amy gutman md ems medication director prehospitalmd@gmail.com

Amy Gutman MD

EMS Medication Director

prehospitalmd@gmail.com

STEMI & PCI Overviews

3 Case Reviews

All cases occurred between 2007 & 2010 (blinded)

STEMI responsible for 500,000 hospital admissions & 75,000 deaths annually

Thrombosis (clots form coronary artery plaques) is most common cause of STEMI

Early reperfusion reduces mortality and morbidity by “rescuing” heart muscle from ischemia and necrosis

Door-to-balloon time for primary PCI of <90 mins

Annual operative volumes of >400 procedures

Recommendation that elective PCI not be performed at facilities without onsite cardiac surgery facilities to perform “rescue” CABG

Acute Coronary Syndrome (ACS)Acute Coronary Syndrome (ACS)

STEMISTEMI NSTEMI NSTEMI

Cardiac MarkersCardiac Markers ((Troponin, CKMB))

Myocardial InfarctionMyocardial Infarction

STEMISTEMI Non-STEMINon-STEMI PCI vs Fibrinolysis Stress Test, Delayed Cath Lab

Unstable AnginaUnstable Angina--

++

STEMIs due to blockage of a coronary artery If treated within 90 mins, >25% of STEMIs regain

complete function of the heart muscle

NSTEMIs due to sudden narrowing of a coronary artery with preserved but diminished cardiac blood flow Pts with NSTEMI presumed to have unstable angina, &

do not necessarily require acute opening of a vessel

Anticoagulation & antiplatelet agents prevent narrowed artery from occluding, followed by stress testing & possibly delayed (1-3 days) coronary angiography

If NSTEMI with continued CP, will proceed to catherization lab

Fibrinolysis (“Clot Busters”)Fibrinolysis (“Clot Busters”) 50-60% achieve normal arterial flow 30% recurrence of ischemia 3-5% re-infarction 1-4% hemorrhagic CVA 20-30% contraindications for thrombolytics

Active internal bleeding, recent stroke, uncontrolled HTN

PCIPCI 95% normal arterial flow (TIMI 3) 10-15% recurrence of ischemia 1-3% re-infarction <1% hemorrhagic CVA Few contraindications

1. Patient Brought To Cath Lab2. Cath wire threaded through

femoral or brachial artery3. Wire passes through aorta &

guided into coronary arteries

RCA Blockage Before Stenting

RCA Opened After Stenting

Wall Affected ST Segment Elevation Artery Septal V1, V2 LADAnterior V3, V4 LAD Anteroseptal V1, V2, V3, V4 LAD Anterolateral V3, V4, V5, V6, I, aVL LAD, Circumflex Inferior II, III, aVF RCA, Circumflex Lateral I, aVL, V5, V6 Circumflex

Wall Affected ST Segment Elevation Artery Septal V1, V2 LADAnterior V3, V4 LAD Anteroseptal V1, V2, V3, V4 LAD Anterolateral V3, V4, V5, V6, I, aVL LAD, Circumflex Inferior II, III, aVF RCA, Circumflex Lateral I, aVL, V5, V6 Circumflex

EMTs & Paramedics Recognized for Outstanding Patient Care

42 yo WM with CC of “Chest Pain”PMH: CADAllergies: PercocetTX: IV, O2, Monitor; ASA, NTG

Outstanding documentation & performance of ACLS protocols!

Admitted 7/14 with V2–V6 STEMI & VFib arrest

<30 mins to cath lab from prehospital callAnterior – lateral STEMI progressed to

inferior – anterior – lateral ischemia just prior to cardiac cath

100% LAD occlusion opened up with stent

Discharged on 7/17 with normal heart function

55 yo Black MaleCC: Chest pain, generalized weakness,

fatiguePMH: NoneMedications: NoneAllergies: NoneRX: IV, O2, Monitor, ASA

Right ventricular infarction complicates 40% of I-STEMIs Isolated RV infarction

extremely uncommon

Preload sensitive due to poor RV contractility Develop rapid & severe

hypotension from nitrates or preload-sensitive agents

Hypotension in right STEMI treated with fluids Nitrates contraindicated

ST elevation V1 (only standard lead looking directly at RV)

ST elevation in lead III > II Lead III more “right facing” than lead II & more sensitive to injury

current

Magnitude of ST elevation in V1 > ST elevation in V2

ST segment in V1 isoelectric & ST segment in V2 depressed Combination of ST elevation in V1 & ST depression in V2

highly specific for RV MI

Right ventricular infarction confirmed by ST elevation in right-sided leads (V3R-V6R)

Place leads V1-6 in a mirror-image position on the right side of the chest

Leave V1 & V2 in usual positions & transfer leads V3-6 to right side of chest (i.e. V3R to V6R).

Most useful lead is V4R, obtained by placing V4 lead in 5th RICS MCL

ST elevation in V4R has sensitivity of 88%, specificity of 78% in diagnosis of RV MI

•Good Documentation of HPI & treatment

•Excellent justification of why NTG appropriately not given

•Followed ALS Protocols

3 Vessel Disease:CircumflexLeft Anterior DescendingRight Coronary Artery

Important Point:This young patient with no prior disease

was a walking “time bomb” who likely would have died or had severely decreased quality of life if he had not gotten to a cath lab immediately

Admitted on 12/14

Prehospital notification of anterior STEMIDoor to Balloon 22 mins (4 mins in ED for

CXR EKG to r/o aortic dissection)RCA and proximal LAD stents

Discharged 12/17 with normal heart function

43 yo W MaleCC: Chest pain that “started 20 minutes

ago”PMH: HTN, NIDDM• Great documentation of HPI, Exam, EKG

findings, & Treatment & Change in Symptoms post Treatment

• Hypotension post NTG makes you think of what type of

infarction?

• What is the immediate treatment?

Stent of 100% occluded RCA

Discharged from hospital 3 days post catherizationDiagnosed with

inferior MIPost cath echo

showed minimal heart damage

Recognition, pre-notification, & early cardiac catherization are keys to improving survival in STEMI patients

These patients walked out of the hospital who would have otherwise died due to outstanding care provided by the EMTs & paramedics