Non-STEMI that need Cath Lab NOW!; Smith at SMACC.

NON-STEMI THAT NEED THE CATH LAB NOW

Stephen W. SmithAssociate Professor of EM

Hennepin County Med CenterUniversity of MN

4 days ago

4 days ago presenting ECG - pain free

46 yo male

2.5, 420 ,2 = 27.11

25 min later

Side by Side

Missed, ruled in with max trop I = 130 ng/ml. Cath next day.

Proximal LAD occlusion, convalescent anterior WMA

42 yo with chest pain

Computerized QTc = 388

QTc = 388, STE60V3 = 4 mm, RAV4 = 32 mm: formula = 17.24 (<< 23.4)

Lateral AMI confirmed by reciprocal depression in lead IIIFirst Diagonal occlusion — NOT “inferior ischemia”

47 yo woman with CP

RCA occlusion, but not STEMI

60 yo woman with Chest Pain

Prehospital ECG: STE at 60 ms after the J-point in lead V3 = 2.0 mm,  QTc = 422 ms, R-wave amplitude in lead V4 = 4mm: formula =  25.99 (> 23.4)

Referred for STEMI from clinic

First is outside ECG, 2nd is ED: QTc = 392. 392, 2, 12 = 21.61

390, 2, 11 = 21.8

Male in 60s with chest pain

Chest pain, resolved

Still no chest pain, but trop slightly positive, repeat ECG

Young woman, crushing and stabbing CP

Initial trop 6.1 (+), serial ecgs unchanged, no WMA, dx myocarditis. No MRI, no rub, no effusion, so diagnosis not certain

24 yo woman, heavy EtOH and vomiting night before, now CP

After Cath

Saw this in a pile of ECGs

First trop neg. 2nd trop I returns at 4 hours = 3.8 ng/ml. Repeat ECG:

Formula = 24.5, peak trop 100, 40% LVEF

“Heartburn”

25 yo male with chest pain

Texted to me during meeting

50 yo male with refractory chest pressure

Down-Up T-waves

K = 2.3

61 yo with chest pain

Right sided ECG:  (V1-V6 are really V1R through V6R, on the right chest):

Chest pain

Isolated Posterior STEMI

51 yo woman with 1 hr of typical Chest Pain.

Old ECG

No emergent PCINext day Troponin 72, CK 3200. Cath next day: culprit lesion 2nd OM. Stented. Convalescent echo: posterior akinesis, 55%

65 year-old with 2 hours of CP. No h/o MI.

previous

V3

V6

V5

V4

RVLVRA

A

RVLV

ADIAPHRAGM

V9 V8V7

5th intercostal space

56 yo male with 2 hours of typical CP

Given tPA. Reperfused, troponin 5.4, posterior WMA. Later angio with 99%

OM-1, stented.

50 yo m with chest pain

Formula, with QTc 418, = 25.85. 4 hours later:

Becoming hypotensive. To cath lab. Proximal LAD occlusion. Much myocardial loss, but survived.

Elderly woman with CP

Elderly woman with chest pain--12 min later

Chest Pain

75 yo with chest pain

60 yo with chest pain uncontrolled by medical Rx

First trop I 0.063. Repeat unchanged, but pain not controlled. Taken for immediate PCI: 95% LAD proximal to large D1 with

thrombus/TIMI-II

Contrast

Chest Pain

Early repol, 2.5, 401, 21 = 19.8

Woman in 40’s with chest pain

Formula (but Q wave V3): 2, 442, 8.5 = 25.64

Previous 2 cases, compare and contrast

58 yo with 1 hour of Chest pain

SyncopeCath lab activated

Subtle Inferior MI?

40 yo diagnosed with GERD 5d ago

ClinicECG

Bedside Ultrasound

32 yo male with CP, cough, ST (cont’d next slide)

37 minutes

1st ECG that you just saw

After Cath and PCI

Same case: 24 hour ECG