Amy Gutman MD EMS Medication Director

STEMI & PCI Overviews 3 Case Reviews All cases occurred between 2007 & 2010 (blinded)

STEMI responsible for 500,000 hospital admissions & 75,000 deaths annually Thrombosis (clots form coronary artery plaques) is most common cause of STEMI Early reperfusion reduces mortality and morbidity by “rescuing” heart muscle from ischemia and necrosis

Door-to-balloon time for primary PCI of <90 mins Annual operative volumes of >400 procedures Recommendation that elective PCI not be performed at facilities without onsite cardiac surgery facilities to perform “rescue” CABG

Acute Coronary Syndrome (ACS) STEMI NSTEMI STEMI NSTEMI Cardiac Markers () (Troponin, CKMB) Myocardial Infarction STEMI Non-STEMI STEMI Non-STEMI PCI vs Fibrinolysis Stress Test, Delayed Cath Lab Unstable Angina - +

STEMIs due to blockage of a coronary artery If treated within 90 mins, >25% of STEMIs regain complete function of the heart muscle NSTEMIs due to sudden narrowing of a coronary artery with preserved but diminished cardiac blood flow Pts with NSTEMI presumed to have unstable angina, & do not necessarily require acute opening of a vessel Anticoagulation & antiplatelet agents prevent narrowed artery from occluding, followed by stress testing & possibly delayed (1-3 days) coronary angiography If NSTEMI with continued CP, will proceed to catherization lab

Fibrinolysis (“Clot Busters”) Fibrinolysis (“Clot Busters”) 50-60% achieve normal arterial flow 30% recurrence of ischemia 3-5% re-infarction 1-4% hemorrhagic CVA 20-30% contraindications for thrombolytics Active internal bleeding, recent stroke, uncontrolled HTN PCI PCI 95% normal arterial flow (TIMI 3) 10-15% recurrence of ischemia 1-3% re-infarction <1% hemorrhagic CVA Few contraindications

1.Patient Brought To Cath Lab 2.Cath wire threaded through femoral or brachial artery 3.Wire passes through aorta & guided into coronary arteries

RCA Blockage Before Stenting RCA Opened After Stenting

Wall AffectedST Segment Elevation Artery SeptalV1, V2LAD AnteriorV3, V4LAD AnteroseptalV1, V2, V3, V4LAD AnterolateralV3, V4, V5, V6, I, aVLLAD, Circumflex InferiorII, III, aVFRCA, Circumflex LateralI, aVL, V5, V6Circumflex

Wall AffectedST Segment Elevation Artery SeptalV1, V2LAD AnteriorV3, V4LAD AnteroseptalV1, V2, V3, V4LAD AnterolateralV3, V4, V5, V6, I, aVLLAD, Circumflex InferiorII, III, aVFRCA, Circumflex LateralI, aVL, V5, V6Circumflex

EMTs & Paramedics Recognized for Outstanding Patient Care

42 yo WM with CC of “Chest Pain” PMH: CAD Allergies: Percocet TX: IV, O2, Monitor; ASA, NTG

Outstanding documentation & performance of ACLS protocols!

Admitted 7/14 with V2–V6 STEMI & VFib arrest <30 mins to cath lab from prehospital call Anterior – lateral STEMI progressed to inferior – anterior – lateral ischemia just prior to cardiac cath 100% LAD occlusion opened up with stent Discharged on 7/17 with normal heart function

55 yo Black Male CC: Chest pain, generalized weakness, fatigue PMH: None Medications: None Allergies: None RX: IV, O2, Monitor, ASA

Right ventricular infarction complicates 40% of I-STEMIs Isolated RV infarction extremely uncommon Preload sensitive due to poor RV contractility Develop rapid & severe hypotension from nitrates or preload-sensitive agents Hypotension in right STEMI treated with fluids Nitrates contraindicated

ST elevation V1 (only standard lead looking directly at RV) ST elevation in lead III > II Lead III more “right facing” than lead II & more sensitive to injury current Magnitude of ST elevation in V1 > ST elevation in V2 ST segment in V1 isoelectric & ST segment in V2 depressed Combination of ST elevation in V1 & ST depression in V2 highly specific for RV MI Right ventricular infarction confirmed by ST elevation in right- sided leads (V3R-V6R)

Place leads V1-6 in a mirror- image position on the right side of the chest Leave V1 & V2 in usual positions & transfer leads V3- 6 to right side of chest (i.e. V3R to V6R). Most useful lead is V4R, obtained by placing V4 lead in 5th RICS MCL ST elevation in V4R has sensitivity of 88%, specificity of 78% in diagnosis of RV MI

Good Documentation of HPI & treatment Excellent justification of why NTG appropriately not given Followed ALS Protocols

3 Vessel Disease: Circumflex Left Anterior Descending Right Coronary Artery Important Point: This young patient with no prior disease was a walking “time bomb” who likely would have died or had severely decreased quality of life if he had not gotten to a cath lab immediately

Admitted on 12/14 Prehospital notification of anterior STEMI Door to Balloon 22 mins (4 mins in ED for CXR EKG to r/o aortic dissection) RCA and proximal LAD stents Discharged 12/17 with normal heart function

43 yo W Male CC: Chest pain that “started 20 minutes ago” PMH: HTN, NIDDM Great documentation of HPI, Exam, EKG findings, & Treatment & Change in Symptoms post Treatment

Hypotension post NTG makes you think of what type of infarction? What is the immediate treatment?

Stent of 100% occluded RCA Discharged from hospital 3 days post catherization Diagnosed with inferior MI Post cath echo showed minimal heart damage

Recognition, pre-notification, & early cardiac catherization are keys to improving survival in STEMI patients These patients walked out of the hospital who would have otherwise died due to outstanding care provided by the EMTs & paramedics