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| ==Background==
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| *Abbreviation: STEMI
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| *RV infarction accompanies ~25% of inferior STEMIs
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| **Hemodynamically significant only 10% of the time
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| **Do NOT reduce preload (caution with NTG)
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| **Optimise preload (ensure volume replete)
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| *Posterior (aka inferolateral) infarction is rarely isolated (~3-8% of all AMIs)
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| **Treat as STEMI
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| **Look for reciprocal changes, except in aVR and V1
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| **Apply V7, V8, V9 leads and repeat ECG looking for ST elevation
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| **Usually will see changes in V6 OR II, III, aVF
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| ===Fourth Universal Definition of STEMI===
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| '''Any of the following:'''<ref>Thygesen, K et al. Fourth Universal Definition of Myocardial Infarction (2018). 2018 Nov 13;138(20):e618-e651.PMID: 30571511</ref>
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| #1 mm of ST elevation in any two contiguous leads except V2 and V3.
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| ##The acceptable degree of ST elevation in V2 and V3 changes based on age and gender.
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| ###In women: 1.5mm elevation in V2 and V3
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| #In men under 40: 2.5mm elevation in V2 and V3
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| *In men 40 and older: 2mm elevation in V2 and V3
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| {{ACS anatomical correlation}}
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| [[File:EKG leads.png|thumbnail|ECG vectors]]
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| '''This is bold''' asdf haafsddsf ''this is the italics''
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| === This is the new heading ===
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| ===Prehospital===
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| *Hyperoxia may increase myocardial injury
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| **Avoid supplemental oxygen unless hypoxic<ref name="Air">Stub D et al. Air versus oxygen in ST-Segment-Elevation Myocardial Infarction. Circulation. 2015;121:2143-2150</ref>
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| *Activate cath lab for patients with STEMI on prehospital ECG even if ST elevation has resolved by time of arrival at hospital <ref>Ownbey M, Suffoletto B, Firsch A, et al. Prevalence and interventional outcomes of patients with resolution of ST-segment elevation between prehospital and in-hospital ECG. Prehosp Emerg Care. 2014. Apr-Jun;18(2):174-9</ref>
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| {{STEMI Stages of Development}}
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| ==Differential Diagnosis==
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| {{ST elevation DDX}}
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| ==Evaluation==
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| ===Workup===
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| *[[ECG]]
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| **Use the J-point for measurement in 2 contiguous leads<ref>ACCF/AHA 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013 Jan 29;61(4):e78-140. [http://www.sciencedirect.com/science/article/pii/S0735109712055623/pdfft?md5=1ab12406644b051890dfc4bb1634c2bf&pid=1-s2.0-S0735109712055623-main.pdf PDF]</ref>
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| ***J point is where there is a sudden change in direction
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| **When possible, compare to old ECGs
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| **Repeating ECGs will increase sensitivity
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| *CBC
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| *Chem 7
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| *[[Troponin]]
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| *PT/PTT
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| *Consider [[CXR]]
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| ===Diagnosis===
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| [[File:1200px-Inferior and RtV MI 12 lead.jpg|thumb|Inferior and right sided STEMI]]
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| ''Look for ST segment elevation, reciprocal ST depression, and hyperacute T waves''
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|
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| ====Classic STEMI====
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| *Men
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| **In males ≥ 40 years old 2mm in V2-V3 and 1mm in all other leads<ref name="a">Thygesen K, Alpert JS, Jaffe AS, Simoons ML, Chaitman BR, White HD; Writing Group on behalf of the Joint ESC/ACCF/AHA/WHF Task Force for the Universal Definition of Myocardial Infarction.. Third universal definition of myocardial infarction. Glob Heart. 2012 Dec;7(4):275-95</ref>
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| **In males < 40 years old 2.5mm in V2-V3 and 1mm in all other leads<ref name="a" />
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| *Women
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| **≥1.5 mm in V2-V3 and 1 mm (0.1mV) in all other leads<ref name="a" />
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| ====Posterior STEMI====
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| ''Up to 10% of STEMIs; usually associated with inferior MI''
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| *≥0.5 mm STE is diagnostic
