“STEMI” Without the STE: Non-Traditional Predictors of Acute Coronary Occlusion Amal Mattu, MD, FAAEM, FACEP Professor and Vice Chair of Academic Affairs Department of Emergency Medicine University of Maryland School of Medicine [email protected]
“STEMI” Without the STE:
Non-Traditional Predictors of Acute Coronary Occlusion
Amal Mattu, MD, FAAEM, FACEP
Professor and Vice Chair of Academic Affairs
Department of Emergency Medicine
University of Maryland School of Medicine
ACO Without the STE:
Non-Traditional Predictors of Acute Coronary Occlusion
Amal Mattu, MD, FAAEM, FACEP
Professor and Vice Chair of Academic Affairs
Department of Emergency Medicine
University of Maryland School of Medicine
Case
• 45 yo M presents with chest pain
– Pain associated with nausea and sweats
– Hx/o DM, htn, smokes 1 ppd
– ECG...
Case
Case
• Emergency physician is residency trained, ABEM-certified
Case
• Emergency physician is residency trained, ABEM-certified
– 1:10 am: Patient treated with ASA, SL NTG, morphine
Case
• Emergency physician is residency trained, ABEM-certified
– 1:10 am: Patient treated with ASA, SL NTG, morphine
– 2:15 am: pain persists, SL NTG #3
Case
• Emergency physician is residency trained, ABEM-certified
– 1:10 am: Patient treated with ASA, SL NTG, morphine
– 2:15 am: pain persists, SL NTG #3
– 3:30 am: pain persists, TN mildly elevated
• Repeat ECG ~ unchanged
• NTG drip
• Hospitalist paged to admit
Case
• Emergency physician is residency trained, ABEM-certified
– 4:30 am: pain persists, repeat ECG unchanged
• Hospitalist (by phone) recommends cardiology consult
Case
• 5:00 am: patient develops hypotension
– Cardiology consulted
Case
• 5:00 am: patient develops hypotension
– Cardiology consulted
• Cardiology arrives at 6:05 am...
Case
• 5:00 am: patient develops hypotension
– Cardiology consulted
• Cardiology arrives at 6:05 am...as the patient loses pulses
Case
• 5:00 am: patient develops hypotension
– Cardiology consulted
• Cardiology arrives at 6:05 am...as the patient loses pulses
• Resuscitation attempts are unsuccessful
– Pronounced dead at 6:45 am
Case• Lawsuit filed
Case
• Was this a missed “STEMI”?
Case
• Was this a missed “STEMI”?
• Was this a missed ACO?
ACO, OMI, NOMI
• We are mainly interested in identifying ACOs in order to initiate acute reperfusion therapy (PCI or lytics)
ACO, OMI, NOMI
• We are mainly interested in identifying ACOs in order to initiate acute reperfusion therapy (PCI or lytics)
• Problem: STE is just a surrogate marker for ACO
ACO, OMI, NOMI
• STEMI vs. Non-STE-ACS is a flawed concept
ACO, OMI, NOMI
• STEMI vs. Non-STE-ACS is a flawed concept
– 10-15% of patients with ACS Sx’s and STE rule OUT for ACO
ACO, OMI, NOMI
• STEMI vs. Non-STE-ACS is a flawed concept
– 10-15% of patients with ACS Sx’s and STE rule OUT for ACO
– Up to 40% of patients with ACS Sx’s and ACOs do NOT have STE
• These patients typically get cath/PCI after significant delay
ACO, OMI, NOMI
• Increasing support to replace STEMI vs. Non-STE-ACS with OMI vs. NOMI
• OMI (ACO) needs emergent cath
• NOMI does not
ACO, OMI, NOMI
• Increasing support to replace STEMI vs. Non-STE-ACS with OMI vs. NOMI
• OMI (ACO) needs emergent cath
• NOMI does not
• Are there ECG findings beyond STE that predict ACO?
What are the ECG indications for emergent reperfusion?
What are the ECG indications for emergent reperfusion?
• Concerning Sx’s plus...
– STE in contiguous leads (usual guidelines)
What are the ECG indications for emergent reperfusion?
• Concerning Sx’s plus...
– STE in contiguous leads (usual guidelines)
– Posterior STEMI
Isolated PMI
Anteroseptal ischemia or posterior MI?
Isolated PMI — Posterior Leads
Isolated PMI — Posterior Leads
Isolated PMI
Isolated PMI
What are the ECG indications for emergent reperfusion?
