORTNESS OF BREATH
• NEW HEART FAILURE
• SUDDEN CARDIAC ARREST

6. ECG: within
10 minutes
after first
contact
ST-elevation/new LBBB
NSTEMI
unstable angina
• ST-depression, T wave inversions, or transient
ST-elevation
Nondiagnostic :Follow with serial ECG

7. STEMI ECG
J-point elevation and
concave ST
J-point elevation and
convex ST
ST/T merge with
upward single
convexity

8. STEMI
• New ST-segment elevation at the J-point in two contiguous leads with the cut-points:
≥0.1 mV in all leads other than leads V2-V3
• V2-V3:
• ≥2 mm in men ≥40 years
• ≥2.5 mm in men <40 years
• ≥1.5 mm in women regardless of age

9. NSTEMI
New horizontal or down
sloping ST-depression ≥0.5
mm in two contiguous leads
and/or T inversion >1 mm in
two contiguous leads with
prominent R wave or R/S
ratio >1

10. Nondiagnostic initial ECG
Wait and watch

11. Troponin
Serial ECG is key :at first contact
,at 3hour ,at 6hour
Measurement :
• hS-Tp=00-0.02 nano gram /ml
• Kit test (Qualitive ):>40 nano gram /ml
• Routine quantitative :>give the value
if it is >40 nano gram /ml (ROCHE’s
Lab)

12. The findings
on the ECG
depend upon
Duration – Hyperacute,
acute, evolving, or chronic
Size – Amount of
myocardium affected
Location – Anterior, lateral,
inferior-posterior, or right
ventricle

13. Left bundle
branch block
• ST-depression of at least 1 mm in
leads V1, V2, or V3 or in leads II, III,
or Avf
• ST elevation of at least 1 mm in lead
V5
Concordant changes :
• ST changes in the opposite direction
of the major QRS vector of >5 mm
Discordant changes

14. Old MI:
Fourth
Universal
Definition
• in the absence of left bundle
branch block or left
ventricular hypertrophy
• Any Q wave in leads V2 to V3
≥0.02 sec or QS complex in V2
and V3;
• Q wave ≥0.03 sec and ≥0.1 mV
deep or QS complex in leads I,
II, aVL, aVF; or V4 to V6 in any
two leads of a contiguous lead
grouping (I, aVL; V1 to V6; II, III,
aVF)
• R wave ≥0.04 sec in V1 to V2
and R/S ≥1 with a concordant
positive T wave in the absence
of a conduction defect.

15. Treatment

18. STEMI

20. TLT:STAR

21. NSTEMI