stemi diagnosis criteria

Women, on the other hand, have a longer delay from symptom onset to first medical contact and women are also less likely to receive evidence-based interventions, such as PCI and fibrinolysis. Aspirin is given in the prehospital setting and before PCI. Int. Oral beta-blockers should be initiated during the first 24 hours after admission. EMS personnel should be trained in advanced cardiac life support and the early management of acute STEMI. Naloxone (0.1 mg IV, may be repeated every 10 minutes) may be administered if there are signs of morphine overdose. If an x-ray is done this should be in the Resus bay, except for stable low risk patients who may be suitable to leave the department for their x-ray, this will need to be judged on a case by case basis. The ensuing ischemia is transmural,which means that it affects the entire muscle layer, fromthe endocardium to the epicardium (Figure 2). padding-bottom: 0px; But opting out of some of these cookies may have an effect on your browsing experience. In patients referred forprimary PCI, ticagrelor is the drug of choice among the three P2Y12-receptor inhibitors. A study comparing outcomes from anterior and inferior infarctions (STEMI + NSTEMI) found that compared with inferior MI, patients with anterior MI had higher incidences of: In-hospital mortality (11.9 vs 2.8%) Reduction in preload results inreduced workload on the left ventricle and this may alleviate both ischemia andseverity of pulmonary edema. PCI is superior to fibrinolysis in the vast majority of cases and therefore all patients with acute STEMI should undergo prompt angiographywith the intentionto perform PCI. Refer to Figure 5. J point elevation of 1 mm is considered significant in all leads except leads V2 and V3. They cause the vast majority of deaths in the acute phase. Nitrates (nitroglycerin) induce vasodilatation by relaxing the smooth muscle in arteries and veins. This site uses Akismet to reduce spam. However, if PCI will be delayed by 120 minutes or more (from first medical contact), fibrinolysis should be given (if it is not contraindicated). Tests are done to see how the heart is beating and to check overall heart health. Following their guidelines is the . Almost one in four patients with STEMI have diabetes, which confers an increased risk of complications (e.g heart failure) and death (both in the acute setting and in the long term). If PCI cannot be performedwithin 120 minutes from first medical contact, then fibrinolysis should be considered. He created the Critically Ill Airway course and teaches on numerous courses around the world. The most validated risk models are TIMI Score (Morrow et al) and GRACE Score (Keith et al). By clicking Accept, you consent to the use of ALL the cookies. Guidelines recommend the following: Fibrinolysis is considered unsuccessful if the magnitude of the ST elevations is not reduced by 50% within 60 minutes. They testify that the infarction was extensive. Nowfollows a review of all evidence-based therapies that may be consideredin patients with STEMI. We also use third-party cookies that help us analyze and understand how you use this website. The risk then rapidly abates within 6 hours. Patients with high or very high risk NSTEACS should be referred to cardiology urgently for consideration of a urgent coronary angiogram. Studies have demonstrated the importance of prehospital delay in patients with acute STEMI. Hence, bivalirudin is preferred over the combination UFH+GP IIb/IIIa antagonist in patients undergoing primary PCI. pain or discomfort in your jaw, neck, back, or stomach. It does not affectthe prognosis but relieves symptoms. He is a co-founder of theAustralia and New Zealand Clinician Educator Network(ANZCEN) and is the Lead for theANZCEN Clinician Educator Incubatorprogramme. The following are symptoms of an NSTEMI: feeling short of breath. These models typically include information regardingmedical history, ECG findings, presenting features (notably hemodynamic status) and cardiac troponins. Successfulreperfusion restores blood flow to the ischemic myocardium and halts the infarction process. Reperfusion should be performed if symptom duration is <12 hours. His one great achievement is being the father of three amazing children. Restoration of coronary blood flow is markedly better withPCI, as compared with fibrinolysis (re-flow is greater and the risk of re-stenosis is smaller). These ST-T changes are illustrated in Figure 6. Aspirin is combined with either clopidogrel, prasugrel or ticagrelor. J. Cardiol. Lumbar puncture, liver biopsy or similar