ST Elevation Myocardial Infarction

Emergency Medicine

Clinicals - History

Fact Explanation
Chest pain This is a common presenting complaint. The chest pain is usually described by the patients as a severe tightening type of chest pain with radiation to the left arm and the left side of the jaw and neck. Pain lasts for 20min or more and does not respond to sublingual nitroglycerine. However patients with diabetes related cardiac autonomic neuropathy may not feel the chest pain (“silent infarction”). Chest pain
This is a common presenting complaint. The chest pain is usually described by the patients as a severe tightening type of chest pain with radiation to the left arm and the left side of the jaw and neck. Pain lasts for 20min or more and does not respond to sublingual nitroglycerine. However patients with diabetes related cardiac autonomic neuropathy may not feel the chest pain (“silent infarction”).
Fatigue or malaise This occurs especially in elderly. Although the exact cause has not been found it is believed to be due to early left ventricular dysfunction. Fatigue or malaise
This occurs especially in elderly. Although the exact cause has not been found it is believed to be due to early left ventricular dysfunction.
Light-headedness with or without syncope This also occurs specially in elderly. Syncope may be due to the development arrhythmia, or may occur as a complication of autonomic disturbances. Light-headedness with or without syncope
This also occurs specially in elderly. Syncope may be due to the development arrhythmia, or may occur as a complication of autonomic disturbances.
Nausea with or without vomiting This is due to the sympathetic over activation. This helps to differentiate MI from unstable angina. Nausea with or without vomiting
This is due to the sympathetic over activation. This helps to differentiate MI from unstable angina.
Sweating This occurs due to sympathetic over activation. Sweating
This occurs due to sympathetic over activation.
Cardiogenic shock Especially patients with right ventricular infarct can present with cardiogenic shock. Cardiogenic shock
Especially patients with right ventricular infarct can present with cardiogenic shock.
Clinical triad of hypo tension, clear lung fields, and raised jugular venous pressure This is very common in right ventricular infarction. (Furthermore the inferior leads will have a ST segment elevation as well ) Clinical triad of hypo tension, clear lung fields, and raised jugular venous pressure
This is very common in right ventricular infarction. (Furthermore the inferior leads will have a ST segment elevation as well )
Sudden death A possible presentation of MI. This might be due to cardiogenic shock or due to arrhythmia. Sudden death
A possible presentation of MI. This might be due to cardiogenic shock or due to arrhythmia.

Clinicals - Examination

Fact Explanation
Pulse Bradycardia, tachycardia and arrhythmias will be detected. Pulse
Bradycardia, tachycardia and arrhythmias will be detected.
Blood pressure Low blood pressure is associated with high mortality. Narrow pulse pressure may be observed if the systolic pressure is low. Blood pressure
Low blood pressure is associated with high mortality. Narrow pulse pressure may be observed if the systolic pressure is low.
Pulmonary crepitations Due to acute left heart failure. The severity of heart failure can be categorized according to the Killip score. Pulmonary crepitations
Due to acute left heart failure. The severity of heart failure can be categorized according to the Killip score.
Signs of Ventricular Septal Defect (VSD) VSD occurs as a complication. Severe clinical deterioration and a loud pan systolic murmur should make the clinician suspicious of a possible VSD due to rupture of the inter-ventricular septum. Signs of Ventricular Septal Defect (VSD)
VSD occurs as a complication. Severe clinical deterioration and a loud pan systolic murmur should make the clinician suspicious of a possible VSD due to rupture of the inter-ventricular septum.
Signs of Mitral regurgitation (MR) MR occurs due to rupture or dysfunction of papillary muscles. Sometimes may be due to the dilatation of the mitral annulus as a complication of dilatation of the left ventricle. Pan-systolic murmur at the cardiac apex will be audible. Signs of Mitral regurgitation (MR)
MR occurs due to rupture or dysfunction of papillary muscles. Sometimes may be due to the dilatation of the mitral annulus as a complication of dilatation of the left ventricle. Pan-systolic murmur at the cardiac apex will be audible.
Signs of Tricuspid Regurgitation [TR] This occurs in right ventricular infarction due to right ventricular and tricuspid annulus dilatation. TR produces a pan-systolic murmur at the lower left sternal edge. Signs of Tricuspid Regurgitation [TR]
This occurs in right ventricular infarction due to right ventricular and tricuspid annulus dilatation. TR produces a pan-systolic murmur at the lower left sternal edge.