• Concerning Sx’s plus...
– STE in contiguous leads (usual guidelines)
– Posterior STEMI
– Non-STE-ACS with...
• Refractory ischemia (frequent litigation)
• Developing acute heart failure
• Electrical instability
• Hemodynamic instability
(2014 ACC/AHA guidelines-–cath w/i 2 hrs, Class IA)
Courtesy Haney Mallemat, MD
What are the ECG indications for emergent reperfusion?
• Increasing literature but not yet in the U.S. guidelines
What are the ECG indications for emergent reperfusion?
• Increasing literature but not yet in the U.S. guidelines
– LBBB with Sgarbossa criteria (& modified)
– Pacers with Sgarbossa criteria (& modified)
– de Winter T-waves
– STE in aVR with diffuse STD
Normal LBBB
Normal LBBBRule of appropriate discordance
(true for pacemakers also)
AMI in LBBBSgarbossa, et al. NEJM 1996
A B C
A -- Concordant ST elevation > 1 mm in any lead (very specific)
B -- Concordant ST depression > 1 mm in V1, V2, or V3 (very specific)
C -- Discordant ST elevation > 5 mm (less specific)
AMI in LBBBSgarbossa, et al. NEJM 1996
A B C
A -- Concordant ST elevation > 1 mm in any lead (very specific)
B -- Concordant ST depression > 1 mm in V1, V2, or V3 (very specific)
C -- Discordant ST elevation > 5 mm (less specific)
LBBB with ACO
Courtesy Bill Brady, MD
Courtesy Bill Brady, MD
“Sgarbossa A”
LBBB with ACO
“Sgarbossa B”
85 yo woman with CPCourtesy Dr. Eric Klotz
“Sgarbossa A & B”Courtesy Dr. Eric Klotz
Revised Sgarbossa “C”(
• Sgarbossa criteria “C” is not specific enough
C
Revised Sgarbossa “C”(Smith, et al. Ann Emerg Med 2012)
• Maybe the ratio of the ST deviation : size of the QRS is more important (> 25%)
C
Cai, et al. Amer Heart J 2013
Revised Sgarbossa “C”(Smith, et al. Ann Emerg Med 2012)
Cai, et al. Amer Heart J 2013
Revised Sgarbossa “C”(Validation: Am Heart J 2015)
Pt. with LBBB & CPIIIIII
aVRaVLaVF
V1V2V3
V4V5V6
V1
SANCHEZ, CAMILAID:005665334
20-AUG-2014 12:50:36LAC-USC MEDICAL CENTER
Sinus bradycardiaLeft bundle branch blockAbnormal ECGNo previous ECGs available
25mm/s10mm/mV
40Hz8.0.1
12SL241 HDCID: 0
Referred by:Unconfirmed
BPM58
Vent. ratems
178PR interval
ms148
QRS durationms
QT/QTc480/471
1428
82P-R-T axes
12-NOV-1937 (76 yr)Female
Caucasian
Room:RESUSLoc:29
Option:1Technician: BOYCETest ind:
Page 1 of 1
SID: 82489 EID: EDT: ORDER:
Courtesy Dr. Paul Jhun
Pt. with LBBB & CPIIIIII
aVRaVLaVF
V1V2V3
V4V5V6
V1
SANCHEZ, CAMILAID:005665334
20-AUG-2014 12:50:36LAC-USC MEDICAL CENTER
Sinus bradycardiaLeft bundle branch blockAbnormal ECGNo previous ECGs available
25mm/s10mm/mV
40Hz8.0.1
12SL241 HDCID: 0
Referred by:Unconfirmed
BPM58
Vent. ratems
178PR interval
ms148
QRS durationms
QT/QTc480/471
1428
82P-R-T axes
12-NOV-1937 (76 yr)Female
Caucasian
Room:RESUSLoc:29
Option:1Technician: BOYCETest ind:
Page 1 of 1
SID: 82489 EID: EDT: ORDER:
Pt. with LBBB & CP
IIIIII
aVRaVLaVF
V1V2V3
V4V5V6
V1
SANCHEZ, CAMILAID:005665334
20-AUG-2014 12:50:36LAC-USC MEDICAL CENTER
Sinus bradycardiaLeft bundle branch blockAbnormal ECGNo previous ECGs available
25mm/s10mm/mV
40Hz8.0.1
12SL241 HDCID: 0
Referred by:Unconfirmed
BPM58
Vent. ratems
178PR interval
ms148
QRS durationms
QT/QTc480/471
1428
82P-R-T axes
12-NOV-1937 (76 yr)Female
Caucasian
Room:RESUSLoc:29