procedures within 24 hours. ECG changes consistent with critical coronary artery stenosis, e.g. Aspirin has a remarkable effect: it reduces 30-day mortality by 23%. ST segment elevation is measuredin the J-point and the elevation must be significant in at least 2 contiguous ECG leads. An individual assessment of bleeding riskis warranted andDAPT should be avoided if the risk is high. CABG has a limited role in the acute phase of STEMI. Without unnecessary delay, the patient should then be transported to a hospital with the facilities and expertise to perform percutaneous coronary intervention (PCI), as it improves outcomes markedly. This reduces the workload on the myocardium and thus the oxygen demand. 126(16):2020-35. This guideline presents an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Intravenous antiplatelet agents: Glycoprotein (GP) IIb/IIa receptorantagonists, 10. Note that some patients that fit specific low risk stratification criteria may be suitable for validated accelerated diagnostic pathways. PubMed PMID: Thygesen K, Alpert JS, Jaffe AS. Mechanical complications of myocardial infarction, Life-threatening arrhythmias or cardiac arrest. In some instances (discussed below) reperfusion may also be administered without any delay. Panel 1:ECG criteria for the diagnosis of acute STEMI. For clarity, STEMI is a clinical syndrome (defined by symptoms and ECG) and biomarkers are not necessary to initiatepotentially life-saving interventions. Prasugrel reduces cardiovascular mortality, non-fatal acute myocardial infarction and stroke more than clopidogrel. Second-degree and third-degree AV block (without pacemaker) are contraindications. The phrase "time is muscle" is apt when talking about a STEMI because every minute of delay in treatment increases the amount of myocardial death. Reperfusion in acute STEMI: PCI and fibrinolysis, STEMI (ST Elevation Myocardial Infarction), Pathophysiology of STE-ACS (ST Elevation Acute Coronary Syndrome)and STEMI (ST Elevation Myocardial Infarction). STEMI (S-T Segment Elevation Myocardial Infarction) presentation with clinical symptoms consistent with an acute coronary syndrome together with S-T segment elevation on ECG New LBBB may be included in this sub-heading as the treatment approach is similar to STEMI NSTEACS (non S-T Segment elevation acute coronary syndrome) Prasugrel is more potent than clopidogrel. Maintenance doses are clopidogrel 75 mg daily, prasugrel 10 mg daily, and ticagrelor 90 mg twice daily. Introduction Acute coronary syndrome (ACS) can be divided into subgroups of ST-segment elevation myocardial infarction (STEMI), non-ST-segment elevation myocardial infarction (NSTEMI), and unstable angina. The effect of these agents diminishes gradually because of a reorganization taking place in the thrombotic material. margin-right: 10px; The presence of significant ST elevations in patients with chest pain (or other symptoms suggestive of myocardial ischemia) is sufficient to diagnose STEMI. We use cookies on our website to give you the most relevant experience by remembering your preferences and repeat visits. } PCI isless dependent on symptom duration (fibrinolysis is dependent on symptom duration because the thrombus material reorganizes gradually and becomes less susceptible to fibrinolytic agents). 1-3 The purpose of the present guideline is to focus on the numerous advances in the diagnosis and management of patients with STEMI since 1999. These recommendations were evaluated over almost a decade and several studies found that this management resulted in many unnecessary activations of the catheterization laboratory. Death due to pumping failure (cardiogenic shock) is uncommon in the acute phase. . This present guideline will affect the following documents: Third universal definition of myocardial infarction. Moreover, fibrinolysis may cause serious bleeding and even death due to hemorrhage. Most communities have therefore created a regional system of STEMI care that aim to rapidly identify and handle patients with STEMI. Each hour of prehospital delay increases mortality by 10%. Mortality in STEMI has also declined dramatically in the past decades. Ischemic bradyarrhythmia (bradycardia) is also common, especially with inferior infarctions. The entire chain of care, from prehospital assessment to hospital discharge will be covered in this chapter. The first step in the management of patients with STEMI is obviously rapid recognition since the effects of interventions (antithrombotic therapy, anti-ischemic therapy and reperfusion) are greatest when performed early. [. 