Investigations - Diagnosis

Fact Explanation
Electrocardiogram (ECG) Persistent ST-segment elevation indicates evolving myocardial infarction. New Q waves indicate established myocardial infarction. New onset left bundle-branch block is also an indication to diagnose MI. ST segment elevation in V7and V8 leads indicates a posterior MI. The ST-segment elevation in V4R and or Q waves and ST-segment elevation in V1 are all suggestive of a right ventricular infarction. Q wave of any magnitude and or ST segment elevation in lead V2 are suggestive of an anterior MI. ST segment elevation in inferior leads, (lead II,III and aVF) is suggestive of an inferior MI. In ECG prominent symmetrical hyper-acute T-waves, elevation of the ST segment, resolution of the ST segment and the appearance of the Q waves appear in sequence. ECG might be normal during the initial stages of MI. Electrocardiogram (ECG)
Persistent ST-segment elevation indicates evolving myocardial infarction. New Q waves indicate established myocardial infarction. New onset left bundle-branch block is also an indication to diagnose MI. ST segment elevation in V7and V8 leads indicates a posterior MI. The ST-segment elevation in V4R and or Q waves and ST-segment elevation in V1 are all suggestive of a right ventricular infarction. Q wave of any magnitude and or ST segment elevation in lead V2 are suggestive of an anterior MI. ST segment elevation in inferior leads, (lead II,III and aVF) is suggestive of an inferior MI. In ECG prominent symmetrical hyper-acute T-waves, elevation of the ST segment, resolution of the ST segment and the appearance of the Q waves appear in sequence. ECG might be normal during the initial stages of MI.
Troponin (I or T) Troponin (a cardiac enzyme, released after death of cardiac myosites) elevation peaks around 6 to 9 hours after the onset of clinical symptoms and remain elevated for 7 to 14 days.These enzymes are more cardio specific than CK-MB and have high specificity. Troponin (I or T)
Troponin (a cardiac enzyme, released after death of cardiac myosites) elevation peaks around 6 to 9 hours after the onset of clinical symptoms and remain elevated for 7 to 14 days.These enzymes are more cardio specific than CK-MB and have high specificity.
Creatinine Kinase MB (CK-MB) This is less cardio specific when compared to troponin and it is the next choice of cardiac bio marker when troponin assays are not available. Initial assay at the time of the presentation should be followed by a second assay after 6 to 9 hours of onset of symptoms to demonstrate a rise or fall of CK-MB. CK-MB is valuable in diagnosing re-infarction. Creatinine Kinase MB (CK-MB)
This is less cardio specific when compared to troponin and it is the next choice of cardiac bio marker when troponin assays are not available. Initial assay at the time of the presentation should be followed by a second assay after 6 to 9 hours of onset of symptoms to demonstrate a rise or fall of CK-MB. CK-MB is valuable in diagnosing re-infarction.
Heart-type fatty acid-binding protein (H-FABP) This is a newer cardiac bio marker with early diagnostic and prognostic value and can be used with in the first 6 hours of onset of symptoms. Heart-type fatty acid-binding protein (H-FABP)
This is a newer cardiac bio marker with early diagnostic and prognostic value and can be used with in the first 6 hours of onset of symptoms.
2D echocardiogram Regional wall motion abnormalities indicate impending infarction. Absence of regional wall motion abnormalities excludes a major infarction. Complications like mitral regurgitation and ventricular septal defect can also be identified by echo cardiogram. 2D echocardiogram
Regional wall motion abnormalities indicate impending infarction. Absence of regional wall motion abnormalities excludes a major infarction. Complications like mitral regurgitation and ventricular septal defect can also be identified by echo cardiogram.
Coronary angiography Detects the site of the lesion. Coronary angiography
Detects the site of the lesion.
Lactate dehydrogenase (LDH) This is not routinely used now due to lack of specificity. Lactate dehydrogenase (LDH)
This is not routinely used now due to lack of specificity.
Myocardial perfusion scintigraphy Helps to exclude an acute MI. Myocardial perfusion scintigraphy
Helps to exclude an acute MI.

