ST elevation MI (STEMI) Electrocardiography

Dx by :
1. Clinical hx
2. 12-lead ECG
3. ↑ biochem markers

S&S
Chest pain  >20 min
 Radiate to
jaw/neck/arm
 X respond to GTN
 Need opiate
analgesia
Elderly & diabetic px  Dyspnoea
Atypical features :  Fatigue
 Pre-syncope
 Syncope
Ass symp  Sweating
 Palpitation
 N&V
 Anxiety
 Weakness
Anatomical correlation
Non specific phys sx  Pallor
Vessel Area o infarction
 Irregular pulse
occluded
 4th  sound
Lf ant  Ant wall o LV
 Hypotension descending art  Ant part o septum
(affect intraventricular
General IX conduction)
1. FBC Lf circumflex art  Lat or inf wall o LV
2. BUSE
 Post wall o LV
3. Blood sugar
4. Cholesterol (w/in 24 hr / aftr 3/12 o MI) Rt coronary art  Post & inf surface o
5. Portable CXR LV
6. Serum creatinine  Post part o sptum
7. Coagulation profile  RV

STEMI (Q wave infarction)

ECG ∆ Onset Duration
ST elevation w/in Days/weeks
min/hours
T inversion Immediate or Several
hours months
Q wave Hours or Remain
days indefinitely

Nha 0813 – source : kumar & clerk – CPG STEMI 2007

 other Dx technique :
Cardiac Enzymes Radionuclide studies
Pyrophosphate When ECG unhelpful
scan  Preexisting
abnorm(LBBB)
 Px present late
 Cardiac marker x ↑
Echocardiography Identify :
 Regional wall motion
abnorm
 Valvular abnorm
 Lf, Rt ventrivular fx
Show image :
 Cardiac struct
 Pericardium
 Aorta
Coronary When intervention tx is
angiography indicated

Algorithm o tx o STEMI
Enzymes

Normalize, d
hrEarliest rise,

Peak, hr

Other source
enzyme

Trop T 3-12 12-24 5-14

Trop I 3-12 24 5-10
CK-MB 3-6 12-24 1-2
CK 6-8 24-30 3-4 IM inject
Defibrillatn
Convulsion
Vigorous
exercise
Cerebral
infarc
AST 8-12 36-48 3-5 Alcoholism
Hepatitis
Biliary obst
Cardiac
arrest
LDH 12-24 48-96 7-10 Haem
anaemia
Pulm
infarc
Neoplastic
dz
HBD 12 72 10-14
HBD :
- hydroxybutarate dehydroxygenase
- measure LDH1 & LDH2 [ ] can b obtained by
measuring serum HBD actvt

Nha 0813 – source : kumar & clerk – CPG STEMI 2007

 CX of STEMI Mechanical cx  Free wall rupture
 Ventricular septal
Arrythmias rupture
Brady~ Tachy~  Papillary muscle
 Arterio-  Pulseless ventricular rupture
ventricular tachy~
block  Stable ventricular
 Asystole tachycardia Rt ventricular  Clinical triad :
/pulseless  Ventricular infarct  Hypotension
electrical actvt premature  Clear lung fields
contraction  ↑ JVP
 Accelerated others  DVT
idioventricular  LV trombus &
rhythm arterial embolism
 Arterial fibrillation  Chest pain post
Lf ventricular dysfx & shock STEMI cause :
Re-infarction
Post infact angina
Pericarditis

Figure 1Killip's classification

Ddx  Mechanical cx
 Pump failure d/t extensive
myocardial infarc
 Rt ventricular infarct
 Hypovolaemia
 Arrythmias
 Drugs
 Aortic dissection
Ix  Chest radiography
 ECG
 Echocardiography
 ABG
 Pulmonary artery catheter
Mx failre acute mx
 02 therapy
 Diuretics
 IV nitroglycerine
 IV morphine
 Inotropes if hypotensive
Cardiogenic shock sys tolic BP<90
mmHg
 Emergency PCI
 CABG

Nha 0813 – source : kumar & clerk – CPG STEMI 2007