163(19):2345-2353, October 27, 2003. free wall rupture) or (4) cardiogenic shock. The difference between STE-ACS (STEMI) and NSTE-ACS (NSTEMI, UA) is merely the presence of ST elevations on ECG. This should not be allowed to delay any treatment measures, especially reperfusion therapies. Risk factors (these are of little diagnostic use in the acute setting): UNIVERSAL CLASSIFICATION OF MYOCARDIAL INFARCTION, NEW YORK HEART ASSOCIATION FUNCTIONAL CLASSIFICATION OF ANGINA, RISK STRATIFICATION OF PATIENTS WITH CONFIRMED ACS, CLINICAL ASSESSMENT OF ACUTE CORONARY SYNDROME, An ECG should be performed as soon as possible in a patient with a presentation consistent with ACS, Clinical Risk Stratification for ACS in Patients Presenting with Chest Pain (i.e. The options include: Clopidogrel is inferior to prasugrel and ticagrelor. It is easy to see why researchers have struggled to identify ECG criteria for the diagnosis of acute STEMI in the setting of LBBB. Chris is an Intensivist and ECMO specialist at theAlfred ICU in Melbourne. width: auto; As noted above, the optimal antiplatelet effect requires the addition of eitherticagrelor, prasugrel or clopidogrel. This has reaffirmed the ACC/AHA adage that "the appropriate and timely use of some form of reperfusion therapy is likely more important than the choice of therapy" given the undeniable harm of delay in treatment. Meyers, H. P. et al. Men age <40 years: 2,5 mm in V2-V3 and 1 mm in all other leads. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education. In patients with STEMI the ST-T changes are normalized within days or weeks. Reperfusion, with either PCI or fibrinolysis, is considered in the following situations: As mentioned above, numerous studies conducted in the past decades have shown that PCI is superior to fibrinolysis. border: none; 1 lead anywhere with 1 mm STE and proportionally excessive discordant STE, as defined by 25% of the depth of the preceding S-wave. Heart. EMS can then immediately start a diagnostic workup, establish intravenous lines, assess vital functions, and address hemodynamic and electrical instability. Heart Vasc. Morphine may cause bradycardia which can be countered with atropine 0.5 mg IV (may be repeated as necessary). It may be reasonable to administer intravenous GP IIb/IIIa receptor antagonists in the pre-catheterization laboratory setting (e.g., ambulance, ED) to patients with STEMI for whom primary PCI is intended. The dispatch center,ambulance, emergency department (ED), catheterization laboratory and cardiology ward must act in concert to provide optimal care. A loading dose of 160 to 320 mg is indicated in all patients with acute STEMI. Less than ordinary activity causes fatigue, palpitation, dyspnea, or anginal pain. The "MI" stands for myocardial infarction, which is the medical term for heart attack. This category only includes cookies that ensures basic functionalities and security features of the website. Fibrinolysis (tenecteplase, alteplase, reteplase) is very effective in lysing a thrombus if it is given early (within 2 hours of symptom onset). Chew DP, Scott IA, Cullen L, et al. Twenty of these 146 patients were then excluded due to >24 h earlier diagnosis by OMI ECG findings compared to STEMI criteria (these OMIs were missed by STEMI criteria, identified by OMI ECG findings, and had extremely delayed catheterization greater than 24-48 h). An initial dose of 2 mg to 5 mg IV may be recommended. Several validated risk models (risk calculators) have been developed to simplify risk stratification. Unfractionated heparin (UFH), enoxaparin or bivalirudin are anticoagulants that may be given to patients with acute STEMI. Similarly, the risk of developing heart failure (due to acute STEMI) also increases by 10% per hour of treatment delay. Intravenous beta-blockers may be considered in patients with persistent hypertension. Anticoagulation is continued a few days after primary PCI. Tests The most useful and validated criteria were developed byElena Sgarbossa and associates. If only UFH is available, the loading dose is 70100 U/kg, given as a bolus. DAPT is continued for 12 months in all patients, and the indication is stronger in patients who undergo PCI with placement of a stent (both bare metal stents and drug-eluting stents). DAPT should be considered in all patients undergoing primary PCI. Pain activatesthe sympathetic nervous system which results in (1) peripheral vasoconstriction, (2) positive inotropic effect and (3) positive chronotropic effect. In summary, adiagnosis of acute myocardial infarction (AMI) requires evidence of myocardial