Investigations - Management

Fact Explanation
Pulse oxymetry Measures oxygen saturation. Pulse oxymetry
Measures oxygen saturation.
Electrocardiogram (ECG) Complications like atrial fibrillation ventricular tachycardia and ventricular fibrillation can be detected. Holter monitoring should be done during the first 24hours. Electrocardiogram (ECG)
Complications like atrial fibrillation ventricular tachycardia and ventricular fibrillation can be detected. Holter monitoring should be done during the first 24hours.
Stress ECG This should be done within six weeks of MI to detect exertion induced ischemia. Stress ECG
This should be done within six weeks of MI to detect exertion induced ischemia.
Echo cardiogram Detects left ventricular mural thrombi and other complications associated with MI. (Eg: ventricular septal defects, mitral regugitation) Echo cardiogram
Detects left ventricular mural thrombi and other complications associated with MI. (Eg: ventricular septal defects, mitral regugitation)
Myocardial perfusion scintigraphy This investigation provides the actual size of myocardial necrosis and ischemia. Although not routinely practiced if done prior to the thrombolysis and after the thrombolysis it reflects the success of reperfusion, as the zone of ischemia reduces after successful reperfusion. Also detects myocardial stunning (re-perfused myocardium but with delayed contractile recovery) and myocardial hibernation. In the presence of these reversible conditions, coronary intervention should be planned to achieve reperfusion. Myocardial perfusion scintigraphy
This investigation provides the actual size of myocardial necrosis and ischemia. Although not routinely practiced if done prior to the thrombolysis and after the thrombolysis it reflects the success of reperfusion, as the zone of ischemia reduces after successful reperfusion. Also detects myocardial stunning (re-perfused myocardium but with delayed contractile recovery) and myocardial hibernation. In the presence of these reversible conditions, coronary intervention should be planned to achieve reperfusion.
Coronary angiography Demonstrates the anatomy of the coronary circulation and estimate the degree of narrowing so enable further planning of the treatment. Patients with more risk factors like old age, multiple infarcts and multiple cardiovascular risk factors should have an early coronary angiography. Coronary angiography
Demonstrates the anatomy of the coronary circulation and estimate the degree of narrowing so enable further planning of the treatment. Patients with more risk factors like old age, multiple infarcts and multiple cardiovascular risk factors should have an early coronary angiography.
Cardiac catheterization right heart catheterization detects the right atrial pressure and enable early detection of cardiogenic shock. Detects the pulmonary artery and wedge pressure which is useful in the management of left heart failure. Cardiac catheterization
right heart catheterization detects the right atrial pressure and enable early detection of cardiogenic shock. Detects the pulmonary artery and wedge pressure which is useful in the management of left heart failure.
MRI Detects the thickness of resting myocardium. MRI
Detects the thickness of resting myocardium.
Chest X-ray (CXR) CXR aids in diagnosing heart failure. Chest X-ray (CXR)
CXR aids in diagnosing heart failure.
Arterial blood gas analysis Arterial hypoxemia is a common occurrence within the first 24hours of myocardial infarction. It is worsened by the respiratory depression caused by the opioid analgesics. Arterial blood gas analysis
Arterial hypoxemia is a common occurrence within the first 24hours of myocardial infarction. It is worsened by the respiratory depression caused by the opioid analgesics.
Serum electrolytes Electronic disturbances can occur due to autonomic disturbance and it is an easily correctable condition. Persistent electrolyte imbalance might lead to the development of arrhythmia. Serum electrolytes
Electronic disturbances can occur due to autonomic disturbance and it is an easily correctable condition. Persistent electrolyte imbalance might lead to the development of arrhythmia.
Lipid profile Total cholesterol, LDL and HDL cholesterol levels and fasting triglyceride levels should be measured. Lipid profile
Total cholesterol, LDL and HDL cholesterol levels and fasting triglyceride levels should be measured.
Fasting blood sugar Diabetes increases the risk of cardiac mortality by two to five times in women and three times in men, compared to the age and sex matched normal population. Fasting blood sugar
Diabetes increases the risk of cardiac mortality by two to five times in women and three times in men, compared to the age and sex matched normal population.