Option:1Technician: BOYCETest ind:
Page 1 of 1
SID: 82489 EID: EDT: ORDER:
Pt. with LBBB & CP
IIIIII
aVRaVLaVF
V1V2V3
V4V5V6
V1
SANCHEZ, CAMILAID:005665334
20-AUG-2014 12:50:36LAC-USC MEDICAL CENTER
Sinus bradycardiaLeft bundle branch blockAbnormal ECGNo previous ECGs available
25mm/s10mm/mV
40Hz8.0.1
12SL241 HDCID: 0
Referred by:Unconfirmed
BPM58
Vent. ratems
178PR interval
ms148
QRS durationms
QT/QTc480/471
1428
82P-R-T axes
12-NOV-1937 (76 yr)Female
Caucasian
Room:RESUSLoc:29
Option:1Technician: BOYCETest ind:
Page 1 of 1
SID: 82489 EID: EDT: ORDER:
S wave = 16 mm
Pt. with LBBB & CP
IIIIII
aVRaVLaVF
V1V2V3
V4V5V6
V1
SANCHEZ, CAMILAID:005665334
20-AUG-2014 12:50:36LAC-USC MEDICAL CENTER
Sinus bradycardiaLeft bundle branch blockAbnormal ECGNo previous ECGs available
25mm/s10mm/mV
40Hz8.0.1
12SL241 HDCID: 0
Referred by:Unconfirmed
BPM58
Vent. ratems
178PR interval
ms148
QRS durationms
QT/QTc480/471
1428
82P-R-T axes
12-NOV-1937 (76 yr)Female
Caucasian
Room:RESUSLoc:29
Option:1Technician: BOYCETest ind:
Page 1 of 1
SID: 82489 EID: EDT: ORDER:
S wave = 16 mm
ST deviation = 5 mm
Pt. with LBBB & CP
IIIIII
aVRaVLaVF
V1V2V3
V4V5V6
V1
SANCHEZ, CAMILAID:005665334
20-AUG-2014 12:50:36LAC-USC MEDICAL CENTER
Sinus bradycardiaLeft bundle branch blockAbnormal ECGNo previous ECGs available
25mm/s10mm/mV
40Hz8.0.1
12SL241 HDCID: 0
Referred by:Unconfirmed
BPM58
Vent. ratems
178PR interval
ms148
QRS durationms
QT/QTc480/471
1428
82P-R-T axes
12-NOV-1937 (76 yr)Female
Caucasian
Room:RESUSLoc:29
Option:1Technician: BOYCETest ind:
Page 1 of 1
SID: 82489 EID: EDT: ORDER:
S wave = 16 mm
ST deviation = 5 mm
ST deviation > 25% of the size of the S wave (5/16 > 25%)
LBBB…anything more?Courtesy Dr. Kristin McKee
LBBB…anything more?Courtesy Dr. Kristin McKee
LBBB…anything more?
Is the ST:S > 25%?
LBBB…anything more?
S wave = 20 mm
LBBB…anything more?
S wave = 20 mm
ST deviation = 9 mm
LBBB…anything more?
S wave = 20 mm
ST deviation = 9 mm
ST deviation > 25% of the size of the S wave (9/20 > 25%)
Case
Courtesy Adam Thompson, EMT-P
Case
Courtesy Adam Thompson, EMT-P
Case
Courtesy Adam Thompson, EMT-P
Case
S wave = 7 mm
Case
S wave = 7 mm
STE = 5 mm
Case
S wave = 7 mm
STE = 5 mm
STE > 25% of the size of the S wave (5/7 > 25%)
AMI with Pacers
Normal Pacemaker
“Sgarbossa A”Courtesy Dr. Jim Campagna
(New York)
“Sgarbossa B”Courtesy Dr. Santiago Harris
Handy Scanner for Android
Courtesy Dr. Patrick Bruss
Modified “Sgarbossa C”
Modified “Sgarbossa C”
Modified “Sgarbossa C”
S wave =22 mm
STE = 7 mm
ST deviation > 25% of the size of the S wave (7/22 > 25%)
2017 ESC STEMI Guidelines
Indications for Emergent CLA
High-Risk ECG Patterns in ACS—Need for Guideline Revision(Birnbaum, et al. J Electrocardiol 2013)
• Acute occlusion of the proximal LAD or less commonly 1st diagonal or left Cx
• Urgent cath should be “strongly considered”
de Winter T Waves
Courtesy Mat Goebel
de Winter T Waves
Case 1
Upsloping ST depression, tall symmetric Ts
90 min laterCourtesy Mat Goebel
From de Winter, NEJM 2008
De Winter T-waves
•Although no STE, high concern for decompenstation
– Active Sx’s
– Unstable LAD stenosis
– Now → treat aggressively, get
ECGs, may evolve → STEMI
– Future → STEMI equivalent (CLA)?
