1. Symptoms of Ischemic Heart Disease
Patient history is often diagnostic.
Chest discomfort with variable characteristics
-pain, pressure, tightness, crushing, squeezing,
stabbing, choking sensations
-substernal origin with variable radiation to arm,
neck, or jaw
-especially when associated with exertion
-duration in minutes (5-30), not seconds or hours
Associated symptoms or anginal equivalents (dyspnea, nausea/vomiting, indigestion, diaphoresis, syncope)

2. Physical Findings in Ischemic Heart Disease
Physical exam is most useful to rule out differential diagnoses and often is normal in ischemic heart disease.
Diaphoresis or other sign of hypoperfusion
Congestive signs: JVD, rales, S3
Abnormal heart sounds: S3, new murmur
Hypoxia
Arrhythmias, especially ventricular, although must rule out MI with new onset afib

3. Etiologies of Ischemia
Atherosclerosis
Congenital coronary anomalies
Coronary arteritis
Radiation therapy
Cocaine
Aortic stenosis
Hypertrophic cardiomyopathy

4. Differential Diagnosis of Chest Pain
Acute coronary syndromes
Other cardiovascular causes
Aortic dissection
Aortic stenosis
Pericarditis
Myocarditis
Hypertrophic cardiomyopathy
Aortic regurgitation
Mitral valve prolapse
Severe anemia
Pulmonary causes
Pulmonary embolus
Pneumothorax
Pleurisy
Gastrointestinal causes
Esophageal spasm or reflux
Esophageal rupture
Peptic ulcer disease
Biliary or pancreatic disease
Musculoskeletal causes
Costochondritis
Muscle strain
Thoracic outlet syndrome
Degenerative spine disease
Psychogenic causes
Anxiety/depression/panic attack
Psychosis
Secondary gain
IT IS IMPERATIVE TO ASSESS FOR POSSIBLE LIFE-THREATENING
ALTERNATIVE DIAGNOSES, SUCH AS AORTIC DISSECTION, PE,
TENSION PNEUMOTHORAX, OR RUPTURED VISCUS..

5. Patient Education for Early Recognition and Response to Chest Pain
Healthcare providers should instruct patients previously prescribed nitroglycerin (NTG) on use for chest discomfort or pain and to call if symptoms do not improve or worsen 5 minutes after ONE sublingual NTG dose*.
(* Nitroglycerin Dose: 0.4 mg sublingually)
STEMI: ACC/AHA guidelines at

6. Prehospital Chest Pain Evaluation
and Treatment
Prehospital EMS providers should administer 162 to 325 mg of aspirin (chewed) to chest pain patients suspected of having STEMI unless contraindicated or already taken by the patient. Although some trials have used enteric-coated aspirin for initial dosing, more rapid buccal absorption occurs with non–enteric-coated formulations.
It is reasonable for all dispatchers to advise patients without a history of aspirin allergy who have symptoms of STEMI to chew aspirin (162 to 325 mg) while awaiting arrival of prehospital EMS providers. Although some trials have used enteric-coated aspirin for initial dosing, more rapid buccal absorption occurs with non–enteric-coated formulations.
STEMI: ACC/AHA guidelines at

7. Hospital fibrinolysis: Onset of symptoms of STEMI
Options for Transport of Patients With STEMI and Initial Reperfusion Treatment
Hospital fibrinolysis:
Door-to-Needle
within 30 min.
Not PCI
capable
Call 9-1-1
Call fast
EMS on-scene
Encourage 12-lead ECGs.
Consider prehospital fibrinolytic if capable and EMS-to-needle within 30 min.
Onset of symptoms of STEMI
9-1-1
EMS
Dispatch
EMS Triage Plan
Inter-Hospital
Transfer
PCI
capable
GOALS 5
min. 8
min.
EMS Transport
Patient
EMS
Prehospital fibrinolysis
EMS-to-needle
within 30 min.
EMS transport
EMS-to-balloon within 90 min.
Patient self-transport
Hospital door-to-balloon
within 90 min.
Dispatch
1 min.
STEMI: ACC/AHA guidelines at