Management - Supportive

Fact Explanation
Basic life support In an unconscious patient management of airway, breathing and circulation (ABC) should be given the priority. Rapid administration of intravenous fluids (200ml in 10 minutes) will help to improve the blood pressure. Blood pressure and volume status should be monitored through out to prevent fluid overload. Infusion of intravenous inotropes should be administered to maintain a systolic blood pressure more than 90mmHg. Basic life support
In an unconscious patient management of airway, breathing and circulation (ABC) should be given the priority. Rapid administration of intravenous fluids (200ml in 10 minutes) will help to improve the blood pressure. Blood pressure and volume status should be monitored through out to prevent fluid overload. Infusion of intravenous inotropes should be administered to maintain a systolic blood pressure more than 90mmHg.
Analgesics Narcotic analgesics are the first choice. Respiratory depression is a possible side effect. Diamorphine and methadone acts more quickly. Initial dose of morphine is 4 to 8 mg and thereafter 2 mg dose titrations are given every 5 minutes till the pain is relieved. Opioids should be combined with an anti emetic to reduce the side effect of vomiting. Morphine will also cause a fall in blood pressure Nitrous oxide is also an effective analgesic. Intravenous nitrates or intravenous beta-blockers can be used if pain does not respond to opioids. Nitrates or opioids do not show any survival benefit. Analgesics
Narcotic analgesics are the first choice. Respiratory depression is a possible side effect. Diamorphine and methadone acts more quickly. Initial dose of morphine is 4 to 8 mg and thereafter 2 mg dose titrations are given every 5 minutes till the pain is relieved. Opioids should be combined with an anti emetic to reduce the side effect of vomiting. Morphine will also cause a fall in blood pressure Nitrous oxide is also an effective analgesic. Intravenous nitrates or intravenous beta-blockers can be used if pain does not respond to opioids. Nitrates or opioids do not show any survival benefit.
Oxygen Given in a rate of 2–4l/min. The effectiveness of the reperfusion therapy depends on the arterial oxygen concentration as well. Oxygen
Given in a rate of 2–4l/min. The effectiveness of the reperfusion therapy depends on the arterial oxygen concentration as well.
Endotracheal intubation and mechanical ventilation If the oxygen tension drops (less than 60 mmHg) despite giving 100% oxygen (8-10 L/min) via the face mask or nasal prongs, intubation and mechanical ventilation is lifesaving. Endotracheal intubation and mechanical ventilation
If the oxygen tension drops (less than 60 mmHg) despite giving 100% oxygen (8-10 L/min) via the face mask or nasal prongs, intubation and mechanical ventilation is lifesaving.
Pharmacological management of heart failure In the presence of mild heart failure slow intravenous infusion of furosemide 20–40mg can be given and repeated 1 to 4 hourly. However severe heart failure may need higher doses. Titrating doses of intravenous nitroglycerine (0.25μg/kg/min titrate the dose every 5minutes) or oral nitrates can be administered if there is no response to diuretics. Hypotension is a possible complication and blood pressure should be monitored. Pharmacological management of heart failure
In the presence of mild heart failure slow intravenous infusion of furosemide 20–40mg can be given and repeated 1 to 4 hourly. However severe heart failure may need higher doses. Titrating doses of intravenous nitroglycerine (0.25μg/kg/min titrate the dose every 5minutes) or oral nitrates can be administered if there is no response to diuretics. Hypotension is a possible complication and blood pressure should be monitored.
Inotropic agents If hypotension or renal hypo perfusion develops intravenous dopamine (0.5–5.0μg.kg/min) is recommended. In the presence of pulmonary edema dobutamine (2.5μg/kg/min increased every 5–10min intervals. Maximum dose-10μg/kg/min) is preferred. Inotropic agents
If hypotension or renal hypo perfusion develops intravenous dopamine (0.5–5.0μg.kg/min) is recommended. In the presence of pulmonary edema dobutamine (2.5μg/kg/min increased every 5–10min intervals. Maximum dose-10μg/kg/min) is preferred.
Correction of electrolyte disturbances Electrolyte disturbances especially hypokalemia can induce arrhythmias. Correction of electrolyte disturbances
Electrolyte disturbances especially hypokalemia can induce arrhythmias.
Correction of acid base disturbances Due to respiratory depression, renal hypo perfusion and anaerobic metabolism acid base disturbances can occur. Correction of acid base disturbances
Due to respiratory depression, renal hypo perfusion and anaerobic metabolism acid base disturbances can occur.
Management of arrhythmias Ventricular tachycardia can be treated with beta-blockers, unless contraindicated. Lidocaine is preferred if there is impending ventricular fibrillation. Defibrillation is indicated if ventricular fibrillation develops. Supraventricular tachycardia is treated with carotid sinus massage and if it fails with beta blockers or intravenous adenosine. Sinus bradycardia is treated with intravenous atropine (0.3–0.5mg, repeated maximum total dose is 1.5–2.0mg). Management of arrhythmias
Ventricular tachycardia can be treated with beta-blockers, unless contraindicated. Lidocaine is preferred if there is impending ventricular fibrillation. Defibrillation is indicated if ventricular fibrillation develops. Supraventricular tachycardia is treated with carotid sinus massage and if it fails with beta blockers or intravenous adenosine. Sinus bradycardia is treated with intravenous atropine (0.3–0.5mg, repeated maximum total dose is 1.5–2.0mg).

