STEMI-90

Published: August 21st, 2016

Category: STEMI

Pre-hospital ECG

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Emergency Department ECG

ECG1

Right Side ECG

ECG2

 

Cardiac Cath Report

Left Main Trunk: Short, angiographically patent LM

Left Anterior Descending Artery:Medium sized transpical vessel with diffuse moderate diseas in proximal and mid segment. There is severe disease in mid to distal LAD after D3 take off. D1 and D2 are small branches with diffuse disease in D2.

Left Circumflex Artery:Is a large diffusly diseased nondominat vessel with ectatic segment proximal to and long segment moderate disease just after OM2 take off. AV groove circumflex and distal circumflex are medium sized vessels which are angiographically patent. OM1 is small and severly diseased. OM2 is large vessel with moderate disease in proximal and severe 90% stenosis just prior to bifurcation into medium sized branches with MLI.

Right Coronary Artery: complete thrombotic occlusion in proximal segment. There is diffuse calcification in proximal segment as well.

Stent placed to proximal RCA

Teaching

Inferior MI

  • 40-50% of all myocardial infarctions.
  • more favorable prognosis than anterior myocardial infarction
  • Up to 40% of patients with an inferior STEMI will have a concomitant right ventricular infarction. These patients may develop severe hypotension in response to nitrates and generally have a worse prognosis.
    • Confirmed with Right sided ECG, Elevation in V4R
  • Up to 20% of patients with inferior STEMI will develop significant bradycardia due to second- or third-degree AV block. These patients have an increased in-hospital mortality (>20%).
  • ECG findings
    • ST elevation in leads II, III and aVF
    • Reciprocal ST depression in aVL (± lead I)
    • RCA (80%): Elevation in III > II, Reciprocal depression in I
    • LCx (20%): Elevation in III = II, No reciprocal depression in I

Right side MI

  • Complicates 40% of inferior MIs
  • Right ventricle is preload dependent which may lead to hypotension if Nitroglycerin is administered.  Treat with IV fluids and rapid transport.
  • Right side ECG
    • A complete set of right-sided leads is obtained by placing leads V1-6 in a mirror-image position on the right side of the chest (see diagram, below).
    • It may be simpler to leave V1 and V2 in their usual positions and just transfer leads V3-6 to the right side of the chest (i.e. V3R to V6R).
    • The most useful lead is V4R, which is obtained by placing the V4 electrode in the 5th right intercostal space in the midclavicular line. ST elevation in V4R has a sensitivity of 88%, specificity of 78% and diagnostic accuracy of 83% in the diagnosis of RV MI

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