Update of NSTEMI and STEMI— Case Studies Timothy A. Mixon MD FACC FSCAI Interventional Cardiology Scott & White Healthcare Associate Professor of Medicine Texas A&M College of Medicine July 18, 2013

STEMI: Recognition

STEMI vs. NSTEMI ? 

NSTEMI ECG

What is the diagnosis? 1. 2. 3. 4.

STEMI NSTEMI Need for information LVH

Answer

ECG Patterns Measured at J-point

LATERAL

SEPTAL

INFERIOR

LATERAL

INFERIOR

INFERIOR

SEPTAL ANTERIOR

Criteria for ST elevation myocardial infarction ≥ 2.0 ST elevation in leads V2-V3 in men (≥ 2.5 in men < 40 y/o) ≥ 1.5 ST elevation in leads V2-V3 in women ≥ 1 mm ST elevation in any two or more other contiguous leads

ANTERIOR LATERAL

LATERAL

Question 1 

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A 66-year-old man is evaluated in the emergency department for left-sided chest pain that began at rest, lasted for 15 minutes, and has since resolved. A similar episode occurred at rest yesterday, and multiple similar episodes that were associated with exertion have occurred over the past 2 weeks. Pertinent medical history includes hypertension and type 2 diabetes mellitus. Family history is notable for his father undergoing coronary artery bypass graft surgery at age 69 years and his brother undergoing coronary artery bypass graft surgery at age 54 years. Current medications are amlodipine, glyburide, and aspirin. On physical examination blood pressure is 125/65 mm Hg, heart rate is 70/min, and respiratory rate is 12/min. Estimated central venous pressure is 6 cm H2O, carotid upstroke is normal, there are no cardiac murmurs, and the lung fields are clear. Extremities show no edema, and peripheral pulses are normal bilaterally.

Question 1 

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Laboratory findings include a serum troponin I level of 1.2 ng/mL (1.2 µg/L), and a creatinine level of 1.4 mg/ dL (106.8 µmol/L). Electrocardiogram shows 1-mm ST-segment depression in leads aVL, V5, and V6. Chest radiograph shows a normal cardiac silhouette, with no infiltrates and no pleural effusions. The patient is treated with aspirin, intravenous nitroglycerin, unfractionated heparin, metoprolol, and pravastatin.

Question 1 What is the next best step? – – – –

A: Coronary Angiogram B: Obtain BNP level C: Pharmacological stress test D: Thrombolytic therapy

Answer

History: Risk for near-term complications High risk 

Nature of angina – – –

   

Low risk 

Ongoing Prolonged, rest pain Accelerated tempo over 48 hrs

Age > 75 Exam: HF, new MR, hypotension ECG: > 0.5 ST changes, VT, new BBB Biomarkers: positive

Nature of angina –

–

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Increasing pattern of prior stable angina New onset angina beginning > 2 weeks ago

Age < 75 Exam: normal ECG: normal, nonspecific findings Biomarkers: negative

NSR with sinus arrhythmia, Inferior MI, likely due to RCA occlusion.

The correct interpretation is… A. B. C. D.

Inferior infarction, complete heart block Inferior infarction due to RCA occlusion Acute pericarditis Isolated posterior wall infarction

Correct Answer

Question 2 

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A 54-year-old woman is evaluated in the emergency department for jaw and shoulder pain that has occurred intermittently for the past week. The symptoms occur with activity and are relieved by rest. Medical and family history are unremarkable. She is not taking any medications. Physical examination shows a blood pressure of 130/68 mm Hg and a pulse of 90/min. There is no jugular venous distention and carotid upstrokes are normal. There are no cardiac murmurs and the lung fields are clear. Extremities show no edema and peripheral pulses are normal bilaterally.