Management - Specific

Fact Explanation
Aspirin Loading dose of 160 to 325 mg orally should be given to the patient to chew as the MI is suspected. This should be followed up by low dose aspirin daily for thrombo-prophylaxis. (75mg at night). Aspirin
Loading dose of 160 to 325 mg orally should be given to the patient to chew as the MI is suspected. This should be followed up by low dose aspirin daily for thrombo-prophylaxis. (75mg at night).
Clopidogrel This is a glycoprotein IIb/IIIa inhibitor and belongs to antiplatelet group. Clopidogrel is used when aspirin is contraindicated and there is no evidence for routine long term use of clopidogrel in addition to aspirin. Clopidogrel
This is a glycoprotein IIb/IIIa inhibitor and belongs to antiplatelet group. Clopidogrel is used when aspirin is contraindicated and there is no evidence for routine long term use of clopidogrel in addition to aspirin.
Percutaneous coronary interventions (PCI) Door to balloon time for primary PCI is 90 minutes. After failed medical thrombolysis rescue PCI can be done. Primary PCI is the preferred treatment for patients in shock and for patients with contraindications for pharmacological thrombolysis. When facilities are available within the effective time period, primary PCI is considered better than the pharmacological thrombolysis. Especially in right ventricular infarcts primary PCI is preferred over the pharmacological thrombolysis. Percutaneous coronary interventions (PCI)
Door to balloon time for primary PCI is 90 minutes. After failed medical thrombolysis rescue PCI can be done. Primary PCI is the preferred treatment for patients in shock and for patients with contraindications for pharmacological thrombolysis. When facilities are available within the effective time period, primary PCI is considered better than the pharmacological thrombolysis. Especially in right ventricular infarcts primary PCI is preferred over the pharmacological thrombolysis.
Tissue plasminogen activator (t-PA) This is considered a superior method of thrombolysis when compared to streptokinase(SK). Also the left ventricular function preservation is higher with t-PA. Tissue plasminogen activator (t-PA)
This is considered a superior method of thrombolysis when compared to streptokinase(SK). Also the left ventricular function preservation is higher with t-PA.
Streptokinase Risk of stroke is lower with streptokinase when compared to t-PA or anistreplase. Reperfusion therapy limits the infarct size. Timely reperfusion is effective in preventing heart failure, shock and severe life-threatening arrhythmias. If the infarction is established for more than 12hours fibrinolytic therapy should not be given, unless there is ECG evidence of ongoing ischaemia. Streptokinase
Risk of stroke is lower with streptokinase when compared to t-PA or anistreplase. Reperfusion therapy limits the infarct size. Timely reperfusion is effective in preventing heart failure, shock and severe life-threatening arrhythmias. If the infarction is established for more than 12hours fibrinolytic therapy should not be given, unless there is ECG evidence of ongoing ischaemia.