8. Emergent Diagnostic Testing
12-lead EKG
Cardiac enzymes (CPK, CKMB, Troponin)
CBC
Basic or comprehensive chemistry panel
Coagulation studies
D-Dimer
PA and lateral CXR

9. Cardiac Biomarkers in ACS
CPK (creatine phosphokinase) – enzyme common in skeletal, smooth, and cardiac muscle as well as brain and kidney; three isoenzymes:
MB – cardiac and some skeletal muscle
MM – primarily in skeletal muscle
BB – primarily in brain and kidney
Troponin – protein that regulates interaction of actin and myosin
Troponin C – common to skeletal and cardiac muscle
Troponin T and I – diagnostic & prognostic value in myocardial injury
Cardiac biomarkers provide the most accurate diagnosis of acute myocardial injury and are the reference standard for the diagnosis of MI.

10. Other Biomarkers
Nonspecific serum markers – elevated in MI but non-specific
AST (aspartate aminotransferase)
LDH (lactate dehyrogenase)
Myoglobin – rapid release and return to baseline but
elevated with muscle infarct and renal failure
Newer biomarkers – predictive of risk in ACS but not commonly used for this purpose
BNP (B-type natriuretic peptide)
CRP (C-reactive protein)

11. Cardiac Biomarkers in ACS
100 50
Cardiac troponin-no reperfusion 20
Cardiac troponin-reperfusion
Multiples of the URL
CKMB-no reperfusion 10
CKMB-reperfusion 5 2
Cardiac biomarkers in ST-elevation myocardial infarction (STEMI).Typical cardiac biomarkers that are used to evaluate patients with
STEMI include the MB isoenzyme of CK (CK-MB) and cardiac specific troponins. The horizontal line depicts the upper reference limit (URL)
for the cardiac biomarker in the clinical chemistry laboratory. The URL is that value representing the 99th percentile of a reference control group without STEMI. The kinetics of release of CK-MB and cardiac troponin in patients who do not undergo reperfusion are shown in the solid green and red curves as multiples of the URL. Note that when patients with STEMI undergo reperfusion, as depicted in the dashed green and red curves, the cardiac biomarkers are detected sooner, rise to a higher peak value, but decline more rapidly, resulting in a smaller area under the curve and limitation of infarct size. Modified with permission from Alpert et al. J Am Coll Cardiol 2000;36:959 and Wu et al. Clin Chem 1999;45:1104.
Upper reference limit 1
Days After Onset of STEMI
URL = 99th %tile of
Reference Control Group
Alpert et al. J Am Coll Cardiol 2000;36:959.
Wu et al. Clin Chem 1999;45:1104.
STEMI: ACC/AHA guidelines at

12. Cardiac Biomarkers in STEMI
Troponins- Now the Gold Standard!
Rise after 3-6 hours
Negative Troponin within 6 hours of onset of S&S rules out the MI
Peaks at about 20 hours
May be raised for 14 days

13. Cardiac Biomarkers: Troponin T & I
Troponin I
90% sensitivity for MI 8 hours after onset of S&S and 95% specificity
Negative rules out MI
Obtain two negative troponin values hours apart
Normally exceedingly low
Even a small elevation indicates myocardial damage
Troponin T
Levels may help to stratify risk
Less specific than Troponin I
Increased in angina
Increased in chronic renal failure
Highly sensitive for detecting myocardial ischemia

14. Troponin I Levels and Mortality in Patients with NSTEMI8 6
% Mortality at 42 Days 4 2
As illustrated in this analysis by Antman from the TIMI IIIB study, the greater the troponin level in patients who present with NSTE-ACS, the greater the risk of future mortality. Note though that even small elevations of troponin are associated with significantly increased risk. 0-
<0.4
0.4-
<1.0
1.0-
<2.0
2.0-
<5.0
5.0-
<9.0
>9.0
Troponin I Level
Adapted with permission from Antman EA, Tanasijevic MJ, Thompson B, et al. Cardiac-specific troponin I levels to predict the risk of mortality in patients with acute coronary syndromes. N Engl J Med. 1996;335: Copyright © 1996, Massachusetts Medical Society. All rights reserved.