Question 2 con’t 

Laboratory studies: – – – – –



Hematocrit 42% Platelet count 220,000/µL (200 × 109/L) Troponin I 9.0 ng/mL (9.0 µg/L) Creatinine1.0 mg/dL (76.3 µmol/L) Electrocardiogram shows 1.0-mm ST-segment depression in leads V1 through V4 with T-wave inversions.

The patient is given aspirin, intravenous nitroglycerin, low-molecular-weight heparin, metoprolol, and atorvastatin. The pain subsides after approximately 20 minutes, and she is admitted to the coronary care unit. One hour later, she has recurrent jaw and shoulder pain. She denies chest pain. A repeat electrocardiogram is unchanged.

Question 2 

What is the next best step? – –

– –

A: Stop metoprolol and start verapamil B: Stop low-molecular weight heparin and start unfractionated heparin C: Start enalapril D: Start a glycoprotein IIb/IIIa inhibitor

Answer

Based on this ECG, I would be concerned about…

A. B. C. D.

Posterior injury pattern Impending heart block Left main stenosis or occlusion Cannot localize the coronary lesion

Answer

Question 3 

    

58 y/o woman seen in ER for 2 episodes of substernal pressure lasting 15 minutes each, occurring with mild exertion 2 days ago, radiating to both shoulders Risk factors: HTN, smoking, Fam Hx Normal physical exam Troponin negative at 4 and 8 hours Symptom-free in ER TIMI risk score = 1

What would you recommend?

A.

B. C. D.

Emergent catheterization due to ECG changes Outpatient cardiac evaluation within 48-72 hrs GI and Psych Consults Admit. Aspirin, UFH, clopidogrel, eptifibatide

Answer

Follow Up     

Continued symptoms twice weekly Mostly at rest. Occasionally with mild activity (walking to mailbox) ? Improving with gastric acid suppression Labs: TC 211, Tri 121, HDL 51, LDL 136 Dipy thallium: EF 59%, reversible ischemia in mid-apical anterior wall

Proximal LAD 85% stenosis

Final angios, after drugeluting stent implantation

65 year old man presents with chest pain x 30 minutes. Based on this you think…

Based on this you think… A.

B. C.

D.

ECG is paced, and therefore not interpretable for ischemia/infarction Normal variant findings Diagnostic of inferior infarction. Call the cath lab now. LBBB, therefore not interpretable for ischemia/infarction

Answer

Question 4 

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A 65-year-old woman is evaluated in the hospital 36 hours after presenting in the emergency department with midsternal chest pain. Electrocardiogram on presentation demonstrated no ST-segment shifts, but T-wave inversion was present in leads V3 and V4. She was given nitroglycerin, unfractionated heparin, and a glycoprotein IIb/IIIa inhibitor and was admitted to the hospital. She has a history of hypertension and hyperlipidemia and is a prior smoker. Her medications prior to admission were metoprolol, 25 mg twice daily; atorvastatin, 80 mg/d; and aspirin, 325 mg/d. On examination, the patient is afebrile. Blood pressure is 132/82 mm Hg, pulse is 68/min and regular, and respiration rate is 16/min. BMI is 25. There is no jugular venous distention, and no crackles are auscultated. Heart sounds are normal. There is no rub, murmur, or gallop.

Question 4 

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Her serum cardiac troponin I level rose to a peak of 4.2 ng/mL (4.2 µg/L) at 24 hours following the index event. Results of a basic metabolic profile, including blood glucose levels, are normal. Coronary angiography demonstrates diffuse, mild luminal irregularities in all coronary arteries, along with diffuse severe disease in the distal left anterior descending coronary artery not amenable to percutaneous coronary intervention. Left ventriculography demonstrates a left ventricular ejection fraction of 55% with a small focal region of hypokinesis in the apex. The left ventricular enddiastolic pressure is 12 mm Hg. The glycoprotein IIb/IIIa inhibitor is discontinued.

