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patient
Case presentation
Case
54 year old male with history of DM2 for 20 years, HTN, who
presented to the ED with 4 hour onset of chest pain which
was described as in the anterior chest without radiation. The
pain seemed to improve when he sits down and worsening
when he walked upstairs
VS: T 36.9, HR: 105, BP: 135/86, RR 22, O2 sat. 99% RA
ECGs are shown as followed
EKG
STEMI:
Q waves , ST elevations, hyper acute T waves; followed by T wave
inversions.
Clinically significant ST segment elevations:
> than 1 mm (0.1 mV) in at least two anatomical contiguous leads
or 2 mm (0.2 mV) in two contiguous precordial leads (V2 and V3)
Cardiac Enzymes
Troponin is primarily used for diagnosing MI because it has
good sensitivity and specificity.
CK-MB is more useful in certain situations such as post
reperfusion MI or if troponin test is not available
Other conditions can cause elevation in troponin such as
renal failure or heart failure
The increasing troponin trend is the important thing to look
for in diagnosing MI. Order Troponin together with ECG
when doing serial testing to rule out ACS.
Diagnosis
612 hours
No heart muscle salvage (permanent loss) with potential infarct
healing benefit
> 12 hours
Reperfusion is not routinely recommended if the patient is
asymptomatic and haemodynamically stable
In cases of major delay to hospitalisation (> 30 minutes) ambulance crews should consider prehospital fibrinolysis.
Reference
1. Acute Coronary Syndrome Guidelines Working Group. Guidelines for the management of acute coronary syndromes 2006. Med J Aust 2006; 184(8 Suppl):S929.
STEMI Management
Initial management for STEMI:
Cardiac monitor
Supplemental O2
Good IV access
Nitrates*
Beta blocker
Morphine
Clopidogrel
Aspirin
Call expert
Bleeding Risk
The following risk factors should be considered when assessing bleeding risk and choosing
antithrombotic therapies in patients with ACS (Grade B):
Fibrinolysis
Fibrinolysis is the administration of a pharmacologic agent to break down blood clots in the
coronary vessels to restore blood flow to the heart muscle. 1
Absolute contraindications
Reference
1. Dugdale DC , Chen Y-B, Zieve D, et al. Fibrinolysis primary or secondary fibrinolysis. Available from: http://www.nlm.nih.gov/medlineplus/ency/article/000577.htm. Accessed 7
August 2011.
FIBRINOLYSIS
Relative contraindications
Pregnancy.
Fibrinolitic therapy
Management of hyperglycaemia in
ST-segment elevation myocardial infarction
Thank You