AMI/ACS Diagnosis: History and Physical
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AMI/ACS Diagnosis:History and Physical
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AMI/ACS Diagnosis: HistoryAMI/ACS Diagnosis: History
How do we assess risk in chest pain patients?
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AMI/ACS: Risk AssessmentAMI/ACS: Risk Assessment
Pain characteristics Palliative/provocative features Associated cardiac symptoms Cardiac history Cardiac risk factors Family Hx: early AMI, sudden death
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AMI/ACS: Risk AssessmentAMI/ACS: Risk Assessment
Low, medium, high risk Does the patient have an acute
coronary syndrome (ACS)? Is there a ruptured plaque that is
occluded by a white or red thrombus?
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AMI/ACS
History Important clinical tool Chest pain may not be “classic”
Crushing, heaviness 24% Burning pain 23% Pleuritic pain 19% Reproducible pain 8-15% Sharp/stabbing pain 5%
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Anginal EquivalentsAnginal Equivalents
25-30% of MI’s clinically silent Diabetic and elderly at risk Older pts
Less likely to present with CP Less likely to have diaphoresis, N/V
SOB, dizziness, syncope may be sx
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Anginal Equivalents
Atypical PresentationsAtypical Presentations Back, neck, jaw, abdominal pain Dyspnea Diaphoresis N/V Syncope Confusion Generalized weakness Dizziness, TIA
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AMI/ACS
HistoryAssociated symptoms
Diaphoresis 80% Nausea 60% Belching 47% Vomiting 39%
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Coronary Atherosclerosis
Risk Risk Factors Male gender Age > 50 HTN Diabetes Hypercholesterolemia Post menopausal Family history of atherosclerosis
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Coronary Atherosclerosis
Risk Risk Factors Smoking Cocaine usage Peripheral Vascular Disease Obesity Hyper-triglyceridemia
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AMI/ACS History: AMI/ACS History: Prior Cardiac CatheterizationPrior Cardiac Catheterization
How long of a time does the report of a “negative” cardiac catheterization exclude a likely acute coronary syndrome?
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AMI/ACS History: AMI/ACS History: Prior Cardiac CatheterizationPrior Cardiac Catheterization
Perhaps 6-12 months, unless patient presents with STEMI or unstable
Must determine clean coronaries as opposed to non-occlusive lesions
The latter addresses the 60% lesion that is prone to disruption and STEMI
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AMI/ACS Diagnosis
Physical Exam
Pleuritic, positional painPalpable tendernessCHF, DVT, PE, AAANew murmur (valve)Unequal BP, pulsesCardiac dysrhythmia
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AMI/ACS Diagnosis:EKG
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AMI/ACS Diagnosis: EKGAMI/ACS Diagnosis: EKG
How do we diagnose AMI/ACS? How soon after triage should the
first EKG be performed?
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EKG Diagnosis
Ischemia or NSTEMI (ACS)Ischemia or NSTEMI (ACS)
Ischemia or NSTEMI ST segment depression Symmetric T wave inversions Inverted/biphasic T waves Non-specific ST or T ’s
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EKG Diagnosis
Acute Myocardial InfarctionAcute Myocardial Infarction
Infarction (AMI) Peaked T waves (earliest finding) ST segment elevation Normalization of ST segment Development of Q waves
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AMI/ACS: EKG LocalizationAMI/ACS: EKG Localization
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AMI/ACS: EKG LocalizationAMI/ACS: EKG Localization
Anatomic Location EKG Location Coronary Artery
Septal V1-2 LAD lesion
Anterior V3-4 LAD lesion
Lateral V4-6, I, aVL Circumflex branch of LAD
Inferior II,III, aVF RCA (90%)
Posterior V8-9 Circumflex or dominant branch of RCA
Right Ventricular V4R RCA
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AMI/ACS: EKG LocalizationAMI/ACS: EKG LocalizationAMI/ACS: EKG LocalizationAMI/ACS: EKG Localization
aVF inferiorIII inferior V3 anterior V6 lateral
aVL lateralII inferior V2 septal V5 lateral
aVRI lateral V1 septal V4 anterior
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AMI/ACS: Coronary ArteriesAMI/ACS: Coronary Arteries
Left
• Septal wall of LV
• Anterior and lateral walls of LV
• Inferior wall LV (10%)
• Both bundle branches
Right
• Inferior wall of LV
• Posterior wall of LV (90%)
• AV node (90%)
• Right ventricle
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Anteroseptal MI
ST elevation in V1, V2
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Anteroseptal MI
ST elevation in V1, V2
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Anterior Wall MI
ST elevation in V2, V3
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Anterolateral Wall MI
ST elevation in V2-V6
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Anterolateral Wall MI ST elevation in V4, V5
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Inferior Wall MI ST elevation in II, III, AVF
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AMI/ACS Diagnosis: EKGAMI/ACS Diagnosis: EKG
How do we diagnose true posterior wall AMI? RV AMI?
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True Posterior AMI Initial R waves V1, V2; R/S ratio >1
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True Posterior AMI Initial R waves V1, V2; R/S ratio >1
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Right Ventricular AMI ST elevation in II, III, aVF Also noted in in V4R to V6R
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Right Ventricular AMI RCA occlusion Inferior and RV infarction
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AMI Diagnosis: EKGAMI Diagnosis: EKG
What are the indications for additional EKG leads? Which are done? How? Why?
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Lead Placement for aLead Placement for aRV and Posterior ECGRV and Posterior ECGLead Placement for aLead Placement for aRV and Posterior ECGRV and Posterior ECG
V1
V3V4RV8
V9V2
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AMI/ACS: EKG Extra LeadsAMI/ACS: EKG Extra Leads
EKG shows posterior wall AMI Inferior wall MI with hypotension:
??? RV infarction Ischemic changes, cardiogenic
shock, search for PTCA indications
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Right-sided 12-Lead ECG: Patient Right-sided 12-Lead ECG: Patient With Inferior ST-Segment ChangesWith Inferior ST-Segment ChangesRight-sided 12-Lead ECG: Patient Right-sided 12-Lead ECG: Patient
With Inferior ST-Segment ChangesWith Inferior ST-Segment Changes
Lead V4R = diagnostic ST-segment elevation
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AMI/ACS: EKG Extra LeadsAMI/ACS: EKG Extra Leads
Zalenski extra leads study Inf AMI, 14% complications Inf AMI and RV AMI, 26%
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EKG Diagnosis
AMI/ACS Dx in LBBB
Rules for detecting MI with LBBB ST > 1mm and concordant with QRS = 5 pts ST > 1mm in V1, V2, or V3 = 3 pts ST > 5mm and discordant with QRS = 2 pts
Higher scores more likely MI present with LBBB
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EKG Diagnosis
AMI/ACS Dx in LBBB
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EKG Diagnosis
ST Elevation in Pericarditis
Diffuse ST elevation, atypical
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AMI/ACS
EKG DiagnosisEKG non-diagnostic in 50%
of AMI cases (NSTEMI)Cardiac enzymes usefulSerial EKGs useful
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AMI/ACS Dx: EKG TimingAMI/ACS Dx: EKG Timing
An EKG should be obtained within 10 minutes of presentation and initial triage