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| *Look at V1-V3<ref>Ayer A, Terkelsen CJ. Difficult ECGs in STEMI: lessons learned from serial sampling of pre- and in-hospital ECGs. Journal of Electrocardiology 2014;47(4):448–58</ref><ref>Wei EY, Hira RS, Huang HD, et al. Pitfalls in diagnosing ST elevation among patients with acute myocardial infarction. Journal of Electrocardiology 2013;46(6):653–9</ref>
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| **Large R waves (posterior Q waves)
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| **STD
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| **Upright T waves
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| ====Post-arrest STEMI/NSTEMI====
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| *Get immediate ECG after arrest
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| *STEMI: go to cath lab immediately (AHA/ACCF Class IB)<ref>O’Gara PT, Kushner FG, Ascheim DD, et al. 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction. JAC 2013;61(4):e78–e140.</ref>
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| *NSTEMI: go to cath within 2 hrs if VT/VF, intractable ischemic pain, ADCHF (AHA/ACC Class IA)<ref>Amsterdam EA, Wenger NK, Brindis RG, et al. 2014 AHA/ACC Guideline for the Management of Patients with Non-ST-Elevation Acute Coronary Syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014;64(24):e139–228.</ref>
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| ====[[LBBB]] with [[Sgarbossa's criteria]]====
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| *New LBBB alone is no longer STEMI criteria for cath lab as of 2013 per ACC/AHA guidelines<ref>Am Heart J 2013;166:409-13</ref>
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| *Hemodynamically unstable or new HF pts with new LBBB should be discussed with a cardiologist for PCI or fibrinolytics
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| [[File:Sgarbossa.jpg|thumb|Sgarbossa's Original Criteria]]
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| *≥3 points = 98% probability of [[ST-Elevation Myocardial Infarction (STEMI)|STEMI]]<ref>Sgarbossa E. et al.. "Electrocardiographic diagnosis of evolving acute myocardial infarction in the presence of left bundle-branch block. GUSTO-1 (Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries) Investigators". NEJM. 1996. 334(8):481-7</ref>
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| **ST elevation ≥1 mm in a lead with upward (concordant) QRS complex - 5 points
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| **ST depression ≥1 mm in lead V1, V2, or V3 - 3 points
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| **ST elevation ≥5 mm in a lead with downward (discordant) QRS complex - 2 points
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| ***Least specific of criteria, see Smith's modification
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| [[File:modified-sgarbossa.png|thumbnail|Smith's Modified Sgarbossa 3rd Rule]]
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| *Changes the 3rd rule of original [[EBQ:Sgarbossa Criteria Study|Sgarbossa's Criteria]] to be ST depression OR elevation discordant with the QRS complex and with a magnitude of at least 25% of the QRS increases Sn from 52% to 91% at the expense of reducing Sp from 98% to 90%<ref>Smith, S. et al. Diagnosis of ST-Elevation Myocardial Infarction in the Presence of Left Bundle Branch Block With the ST-Elevation to S-Wave Ratio in a Modified Sgarbossa Rule. 60(6). 766-776</ref>
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|
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| ===[[STEMI equivalents]]===
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| *[[Pacemaker_complication|Pacemakers]] in AMI
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| **Sgarbossa criteria can be applied to paced rhythms<ref>Sgarbossa EB, Pinski SL, Gates KB, et al. Early electrocardiographic diagnosis of acute myocardial infarction in the presence of ventricular paced rhythm. GUSTO-I investigators. Am J Cardiol. 1996;77(5):423–424.</ref><ref>Maloy KR, Bhat R, Davis J, et al. Sgarbossa Criteria are Highly Specific for Acute Myocardial Infarction with Pacemakers.West J Emerg Med. 2010;11(4):354–357. </ref>
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| **Low sensitivity but high specificity
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| *[[DeWinter T-waves]]<ref>Birnbaum I, Birnbaum Y. High-risk ECG patterns in ACS—need for guideline revision. J Electrocardiol. 2013;46(6):535–9.</ref>
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| **High risk of ACUTE (vs subacute in [[Wellen's]]) anterior MI (proximal LAD occlusions)<ref>Verouden NJ, Koch KT, Peters RJ, et al. Persistent precordial “hyperacute” T-waves signify proximal left anterior descending artery occlusion.</ref>
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| **Look for 1-3 mm STD at J-point in mid precordial leads with tall symmetric T waves<ref>de Winter RJ, Verouden NJ, Wellens HJ, et al. A new ECG sign of proximal LAD occlusion. N Engl J Med. 2008 Nov 6;359(19):2071-3. </ref>
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| *ST elevation in aVR<ref>Rokos IC, French WJ, Mattu A, et al. Appropriate cardiac cath lab activation: optimizing the electrocardiogram interpretation and clinical decision making for acute ST-elevation myocardial infarction. Am Heart J. 2010 Dec; 160(6):995-1003. </ref>
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| **Reflects subendocardial ischemia in LV (L main vs multi vessal disease)<ref>Kosuge M, Uchida K, Imoto K, et al. An early and simple predictor of severe left main and/or three-vessel disease in patients with non-ST-segment elevation acute coronary syndrome. J Am Coll Cardiol. 2015 Jun 16;65(23):2570-1</ref>
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| **Look for STE >1-1.5 mm in aVR
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| **Can also bee seen in hemorrhage, type A [[Dissection]], [[PE|massive PE]]
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| ==Management==
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| ===[[Thrombolytics]] vs PCI===
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| ''Primary treatment is centered on PCI within 90 min (if available) or thrombolysis if treatment delay is greater than 120min.''