15. EKG Changes in STEMI
ST elevation of 1mm or more in the limb leads or of 2mm or more in precordial leads is significant.
The pattern of ST elevation indicates the location of infarct and the involved coronary artery.
Dynamic changes in the ST segment or the T wave represent an evolving infarct.
A new left bundle branch block is significant.

16. EKG Changes: Ischemia T-wave inversion (flipped T)
ST segment depression
T wave flattening
Biphasic T-waves

17. EKG Changes: Injury
ST segment elevation of greater than 1mm in at least 2 contiguous leads
Heightened or peaked T waves
Directly related to portions of myocardium rendered electrically inactive

18. EKG Changes: Infarct Significant Q-wave where none previously existed
Impulse traveling away from the positive lead
Necrotic tissue is electrically dead
Criteria for Q-wave significance
Depth of Q wave should be 25% the
height of the R wave
Width of Q wave is 0.04 secs
Diminished height of the R wave

19. Dynamic EKG Changes Baseline Hyperacute T wave ST elevation
Inverted T wave
Q wave
1 Year

20. EKG Changes: Anterior/Septal MI
ST changes: V1,V2, V3, V4
Culprit Vessel: LAD

21. EKG Changes: Inferior MI
ST Changes: II, III, aVF
Culprit Vessel: RCA

22. EKG Changes: Lateral MI
ST Changes: I, aVL, V5, V6
Culprit Vessel: Circumflex

23. EKG Changes: Posterior MI
ST Changes: Reciprocal in V1, V2
Culprit Vessels: RCA or Cx

24. Summary of EKG Changes Lat: I, aVL, V5, V6 Ant/Septal: V1, V2, V3, V4
Inf: II, III, aVF Post: Rec V1, V2

25. EKG Changes: Summary

26. Non-invasive Diagnostic Testing
May be considered only after acute MI
or other emergent process has been ruled out.
Echocardiography
Exercise stress testing
Pharmacologic stress testing
-Adenosine
-Persantine
Nuclear stress testing
CTA
Cardiac MRI

27. Acute Pharmacologic Interventions in STEMI
Oxygen
Nitroglycerin
Analgesia (Morphine)
Aspirin
Beta Blockers
MONA
MONAB

28. Oxygen
Supplemental oxygen should be administered to patients with arterial oxygen desaturation (SaO2 < 90%).
It is reasonable to administer supplemental oxygen to all patients with uncomplicated STEMI during the first 6 hours. I
IIa
IIb
III
STEMI: ACC/AHA guidelines at

29. Nitroglycerin
Patients with ongoing ischemic discomfort should receive sublingual NTG (0.4 mg) every 5 minutes for a total of 3 doses, after which an assessment should be made about the need for intravenous NTG.
Intravenous NTG is indicated for relief of ongoing ischemic discomfort that responds to nitrate therapy, control of hypertension, or management of pulmonary congestion.
STEMI: ACC/AHA guidelines at

30. Nitroglycerin Nitrates should not be administered to patients with:
Nitrates should not be administered to patients who have received a phosphodiesterase inhibitor for erectile dysfunction within the last 24 hours (48
hours for tadalafil/Cialis©).
systolic pressure < 90 mm Hg or ≥ to 30 mm Hg below baseline
severe bradycardia (< 50 bpm)
tachycardia (> 100 bpm) or
suspected RV infarction.
STEMI: ACC/AHA guidelines at

31. Analgesia
Morphine sulfate (2 to 4 mg intravenously with increments of 2 to 8 mg intravenously repeated at 5 to 15 minute intervals) is the analgesic of choice for management of pain associated with STEMI.
STEMI: ACC/AHA guidelines at

32. Aspirin
Aspirin should be chewed by patients who have not taken aspirin before presentation with STEMI. The initial dose should be 162 mg (Level of Evidence: A) to 325 mg (Level of Evidence: C)
Although some trials have used enteric-coated aspirin for initial dosing, more rapid buccal absorption occurs with non–enteric-coated formulations.
STEMI: ACC/AHA guidelines at