Emergency coronary artery bypass graft (CABG) A surgical method of establishing reperfusion. Emergency coronary artery bypass graft (CABG)
A surgical method of establishing reperfusion.
Angiotensin Converting Enzyme Inhibitors (ACEI) Should be started within first 48h of MI provided there is no hypotension, hypovolaemia or renal failure. If given within the first 24 hours ACEIs significantly reduce the cardiovascular mortality. Angiotensin Converting Enzyme Inhibitors (ACEI)
Should be started within first 48h of MI provided there is no hypotension, hypovolaemia or renal failure. If given within the first 24 hours ACEIs significantly reduce the cardiovascular mortality.
Beta blockers Beta blockers reduces the blood pressure and heart rate. They also have anti-arrhythmic properties. Beta blockers
Beta blockers reduces the blood pressure and heart rate. They also have anti-arrhythmic properties.
Intravenous magnesium Reduces the peripheral vascular resistance, increases the cardiac output and reduces the risk of arrhythmias. Intravenous magnesium
Reduces the peripheral vascular resistance, increases the cardiac output and reduces the risk of arrhythmias.
Calcium channel blockes Reduces the vasospasm. The use of CCB in the management of MI remains contravertial. However some studies have failed to prove the beneficial effects of magnesium in the management of MI. Calcium channel blockes
Reduces the vasospasm. The use of CCB in the management of MI remains contravertial. However some studies have failed to prove the beneficial effects of magnesium in the management of MI.
Glucose-insulin-potassium This combination is used in the treatment based on the fact that this favorably influence the metabolism of ischemic myocardium. Although some studies have proven a significant reduction in mortality this is not routinely practiced. Glucose-insulin-potassium
This combination is used in the treatment based on the fact that this favorably influence the metabolism of ischemic myocardium. Although some studies have proven a significant reduction in mortality this is not routinely practiced.
n-3 polyunsaturated fatty acids (1g/day) This is proven to reduce the cardiovascular mortality and risk of re-infarction. n-3 polyunsaturated fatty acids (1g/day)
This is proven to reduce the cardiovascular mortality and risk of re-infarction.
Lipid-lowering agents Lipid lowering therapy reduces the serum lipid levels and significantly reduces the risk of re-infarction. Statins is the preferred lipid lowering drug which should be prescribed in addition to dietary guidelines to reduce the serum lipid levels. Statins should be continued despite normal serum lipid levels. Lipid-lowering agents
Lipid lowering therapy reduces the serum lipid levels and significantly reduces the risk of re-infarction. Statins is the preferred lipid lowering drug which should be prescribed in addition to dietary guidelines to reduce the serum lipid levels. Statins should be continued despite normal serum lipid levels.

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