9.

Diagnosis of MI

1.

A: The ECG is the most important test in the evaluation of acute chest pain, and should be done
immediately after stabilizing the patient and taking vitals. In this setting, characteristic ECG changes
are highly specific for myocardial ischemia.

NOTE: A negative ECG in a patient presenting with acute chest pain does NOT rule out an MI.
c

2.

A: The following ECG findings are associated with different subtypes of myocardial infarction:
 ST depression is indicative of a subendocardial infarct (NSTEMI)

 ST elevation is indicative of a transmural infarct (STEMI)

 Pathologic Q waves are indicative of an old transmural infarct
 Q Waves are considered pathologic if they are:
 > 40 ms (1 mm) wide
 > 2 mm deep
 > 25% of depth of QRS complex
 Seen in leads V1-3
c

3.

A: Cardiac troponin I is the most specific biomarker for myocardial necrosis and is commonly used
in the diagnosis of a suspected myocardial infarction.
c

4.

A: Cardiac troponin I begins to rise 3-4 hours after onset, peaks between 18-36 hours and remains
elevated for 7-10 days, returns to normal within 10-14 days.
c
5.

A: CK-MB is an enzyme that reversibly transfers a phosphate group from creatine phosphate to
ADP. Since CK-MB is found in both cardiac and skeletal muscle, it is not as specific as cardiac
troponin I for acute MI diagnosis.
c

6.

A: CK-MB begins to rise 6-12 hours after onset, peaks at 16-24 hours, and returns to normal within 2-
3 days.
c

7.

A: Re-elevation of CK-MB can diagnose a re-infarction between 3 to 10 days post myocardial

infarction. Note that troponin cannot diagnose a second myocardial infarction between days 3 and 10
because troponin is still elevated from the first infarction!
c

8.

A: Although rarely used clinically, measuring serum myoglobin levels in the setting of suspected MI
has the following 2 advantages:
  Serum myoglobin levels rise very quickly after an MI — vs. troponin and CK-MB, which
begin to rise a couple hours after an MI (this is why the levels of the so-called cardiac enzymes
(troponin, CK-MB) are “trended” over the course of several hours following admission)

 Testing serum myoglobin has high negative predictive value (myoglobin has high sensitivity
but low specificity for myocardial damage) if measured within a couple hours of a suspected
acute MI. Thus if serum myoglobin levels are not elevated in this time frame an MI is unlikely.
c

9.
A: AST: aspartate transaminase, nonspecific enzyme found in liver, heart and skeletal muscle