33. STEMI: ACC/AHA guidelines at www.acc.org
NSAIDs
NSAIDS (except ASA) should not be given during the acute hospitalization due to increased risk of mortality, reinfarction, HTN, heart failure, and myocardial rupture.
This restriction includes both nonselective as well as COX-II forms of NSAIDs.
STEMI: ACC/AHA guidelines at

34. Beta-Blockers
Oral beta-blocker therapy should be administered promptly to those patients without a contraindication, irrespective of concomitant fibrinolytic therapy or performance of primary PCI.
It is reasonable to administer intravenous beta-blockers promptly to STEMI patients without contraindications, especially if a tachyarrhythmia or hypertension is present.
STEMI: ACC/AHA guidelines at

35. General Considerations
Primary PCI for STEMI:
General Considerations
Patient with STEMI (including posterior MI) or MI with new or presumably new LBBB
PCI of infarct artery within 12 hours of symptom onset
Balloon inflation within 90 minutes of presentation
Skilled personnel available (individual performs > 75 procedures per year)
Appropriate lab environment (lab performs > 200 PCIs/year of which at least 36 are primary PCI for STEMI)
Cardiac surgical backup available
STEMI: ACC/AHA guidelines at

36. Specific Considerations
Primary PCI for STEMI:
Specific Considerations
Medical contact–to-balloon or door-to-balloon should be within 90 minutes.
PCI preferred if > 3 hours from symptom onset.
Primary PCI should be performed in patients with severe congestive heart failure (CHF) and/or pulmonary edema (Killip class 3) and onset of symptoms within 12 hours.
STEMI: ACC/AHA guidelines at

37. Times to remember 10 minutes time for ED eval
30 minutes door to needle
90 minutes door to balloon
3 hours (symptom onset) Fibrinolytic vs. PCI therapy
12 hours (symptom onset) Time limit for revascularization therapies as supported by data

38. STEMI: ACC/AHA guidelines at www.acc.org
Caveat on Reperfusion
Given the current literature, it is not possible to say definitively that a particular reperfusion approach is superior for all pts, in all clinical settings, at all times of day.
The main point is that some type of reperfusion therapy should be selected for all appropriate pts with suspected STEMI.
The appropriate & timely use of some reperfusion therapy is likely more important than the choice of therapy.
STEMI: ACC/AHA guidelines at

39. STEMI: ACC/AHA guidelines at www.acc.org
Caveat on Reperfusion
The medical system goal is rapid recognition and treatment of patients with STEMI such that either:
1. Door-to-needle time for initiation of fibinolytic therapy
can be achieved within 30 miutes OR
2. Door-to-balloon time for PCI can be kept within 90
minutes.
STEMI: ACC/AHA guidelines at

40. Maintenance Management of the Patient after MI
Aspirin
Plavix
Beta Blocker
ACE inhibitor/ARB
Statin therapy

41. Aspirin
A daily dose of aspirin (initial dose of 162 to 325 mg orally; maintenance dose of 75 to 162 mg) should be given indefinitely after STEMI to all patients without a true aspirin allergy.
STEMI: ACC/AHA guidelines at

42. Thienopyridines (Plavix)
In patients for whom PCI is planned, clopidogrel (Plavix) should be started and continued:
≥ 1 month after bare-metal stent
≥ 3 months after sirolimus-eluting stent
≥ 6 months after paclitaxel-eluting stent
Up to 12 months in absence of high risk for bleeding.
STEMI: ACC/AHA guidelines
Duration of Plavix use varies among interventional cardiologists.
Use of generic Plavix was strongly discouraged,
but the generic form is no longer available.

43. Thienopyridines (Plavix)
2007 STEMI guidelines now include long-term use of Plavix regardless of reperfusion therapy (ie-fibrinolysis, PCI, or neither):
Plavix 75mg po daily (LOE A) for at least 14 days (LOE B) or one year if patients under 75 years of age (LOE C).
Plavix should be held for 5-7 days prior to to CABG.
STEMI: ACC/AHA guidelines

44. Maintenance Management
Beta blockers should be continued indefinitely in all patients who have no known contra- indications.
ACE inhibitor (or ARB) if necessary should be continued indefinitely in all patients post MI.
Aggressive lipid management with a statin should be initiated promptly and continued.