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| #Percutaneous coronary intervention (preferred option)
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| #*Goal: PCI should be attempted if the procedure can be started within 120 minutes (faster than 90 minutes is the goal, the faster the better)
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| #*If the PCI cannot be commenced within 120 minutes then fibrinolysis should be given to suitable candidates
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| #[[Thrombolytics for STEMI|Fibrinolytics]]
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| #*Goal: if it is determined that PCI cannot be performed within 120 minutes then fibrinolytics should be given, and they should be given within 30 minutes
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| ===Adjunctive Therapies===
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| #[[Aspirin]] 162-325mg chewable or 600mg PR
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| #[[Nitroglycerin]]
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| #*Do not give if RV MI
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| #*Do not give with phosphodiesterase inhibitors
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| #[[O2]]
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| #*For SpO2 <90%
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| #*Avoid hypoxia but supplemental O2 without hypoxia can increase infarct size<ref name="Air"></ref>
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| #**AVOID trial<ref>Stub et al. Air Versus Oxygen in ST-Segment Elevation Myocardial Infarction. Circulation. 2015 May 22.</ref> (2015) indicated larger infarct size, more recurrence and arrhythmia for STEMI patients without hypoxia who were treated with O2
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| #Antiplatelet Options
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| #*[[Clopidogrel]]
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| #**See drug link for specific age, indication related dosages
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| #**Generally, loading dose of 600 mg if PCI anticipated (otherwise give 300 mg)
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| #*[[Ticagrelor]]
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| #**May significantly reduce mortality as compared to clopidogrel<ref>Wallentin et Al. Ticagrelor versus Clopidogrel in Patients with Acute Coronary Syndromes. N Engl J Med 2009; 361:1045-1057.</ref>
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| #**180mg loading dose, followed by 90mg BID
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| #**[[Ticagrelor]] offers no added benefit in STEMI when given pre-hospital vs. in-hospital (ambulance vs. cath lab)<ref>Montalescot G et al. Prehospital ticagrelor in ST-segment elevation myocardial infarction. N Engl J Med 2014 Sep 1.</ref>
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| #GPIIB/IIIa Inhibitors
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| #*[[Abciximab]], [[Eptifibatide]]
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| #*Defer to cardiologist for administration
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| #*Given right before PCI depending on specific institutional protocols
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| #[[Beta blockers]]<ref>Campbell-Schere DL, Green LA. ACC/AHA guideline update for the management of ST-segment elevation myocardial infarction. Am Fam Physician.2009 Jun 15;79(12):1080-6.</ref>
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| #*Per AHA guidelines, IV beta blockers should ''not'' be given to patients with STEMI routinely, but may be considered for hypertension treatment barring contraindications as below:
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| #**Low output state, signs of [[heart failure|HF]]
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| #**Increased risk of [[cardiogenic shock]] (age > 70, sinus [[tachycardia]] > 110 bpm or HR < 60 bpm, SBP < 120 mmHg)
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| #**Increased time since onset of STEMI
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| #**Relative contraindications -- [[asthma]], [[COPD]], PR interval > 0.24 sec, [[AV block]]
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| #*PO beta blockers should be initiated within 24 hours of STEMI
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| #[[ACE inhibitor]] or [[ARB]]<ref>ACE inhibitor use in patients with myocardial infarction. Summary of evidence from clinical trials. Latini R, Maggioni AP, Flather M, Sleight P, Tognoni G. Circulation. 1995;92(10):3132.</ref><ref>Antman EM, et al. American College of Cardiology, American Heart Association Task Force on Practice Guidelines, Canadian Cardiovascular Society. Circulation. 2004;110(9):e82.</ref>
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| #*Give within 24 hours in stable patients, '''typically not given in ED'''
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| #*Careful initial dosing, starting at 2.5 mg/day of [[lisinopril]], increasing slowly up to 10 mg/day
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| #Statin in STEMI patients going to cath lab may have less 30-days MACEs and reinfarction post-PCI in SECURE-PCI trial in 2018<ref>Berwanger O, Santucci EV, de Barros e Silva PG, et al., on behalf of the SECURE-PCI Investigators. Effect of Loading Dose of Atorvastatin Prior to Planned Percutaneous Coronary Intervention on Major Adverse Cardiovascular Events in Acute Coronary Syndrome: The SECURE-PCI Randomized Clinical Trial. JAMA 2018;319:1331-40.</ref>
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| #*80 mg [[atorvastatin]] immediately before cath lab and 24 hours after PCI
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| #*Perform in conjunction with your cardiologist
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| #*No cases of rhabdomyolysis or liver failure reported in the atorvastatin group
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| ===Anticoagulation===
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| Heparin is required after thrombolysis to prevent re-thrombosis since all thrombolytics are short acting. Any patient receiving PCI requires heparinzation to prevent thrombosis during the procedure. There is minimal to no benefit for heparin in NSTEMI patients who are not receiving immediate PCI.<ref>Andrade-Castellanos, CA et al. Heparin versus placebo for non-ST elevation acute coronary syndromes. Cochrane Database Syst Rev. 2014 Jun 27;(6):CD003462. PMID: 24972265</ref>