necrosis, which implies that troponin levels must be elevated. font: 14px Helvetica, Arial, sans-serif; This chapter deals with the pathophysiology, definitions, criteria and management of patients with acute STEMI. Ventricular tachycardia (VT)andventricular fibrillation (VF)may occur at any time after occlusion of the coronary artery. ST segment elevations with straight (horizontal, upsloping or downsloping) or convex ST segment strongly suggest acute STEMI(Figure 5A). Treatment and reperfusion therapy may modify the speed by which the ECG normalizes in patients with STEMI. Keith A A Fox, Omar H Dabbous, Robert J Goldberg, Karen S Pieper, Kim A Eagle, Frans Van de Werf, lvaro Avezum, Shaun G Goodman, Marcus D Flather, Frederick A Anderson, Jr, and Christopher B Granger. 33, 100767 (2021). Australian clinical guidelines for the management of acute coronary syndromes 2016, Clinical Adjunct Associate Professor at Monash University, Australia and New Zealand Clinician Educator Network, Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License, Coronary artery disease accounts for > 30% of death in West and presents acutely as acute coronary syndromes, Acute coronary syndrome (ACS) is a catch all term that refers to ischemic symptoms resulting from acute coronary occlusion, All patients who present with a suspected acute coronary syndrome must be assessed in the ED on an urgent (category 2) basis and have an ECG performed within 10 minutes of first acute clinical contact, A clinician with ECG expertise should review the ECG, A CODE STEMI activation system should be in place in any hospital that has an acute percutaneous coronary intervention service, presentation with clinical symptoms consistent with an acute coronary syndrome together with S-T segment elevation on ECG, New LBBB may be included in this sub-heading as the treatment approach is similar to STEMI, NSTEACS refers to any acute coronary syndrome which does not show S-T segment elevation, The ECG may show S-T segment depression or transient S-T segment elevation, but often will be normal, By definition this will be shown by an elevation of serum troponin levels in the absence of S-T segment elevation, A small but still significant proportion (< 4 %) of patients presenting with possible cardiac chest pain in whom biomarkers and ECGs are normal will have unstable angina due to underlying coronary artery disease, Note that unstable angina is measured against a patients usual pattern of stable angina which is most commonly classified according to the New York Heart Associations Functional Classification of Angina, New onset angina should be considered unstable in the first instance. A standardized definition of in-hospital STEMI is that of in-hospital development of new ST-segment elevation or ST-segment elevation equivalents in conjunction with at least one of the additional supportive criteria: Elevated cardiac biomarker, as defined by contemporaneous universal definition of MI criteria. However, a concave ST segment does not rule out STEMI, it onlyreduces the probability of STEMI. Consequently, sympathetic activity will increase the workload on the heart and thus aggravate the ischemia. Analytical cookies are used to understand how visitors interact with the website. The workload on the myocardium is reduced and the oxygen consumption and oxygen demand are reduced. The reason symptoms are more severein patients with STEMI, as compared withNSTEMI and unstable angina (UA), is because the extent of the ischemia is greater in STEMI (i.e a larger portion of the myocardium is ischemic). Abnormal repolarization results in pronounced ST-T changes, includingST elevations (leads V1V3), ST depressions (leads V4, V5, V6, aVL, I) and inverted T-waves (leads with ST depressions). }, #FOAMed Medical Education Resources byLITFLis licensed under aCreative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. Otherpatients may haveacute transmural ischemia located in areas not detected by any of the 12 standard leads. There is no data to support any beneficial effect of oxygen therapy in patients with normal oxygen levels, as measured by pulse oximetry. For details, please refer to LBBB and Acute Myocardial Infarction, which provides an in-depth discussion. Oxygen is also appropriate for patients with pulmonary edema, heart failure and mechanical complications (free wall rupture, ventricular septum defect, mitral prolapse) of acute STEMI (Hoffmann et al.). Ordinary physical activity results in fatigue, palpitation, dyspnea, or anginal pain. Acute and long-term complications of acute myocardial infarction