Key Point
STE in aVR with concurrent diffuse STD
DDx for STE in aVR(with STD in other leads)
• ACS: LMCA, triple vessel, and prox LAD disease
DDx for STE in aVR(with STD in other leads)
• ACS: LMCA, triple vessel, and prox LAD disease
• Any other causes of global cardiac ischemia
– TAD, severe anemia, early post-arrest (w/i 15 min of EPI or shocks)
DDx for STE in aVR (with STD in other leads)
• ACS: LMCA, triple vessel, and prox LAD disease
• Any other causes of global cardiac ischemia
– TAD, severe anemia, early post-arrest (w/i 15 min of EPI or shocks)
• Massive PE
• LVH with strain, esp. with severe htn
• LBBB, pacers
• SVTs (esp. AVRT)
• Severe hypoK+
• Sodium channel pathology (incl. TCAs, hyperK+, Brugada, etc.)
What is the Hx and PE?
• ACS: LMCA, triple vessel, and prox LAD disease
• Any other causes of global cardiac ischemia
– TAD, severe anemia, early post-arrest (w/i 15 min of EPI or shocks)
• Massive PE
• LVH with strain, esp. with severe htn
• LBBB, pacers
• SVTs (esp. AVRT)
• Severe hypoK+
• Sodium channel pathology (incl. TCAs, hyperK+, Brugada, etc.)
• Important points about STE in aVR– Worry about major coronary disease if...
• Patients are actively having symptoms and typically look sick
• STE > 1-1.5 mm• ST depressions are noted in multiple
other leads as well
aVR — The Forgotten
12th Lead
2017 ESC STEMI Guidelines:Indications for Emergent CLA
2017 ESC STEMI Guidelines:Indications for Emergent CLA
4th Univ. Definition of MI (2018)
Circulation Nov 13, 2018Also published in JACC and
European Heart Journal
4th Univ. Definition of MI (2018)
4th Univ. Definition of MI (2018)
• ACS with severe coronary stenoses– Patients are actively having symptoms and
typically look sick– STE > 1-1.5 mm– Multiple other leads with STD– Consider other potential causes
Key Points
Cereal ECG Testing
• Failure to repeat the ECG...
– If the first ECG is poor quality
– If ongoing concerning Sx’s
• ACC/AHA guidelines recommend serial ECGs every 15-30 min for the first hour if there are concerning Sx’s and initial ECG is non-dx’ic
Serial ECG Testing
• Failure to repeat the ECG...
– If the first ECG is poor quality
– If ongoing concerning Sx’s
• ACC/AHA guidelines recommend serial ECGs every 15-30 min for the first hour if there are concerning Sx’s and initial ECG is non-dx’ic
• 15-20% of STEMIs are dx’d on the repeat ECG!
Serial ECG Testing
Takehome Points
Takehome Points
• “STE” as the sole criteria predictor of an ACO is a flawed concept
Takehome Points
• “STE” as the sole criteria predictor of an ACO is a flawed concept
• Don’t forget about refractory ischemia as an indicator (in current guidelines) for cath lab activation
Takehome Points
• “STE” as the sole criteria predictor of an ACO is a flawed concept
• Don’t forget about refractory ischemia as an indicator (in current guidelines) for cath lab activation
• Learn to look for these other ECGs indicators of ACP
Takehome Points
• “STE” as the sole criteria predictor of an ACO is a flawed concept
• Don’t forget about refractory ischemia as an indicator (in current guidelines) for cath lab activation
• Learn to look for these other ECGs indicators of ACP
• Get serial ECGs in concerning cases!