The STEMI Myth: Coronary Occlusion and High-Risk EKGs that ...

[Pages:6]Charles Bruen, MD Outline

The STEMI Myth and High-Risk ECGs

Regions Intermal Medicine SlideMarch 21, 2016

The STEMI Myth: Coronary Occlusion and High-Risk EKGs that Require Reperfusion

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Cardiology

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Critical Care

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ECMO

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Beware dichotomies

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Nothing in biology follows rules like 1 vs 2 mm

Dichotomies are false

ACC/AHA want you to believe STEMI vs NSTEMI

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Algorithms make people stupid

Thrombi are active process

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forming/dissolving

Always changing

Occlusion vs Obstruction

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STEMI = coronary occlusion

NSTEMI = MI without occlusion/subendocardial ischemia

How sensitive STE for occlusion

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70-75%

Even worst after arrest

Ruled in NSTEMI

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25% with occluded infarct, worse outcomes

High risk NSTEMI

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There is a spectrum from NSTEMI to STEMI

Especially the NSTEMI with high-risk features

Reperfusion depends not on mm criteria but is there a life threatening thrombus in vessel?

CharlesTBhreureenis, Ma DspectrumThferoSmTENMSITMEMytIhtoanSdTHEMighI -Risk ECGs OuEtlsinpeecially the NSTEMI with high-risk features

Regions Intermal Medicine SlideMarch 21, 2016

Reperfusion depends not on mm criteria but is there a life threatening thrombus in vessel?

Conditions

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Non diagnostic ECG, +troponin and ongoing pain

Isolated typical angina, refractory

Subtle ischemic STE

Hyperacute T waves

STEMI Mimics

Cardiologists not familiar with

Dynamic ST segments and T waves

Indicates a thrombus that is propagating and lysing

High risk

STEMI Equivalent

Active cath lab -- acute thrombosis in a coronary artery causing Slide 11 persistent ischemia that is refractory to medical management

Optimal timing for NSTEMI (EUSocCard)

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Patients at very high risk

Refractory angina

Severe heart failure

Life threatening ventricular arrythmias

Hemodynamic instability

"Were not included in RCTs, in order not to withhold potentially life-saving treatment"

"Such patients may have evolving MI and should be taken for invasive evaluation ( ................
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