Question 4 Which agent should be added to this patient’s regimen – – – –

A: Verapamil B: Clopidogrel C: Eplerenone D: Warfarin

Answer

Question 5 

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A 62-year-old woman is brought to the emergency department by paramedics for chest pain that has been present for 5 hours. Medical history is notable for type 2 diabetes mellitus, hypertension, and a stroke 1 year ago. Medications include glyburide, lisinopril, atorvastatin, and aspirin. On physical examination, she appears comfortable. She is afebrile, blood pressure is 190/90 mm Hg, pulse rate is 88/min and respiration rate is 16/min. Cardiac examination shows no murmurs, extra sounds, or rubs. The lungs are clear and pulses are equal bilaterally. Neurologic examination is normal.

Question 5  

The electrocardiogram shows 2-mm ST-segment elevation in leads II, III, and aVF. A coronary catheterization laboratory is not available, and the nearest hospital with percutaneous intervention capability is 1 hour away.

Question 5 What is the next best step? A.

B. C. D.

Aggressive medical therapy without reperfusion attempt Immediate thrombolytic therapy Transfer for CABG Transfer for primary PCI

Answer

Question 6 

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A 56-year-old man is evaluated in the emergency department for chest discomfort that began 3 hours ago. He describes the pain, which is well localized to the left chest, as pressure. He denies prior episodes. Medical history is notable for type 2 diabetes mellitus and hyperlipidemia. Medications include aspirin, metformin, and atorvastatin. On physical examination, he is diaphoretic and in moderate distress owing to the chest pain. Blood pressure is 95/60 mm Hg and heart rate is 110/min. There is jugular venous distention, with an estimated central venous pressure of 14 cm H2O. An S3 is heard on cardiac auscultation, but no murmurs are present. The lung fields are clear and there is no peripheral edema.

Question 6 

The electrocardiogram shows sinus tachycardia, 2-mm ST-segment elevation in leads II, III, and aVF, and 0.5mm ST-segment elevation in lead V1. He is given aspirin, metoprolol, unfractionated heparin, and thrombolytic therapy. Twenty minutes later, he has continued chest pain and sublingual nitroglycerin is given. Blood pressure falls to 70 mm Hg systolic and he remains tachycardic, with a heart rate of 100/min.

Question 6 What is the likely cause of hypotension in this patient A. B. C. D.

Pericardial tamponade Right ventricular infarction Increased vagal tone Ventricular septal defect

Answer

NSR, Inferoapical MI, with RV involvement Diagnosis?

ST elevation in V1 has high specificity, but low sensitivity for RV injury pattern. If present, diagnosis secure. If normal V1, consider right sided ECG.

Right sided ECG

Notice loss of R waves across the precordium (consistent with right sided leads) Notice ST elevation in lead rV3-rV5

Extra Slides/ECGs

NSR with sinus arrhythmia, Inferior MI, likely due to RCA occlusion.

NSR with PVCs, Inferior MI, likely due to LCx occlusion.

NSR. High lateral infarct. Found to be due to diagonal obstruction.

70 year old woman who presents to outside hospital with chest pain. ECG?

Follow up ECG 15 minutes later. Diagnosis? NSR. High lateral injury pattern. Note elevations in I and aVL. Reciprocal depression in inferior leads Note value or serial ECGs

Interpretation? Prognosis?

NSR, diffuse ST depression with elevation in lead aVR>V1, worrisome for LM CAD

Diagnosis ?

NSR with third degree AV block. Accelerated junctional rhythm. Inferior ST elevation consistent with acute inferior infarction

Diagnosis ? Sinus arrest. Junctional escape with premature supraventricular complexes. Inferior-lateral injury pattern.

Notice: ST  greater in III than II. Inferior ST  > than posterior ST 

Interpretation? 59 y/o female with stuttering chest pain. ECG at VA (below) reverted to normal with NTG and MSO4

NSR. Posterior injury pattern, suggestive of LCx distribution. Found at cardiac cath to have a proximal LCx stenosis.

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