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AMI/ACS Diagnosis:History and Physical

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AMI/ACS Diagnosis: HistoryAMI/ACS Diagnosis: History

How do we assess risk in chest pain patients?

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AMI/ACS: Risk AssessmentAMI/ACS: Risk Assessment

Pain characteristics Palliative/provocative features Associated cardiac symptoms Cardiac history Cardiac risk factors Family Hx: early AMI, sudden death

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AMI/ACS: Risk AssessmentAMI/ACS: Risk Assessment

Low, medium, high risk Does the patient have an acute

coronary syndrome (ACS)? Is there a ruptured plaque that is

occluded by a white or red thrombus?

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AMI/ACS

History Important clinical tool Chest pain may not be “classic”

Crushing, heaviness 24% Burning pain 23% Pleuritic pain 19% Reproducible pain 8-15% Sharp/stabbing pain 5%

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Anginal EquivalentsAnginal Equivalents

25-30% of MI’s clinically silent Diabetic and elderly at risk Older pts

Less likely to present with CP Less likely to have diaphoresis, N/V

SOB, dizziness, syncope may be sx

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Anginal Equivalents

Atypical PresentationsAtypical Presentations Back, neck, jaw, abdominal pain Dyspnea Diaphoresis N/V Syncope Confusion Generalized weakness Dizziness, TIA

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AMI/ACS

HistoryAssociated symptoms

Diaphoresis 80% Nausea 60% Belching 47% Vomiting 39%

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Coronary Atherosclerosis

Risk Risk Factors Male gender Age > 50 HTN Diabetes Hypercholesterolemia Post menopausal Family history of atherosclerosis

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Coronary Atherosclerosis

Risk Risk Factors Smoking Cocaine usage Peripheral Vascular Disease Obesity Hyper-triglyceridemia

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AMI/ACS History: AMI/ACS History: Prior Cardiac CatheterizationPrior Cardiac Catheterization

How long of a time does the report of a “negative” cardiac catheterization exclude a likely acute coronary syndrome?

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AMI/ACS History: AMI/ACS History: Prior Cardiac CatheterizationPrior Cardiac Catheterization

Perhaps 6-12 months, unless patient presents with STEMI or unstable

Must determine clean coronaries as opposed to non-occlusive lesions

The latter addresses the 60% lesion that is prone to disruption and STEMI

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AMI/ACS Diagnosis

Physical Exam

Pleuritic, positional painPalpable tendernessCHF, DVT, PE, AAANew murmur (valve)Unequal BP, pulsesCardiac dysrhythmia

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AMI/ACS Diagnosis:EKG

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AMI/ACS Diagnosis: EKGAMI/ACS Diagnosis: EKG

How do we diagnose AMI/ACS? How soon after triage should the

first EKG be performed?

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EKG Diagnosis

Ischemia or NSTEMI (ACS)Ischemia or NSTEMI (ACS)

Ischemia or NSTEMI ST segment depression Symmetric T wave inversions Inverted/biphasic T waves Non-specific ST or T ’s

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EKG Diagnosis

Acute Myocardial InfarctionAcute Myocardial Infarction

Infarction (AMI) Peaked T waves (earliest finding) ST segment elevation Normalization of ST segment Development of Q waves

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AMI/ACS: EKG LocalizationAMI/ACS: EKG Localization

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AMI/ACS: EKG LocalizationAMI/ACS: EKG Localization

Anatomic Location EKG Location Coronary Artery

Septal V1-2 LAD lesion

Anterior V3-4 LAD lesion

Lateral V4-6, I, aVL Circumflex branch of LAD

Inferior II,III, aVF RCA (90%)

Posterior V8-9 Circumflex or dominant branch of RCA

Right Ventricular V4R RCA

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AMI/ACS: EKG LocalizationAMI/ACS: EKG LocalizationAMI/ACS: EKG LocalizationAMI/ACS: EKG Localization

aVF inferiorIII inferior V3 anterior V6 lateral

aVL lateralII inferior V2 septal V5 lateral

aVRI lateral V1 septal V4 anterior

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AMI/ACS: Coronary ArteriesAMI/ACS: Coronary Arteries

Left

• Septal wall of LV

• Anterior and lateral walls of LV

• Inferior wall LV (10%)

• Both bundle branches

Right

• Inferior wall of LV

• Posterior wall of LV (90%)

• AV node (90%)

• Right ventricle

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Anteroseptal MI

ST elevation in V1, V2

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Anteroseptal MI

ST elevation in V1, V2

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Anterior Wall MI

ST elevation in V2, V3

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Anterolateral Wall MI

ST elevation in V2-V6

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Anterolateral Wall MI ST elevation in V4, V5

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Inferior Wall MI ST elevation in II, III, AVF

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AMI/ACS Diagnosis: EKGAMI/ACS Diagnosis: EKG

How do we diagnose true posterior wall AMI? RV AMI?

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True Posterior AMI Initial R waves V1, V2; R/S ratio >1

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True Posterior AMI Initial R waves V1, V2; R/S ratio >1

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Right Ventricular AMI ST elevation in II, III, aVF Also noted in in V4R to V6R

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Right Ventricular AMI RCA occlusion Inferior and RV infarction

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AMI Diagnosis: EKGAMI Diagnosis: EKG

What are the indications for additional EKG leads? Which are done? How? Why?

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Lead Placement for aLead Placement for aRV and Posterior ECGRV and Posterior ECGLead Placement for aLead Placement for aRV and Posterior ECGRV and Posterior ECG

V1

V3V4RV8

V9V2

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AMI/ACS: EKG Extra LeadsAMI/ACS: EKG Extra Leads

EKG shows posterior wall AMI Inferior wall MI with hypotension:

??? RV infarction Ischemic changes, cardiogenic

shock, search for PTCA indications

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Right-sided 12-Lead ECG: Patient Right-sided 12-Lead ECG: Patient With Inferior ST-Segment ChangesWith Inferior ST-Segment ChangesRight-sided 12-Lead ECG: Patient Right-sided 12-Lead ECG: Patient

With Inferior ST-Segment ChangesWith Inferior ST-Segment Changes

Lead V4R = diagnostic ST-segment elevation

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AMI/ACS: EKG Extra LeadsAMI/ACS: EKG Extra Leads

Zalenski extra leads study Inf AMI, 14% complications Inf AMI and RV AMI, 26%

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EKG Diagnosis

AMI/ACS Dx in LBBB

Rules for detecting MI with LBBB ST > 1mm and concordant with QRS = 5 pts ST > 1mm in V1, V2, or V3 = 3 pts ST > 5mm and discordant with QRS = 2 pts

Higher scores more likely MI present with LBBB

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EKG Diagnosis

AMI/ACS Dx in LBBB

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EKG Diagnosis

ST Elevation in Pericarditis

Diffuse ST elevation, atypical

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AMI/ACS

EKG DiagnosisEKG non-diagnostic in 50%

of AMI cases (NSTEMI)Cardiac enzymes usefulSerial EKGs useful

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AMI/ACS Dx: EKG TimingAMI/ACS Dx: EKG Timing

An EKG should be obtained within 10 minutes of presentation and initial triage