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stemi on ekg
Transcript of stemi on ekg
12 lead EKG
in 2 or more contiguous leads
>2 inV2-V3 (>1.5 in women)
>1mm in others
right coronary artery
left coronary artery
-left anterior descending
st elevated myocardial infarction
associate region & vessel
when present rules out early repolarization
when absent does not rule out STEMI
General EKG Changes suggestive of Ischemia
Electrocardiogram may be completely normal
ST Elevation or ST depression
Over 1 mm ST changes that are transient with symptoms
Summed ST deviation (sum of affected leads) >2.5 mm
Holmvang (2003) J Am Coll Cardiol 41:905-15
Deep symmetric T-wave inversion
Occurs in multiple precordial leads
Left main Coronary Artery stenosis marker
aVR ST segment elevation > V1 ST segment elevation
Gaitonde (2003) Am J Cardiol 92:846-8
GHS critical value policy
THE BIG ONE!
practice with cheat sheet
with st elevation.................
Increased ST changes
septal MI-LAD branch
40% of all inf mi
higher mortality rate
BP, JVD, clear lungs
How is bp treated in an acute MI?
MI & = !
On a 12 lead ecg...
what's the difference between an inferior mi with reciprical changes & an inferior/posterior mi?
STEMI s/p stent LAD,
plan 'work on RCA' next week
pt has cont increasing ache 2/10-3/10 when awake,
not like the heart attack
when asleep bp 85/60 hr 45
RV (only 40%)
relative V2-V3 depression
LV-inferior/posterior (other 60%)
V2 depression > 1/2 amp AVF
Effects of Right Ventricular Ischemia
Systolic RV dysfunction ⇒
↓ RV CO ⇒ ↓ LV CO
↑ RV volume ⇒ septal shift
Diastolic RV dysfunction ⇒ ↓ compliance ⇒
↑ RVDP ⇒ septal shift ⇒ ↓ LVDP ⇒ ↓ LV CO
↑ RAP ⇒ ↓ septal shift ⇒ ↓ LAP ⇒ ↓ LV CO
An acute inferior wall transmural myocardial infarction presents with the changes in leads 2, 3, and aVF (show ECG 6).
Reciprocal ECG changes occasionally are observed during the initial period of the acute infarction, presenting with ST segment depressions in leads V1 to V3, 1, or aVL.
The ST segment changes in the precordial leads are not reciprocal in some cases, but represent true posterior wall involvement (which may be diagnosed by ST elevation in leads V7 to V9)  or involvement of the right ventricle (which may be diagnosed by ST elevations in right precordial chest leads). (See "Right ventricular myocardial infarction").
precath post cath
What's the best lead to use
for monitoring st elevation?
2nd degree HB type II
2nd degree HB type I
decreased urine output
decreased urine output
increased oxygen requirements
Is it ok to give NTG with an inferior MI?
Describe the GHS critical values policy as it relates to the ‘Acute MI’ result and the responsibilities of the RN related to this policy.
1. Recognize ecg changes of an acute myocardial infarction as well as the expected evolution of these changes
2. Associate the contiguous ecg leads with the anatomical region of injury, in order to differentiate symptoms and appropriate treatment for the different types of MI
3.Correlate the ekg findings with the cardiac cath lab results and apply these to individual patients
Early inferior STEMI:
Hyperacute (peaked) T waves in II, III and aVF with relative loss of R wave height.
Early ST elevation and Q-wave formation in lead III.
Reciprocal ST depression and T wave inversion in aVL.
ST elevation in lead III > lead II suggests an RCA occlusion; the subtle ST elevation in V4R would be consistent with this.
Note how the ST segment morphology in aVL is an exact mirror image of lead III. This reciprocal change occurs because these two leads are approximately opposite to one another (150 degrees apart).
The concept of reciprocal change can be further highlighted by taking lead aVL and inverting it… see how the ST morphology now looks identical to lead III.
20% Inferior MI develope bradycardia
sa nodal artery
av nodal artery
Increased vagal tone
what do you look for?
why do we need to know this?
how to use cath lab report?
How can you estimate
the extent of damage ?
Lesions in the proximal part of a vessel can result in more damage than lesions in the very distal portion
Major vs minor vessel
Location of the lesion
Hypokinesia- decreased but not absent motion of a ventricular segment
Dyskinesia- paradoxical expansion or wall motion usually due to tethering from the adjacent segments
Akinesia - complete absence of wall motion
Left Ventricular function
-end diastolic function
direct measurement of preload
PCW indirect measurement
1. 2. 3. ?
1. 2. 3. ?
-3D picture of the heart
- different perspective/view
street view only
Extra stuff...just for fun!!
Applying ECG & cath result
to the patient
Treatment depends on the type of MI
where do we look ?
Lanza, 2001 CCN
Sub acute/Late Presentation
AGE of MI
Non Ischemic ST Elevations
Early Repolarization/Normal Variant
Pulmonary Embolism/Right Ventricular Strain
Persistant LV aneurysm
Inferior lateral-Cx/Left Dominant
1st negative deflection
Loss of R wave
Apical MI/Wrap around LAD
Non Ischemic causes of ST elevation
Camera = +electrode