STEMI and Acute Coronary Syndromes

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This highly energetic lecture presents the pathophysiology of S-T elevation myocardial infarction in an easy to understand style to help you best identify, triage and treat patients presenting with acute coronary syndromes. Using the latest research behind the AHA Guidelines changes, AHA National Faculty Rom Duckworth will help you better coordinate with you partners along the continuum of cardiac care. Emphasis is placed on risk factors, recognizing truly sick patients and coordinating care with hospital personnel.

Learning Objectives: Students will learn:
-The pathophysiology of S-T elevation myocardial infarction.
-The difference between STEMI, NSTEMI and unstable angina.
-Differing treatment methods and priorities for different cardiac syndromes.
-The function and importance of 12 lead ECG and prehospital diagnostic testing.
-The roles and responsibilities of EMS providers as the key element in “door-to-balloon” and “door-to-needle” time for STEMI patients.

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  • Who has to recognize? Us. Them. Dispatchers.
  • What causes CP?
  • Who has to recognize? Us. Them. Dispatchers.
  • STEMI and Acute Coronary Syndromes

    1. 1. Tuesday, January 22, 2013
    2. 2. From the AHA/ACC STEMI guidelines NSTEMI STEMI
    3. 3. Stenotic Lesion Fibrotic Thick Cap Stable Less Enlargement + Sx BAD!Non-Stenotic Lipid Rich Thin Cap Unstable Enlargement Catastrophic WORSE!!! Detectible?
    4. 4. vs FMC TO DEV: 90 MIN.
    5. 5. Early Recognition of ACS (red flags)Dispatch Resources & Pre-Arrival ASAEMS Recognition & StabilizationInitial Care & Comfort
    6. 6. 12 Lead – STEMI identification.MONA+ MedicationsTriage & Pre-notify EDEducation & Prevention
    7. 7. Central Anterior Chest PainPressure, Tightness, Dull, CrushRadiating to Arms, Neck, BackApprox. 50% ACS Patients
    8. 8. Musculoskeletal or PositionalSharp or StabbingEpigastric DiscomfortMany Elderly, Female, Diabetic
    9. 9. DyspneaPalpitationsSyncopeDiaphoresisNausea / VomitingGeneral Weakness
    10. 10. Over 65 y/oKnown CHDHTNDMHigh CholesterolSedentary Lifestyle
    11. 11. Over 45 y/oObeseBlackCocaine AbuseSmokingBeing a character in “Pulp Fiction”
    12. 12. 1. Ischemia (Angina or NSTEMI) a) lack of oxygenation b) ST depression or T inversion2. Injury (STEMI) a) prolonged ischemia b) ST elevation3. Infarct (DEAD) a) dead tissue b) may or may not show in Q wave
    13. 13. ST segment elevation (STEMI)• Limb leads [I, II, III, AVL, AVF] >one mm (1 small box)• Precordial leads [V1-V6] >two mm (2 small boxes)New or presumed new LBBB = ST elevation (STEMI)ST segment depression (Angina or NSTEMI)• One mm or more (one small box)T Wave Inversion (Angina or NSTEMI)Q Wave (MI)?• One mm or more (1 small box)
    14. 14. A “normal” ECG does NOT rule out ACS. “Non-Diagnostic”ST segment depression or T wave inversion represents ischemia (Angina, NSTEMI).ST segment elevation is evidence of injury (STEMI).Q wave indicative of MI. Not all MI=Q waveIndicators can come in any combination.Process may go forwards or backwards.There are always exceptions to the rules.Look for reciprocal changesEvaluate Rate and Rhythm (DEFIB)Evaluate for Axis DeviationEvaluate QRS Duration and more…
    15. 15. • Morphine (class I, level C) • Analgesia • Reduce pain/anxiety—decrease sympathetic tone, peripheral vascular resistance and oxygen demand. • Careful with hypotension, hypovolemia, respiratory depression, RVI• Oxygen (> 94% sPO2) (class I, level C) • Up to 70% of ACS patient demonstrate hypoxemia • May limit ischemic myocardial damage by increasing oxygen delivery/reduce ST elevation • Shown to have limited benefit, possible harm if >100%
    16. 16. • Nitroglycerin (class I, level B) • Analgesia—titrate infusion to keep patient pain free • Dilates coronary vessels—increase blood flow • Reduces systemic vascular resistance and preload • Careful with recent ED meds, hypotension, bradycardia, tachycardia, RVI• Aspirin (160-325mg chewed & swallowed) (class IIa, level B) • Irreversible inhibition of platelet aggregation • Stabilize plaque and arrest thrombus • Reduce mortality in patients with STEMI • Careful with active ulcers, hypersensitivity, bleeding disorders  In AMI, ASA reduced the risk of death by 20-25%  In UA, ASA reduced the risk of fatal or nonfatal MI by 71% during the acute phase.
    17. 17. • Thienopyridines (Prasugrel, Plavix) (class I, level A) • Irreversible inhibition of platelet aggregation • Used in support of cath / PCI intervention or if unable to take aspirin • 3 to 12 month duration depending on scenario• Glycoprotein IIb/IIIa inhibitors (Integrilin) (class IIa, level B) • Inhibition of platelet aggregation at final common pathway • In support of PCI intervention as early as possible prior to PCI.
    18. 18. • Proton Pump Inhibitors (Prilosec, Pepcid) • Given to reduce ulcers and increase compliance • May reduce blood thinning mechanisms of Plavix.• Hyperglycemia control in STEMI (Insulin) (class IIa, level B) • Control of hyperglycenia (180 mg/dl) recommended. • May reduce inflammation and increase LV Ejection Fraction.
    19. 19. • Beta-Blockers (class I, level A) • 14% reduction in mortality risk at 7 days at 23% long term mortality reduction in STEMI • Approximate 13% reduction in risk of progression to MI in patients with threatening or evolving MI symptoms • Be aware of contraindications (CHF, Heart block, Hypotension) • Reassess for therapy as contraindications resolve.• ACE-Inhibitors (class I, level A) • Start in patients with anterior MI, pulmonary congestion, LVEF < 40% in absence of contraindication/hypotension • Start in first 24 hours
    20. 20. • Unfractionated Heparin (class I, level A) – Concurrent with reperfusion therapies of all types. • Reduces clotting during acute in-hospital treatment.• Aldosterone blockers (class I, level A) – Post-STEMI patients • no significant renal failure (cr < 2.5 men or 2.0 for women) • No hyperkalemis > 5.0 • LVEF < 40% • Symptomatic CHF or DM
    21. 21. Education/ Thrombolytics Prevention / Angioplasty Pre Arrival Instructions / ASA TriageHospital Focused Assessment Patient MONA+ Comfort Pre-Hospital 12 Lead
    22. 22. Education/ Thrombolytics Prevention / Angioplasty Pre Arrival Instructions / ASA TriageHospital Focused Assessment Patient MONA+ Comfort Pre-Hospital 12 Lead

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