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| #[[Heparin]] (UFH)
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| #*Bolus 60U/kg (max: 4000U) followed by 12U/kg/h (max: 1000U/h)
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| #*Titrate to PTT 1.5-2.5 x control
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| #[[LMWH]]
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| #*<75yo with serum creatinine < 2.5mg/dL (men) or < 2.0mg/dL (women):
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| #**30mg IV bolus followed by 1mg/kg SC q12h
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| #*≥ 75yo
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| #**0.75mg/kg SC q12h
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| #*CrCl < 30 mL/min
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| #**1mg/kg SC QD
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| #[[Fondaparinux]]
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| #*creatinine < 3.0mg/dL:
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| #**2.5mg IV bolus then 2.5mg SC QD started 24hr after bolus
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| #*Monitor anti-Xa levels
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| #[[Bivalirudin]]
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| #*0.75mg/kg IV bolus followed by 1.75mg/kg/h
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| #*CrCl < 30 mL/min
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| #**0.75mg/kg IV bolus followed by 1.0mg/kg/h
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| ==Special Scenarios==
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| ===[[Cardiac Arrest]] and STEMI===
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| *Consider [[therapeutic hypothermia]] cooling protocol for patients with documented cardiac arrest felt to be caused by lethal cardiac rhythm (e.g. [[ventricular fibrillation]])
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| *Patients with cardiac arrest and ST elevation at any point, even if resolved, should still under go emergent coronary angiography<ref>2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science [http://circ.ahajournals.org/content/122/18_suppl_3/S768.full PDF]</ref>
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| ===Rescue PCI===
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| *Failed reperfusion: consider if repeat ECG 90 minutes after infusion fails to show reduction of elevated ST segments by 50%
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| *Recurrent significant ST elevation following successful lysis
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| *Persistent hemodynamically unstable arrythmias, persistent ischemic symptoms, or worsened cardiogenic shock
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| *Even in those with successful reperfusion, its reasonable to do angiography within the index hospitalization, even within hours of thrombolytic therapy
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| ===Post-STEMI complications===
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| *Cath site hematoma
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| *Heart failure or cardiogenic shock
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| **Hemodynamic support, consider norepinephrine or dobutamine
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| **Mechanical support e.g. balloon pump or Impella, usually placed in cath lab
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| *Ventricular tachycardia or ventricular fibrillation --> if sustained and > 48 hours after STEMI may need ICD
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| *Pericarditis, < 1 week from STEMI --> treat with high dose aspirin, avoid NSAIDs
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| *Bradycardia, if AV nodal involvement, rarely responds to atropine, likely will require pacing
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| *Free wall or ventricular septal rupture
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| *Dressler's syndrome, > 1 week post MI
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| ==Disposition==
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| *Admit direct to cath lab
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| *If not at tertiary care center consider tPA depending transfer time and transfer to cardiac cath lab center
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| ==See Also==
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| *[[Acute Coronary Syndrome (Main)]]
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| *[[NSTEMI]]
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| *[[ACS - Anatomical Correlation]]
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| *[[Myocardial Infarction Complications]]
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| *[[ST segment elevation]]
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| *[[Sgarbossa's criteria]]
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| *[[STEMI equivalents]]
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| *[[STEMI mimics]]
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| ==External Links==
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| *[http://www.mdcalc.com/timi-risk-score-for-stemi/ MDCalc - TIMI Risk Score for STEMI]
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| *[http://www.outcomes-umassmed.org/grace/acs_risk/acs_risk_content.html GRACE score - ACS risk model]
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| *[http://http://myheart.net/articles/stemi/ STEMI heart attack]
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| *[http://circ.ahajournals.org/content/127/4/e362.full ACC-AHA guidelines for STEMI 2013]
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| *[http://emcrit.org/podcasts/left-bundle-branch-block EMCrit LBBB]
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| ==References==
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| <references/>
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| [[Category:Cardiology]]
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