are summarized in Figure 3 (below). If any physical activity is undertaken, discomfort is increased. A loading dose (oral) of aspirin (160 mg to 320 mg) should be given immediately to all patients. Gp IIb/IIIa antagonists may accompanyunfractionated heparin (UFH, which then must be dose reduced) if there are no contraindications. Patients with cardiac disease but without resulting limitation of physical activity. PCI is by far the most effective method. In-hospital mortality is now5% and 1-year mortality is 718%. Minimal S-T changes can be difficult to interpret, especially in those with pre-existing CAD or other significant CVS disease. NSAID (Nonsteroidal anti-inflammatory drugs) and selective cyclooxygenase II (COX-2) inhibitorsare contraindicated in acute STEMI (these drugs increase the risk of death in the setting of STEMI). If tablets are preferred, metoprolol 25 mg may be given every sixth hour until the maximally tolerated dose or 200 mg daily is reached. Following with the Joint ESC/ACCF/AHA/WHF Task Force definition of acute myocardial infarction, any one of the listed criteria meets the diagnosis for MI: 1 A rise and/or fall of cardiac biomarkers (preferably troponin (cTn)) with at least one value above the 99th percentile upper reference limit (URL) together with at least one of the following: Myocardium can endure approximately 30 minutes of ischemia before the cells die(i.e myocardial infarction). STEMI is defined as presentation with clinical symptoms consistent with ACS (generally of 20 minutes duration) with persistent (> 20 minutes) ECG features in 2 contiguous leads of: 2.5 mm (i.e 2.5 small squares) ST elevation in leads V2-3 in men under 40 years, or 2.0 mm (i.e 2 small squares) ST elevation in leads V2-3 in men over 40 years, New LBBB (LBBB should be considered new unless there is evidence otherwise), classic changes in acute myocardial infarction, development of pathological Q wave and TWI. | INTENSIVE | RAGE | Resuscitology | SMACC. dizziness. Gp IIb/IIIa antagonists may be given during transport to high-risk patients who are referred to primary PCI. Administration should proceed with caution if blood pressure drops >30 mmHg from baseline. Due to these circumstances, researchers decided to experiment with patients presenting with LBBB and a suspected acute myocardial infarction. An ST-elevation myocardial infarction (STEMI) is a type of heart attack that is more serious and has a greater risk of serious complications and death. Ticagrelor appears to cause fewer bleeding complications as compared with prasugrel. The most common mechanical complication of acute STEMI (and myocardial infarction in general) is papillary muscle rupture. He is also a Clinical Adjunct Associate Professor at Monash University. The termprimary PCIrefers to PCI performed within 24 hours of symptom onset, whereassecondary PCIrefers to PCI performedlater than 24 hours after symptom onset. Prasugrel is contraindicated in patients with previous stroke, TIA, renalfailure and liver failure. If the patient is also given GP IIb/IIIa antagonists, UFH is reduced to 5060 U/kg. Once the diagnosis is confirmedthe patient must be continuouslymonitored(heart rate and rhythm, blood pressure, respiration, consciousness, symptoms, general appearance). Source: Todt T et al: Relationship between treatment delay and final infarct size in STEMI patients treated with abciximab and primary PCI. Elderly and patients with renaldisease are also less likely to receive recommended interventions, despite evidence of benefit from such measures. A large body of evidence demonstrates that beta blockers are very beneficial in patients with STEMI. Intravenous antiplatelet agents: Glycoprotein (GP) IIb/IIa receptor antagonists, 10. Electrocardiogram with ST-segments elevated. Meanwhile, the incidence of NSTEMI has increased which ispresumably due to the increased sensitivityof troponin assays (Tsao et al.). This may be repeated every 5 minutes until 30 mg have been administered. Circulation. A. Although the PLATO study showed that ticagrelor caused more serious bleedings, as compared with clopidogrel, the overall effect was beneficial and it was concluded that the benefits outweigh the risks. chest pain) and ST elevations on ECG will haveelevated troponin levels, which is why STE-ACS is clinically equivalent toSTEMI. Symptoms of heart failure or the anginal syndrome may be present even at rest. Morphine also causes dilatationof the veins, which reduces cardiac preload. Refer to Panel 1 for all ECG criteria for STEMI. }
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