STEMI

Etiology:

cigarette
smoking
hypertension
lipid
accumulation
atherosclero
sis

coronary blood flow decreases abruptly

STEMI

coronary emboli
congenital abnormalities
coronary spasm
systemic inflammatory
diseases

Harrisons Principles of Internal Medicine. 18th ed.

Clinical Presentation
Precipitating factor: vigorous physical exercise,
emotional stress, medical/surgical illness.
Pain: deep & visceral, heavy, squeezing,
crushing, involves the central portion of the
chest/epigastrium, sometimes radiates to the
arms, abdomen, back, lower jaw, neck.
Weakness, sweating, nausea, vomiting, anxiety,
sense of impending doom.

Harrisons Principles of Internal Medicine. 18th ed.

Physical findings:
Anxious & restless
Substernal chest pain > 30 + diaphoresis
Sympathetic nervous system hyperactivity (anterior
infarction); parasympathetic hyperactivity (inferior
infarction)
Precordium is usually quiet, apical impulse difficult to
palpate
Ventricular dysfunction, murmur
carotid pulse volume stroke volume

Harrisons Principles of Internal Medicine. 18th ed.

Laboratory Findings
ECG
Initial stage: total occlusion ST-segment
elevation
Most patients ultimately evolve Q waves

Serum cardiac biomarkers

Cardiac-specific troponin T (cTnT) & cardiacspecific troponin I (cTnI) may remain
elevated for 7-10 days.
Creatinine phosphokinase (CKMB) rises
within 4-8 h, returns to normal by 48-72 h.
Harrisons Principles of Internal Medicine. 18th ed.

 Cardiac imaging
Two-dimensional echocardiography wall
motion abnormalities
Radionuclide imaging techniques
High-resolution cardiac MRI

Harrisons Principles of Internal Medicine. 18th ed.

Initial Management
Major elements of prehospital care:
1. Recognition of symptoms & seeking of
medical attention
2. Rapid deployment of an emergency
medical team capable of performing
resuscitative maneuvers
3. Expeditious transportation to a hospital
facility skilled in managing arrhythmias &
providing ACLS
4. Expeditious implementation of reperfusion
therapy
Harrisons Principles of Internal Medicine. 18th ed.

Harrisons Principles of Internal Medicine. 18th ed.

Management in the ED
GOALS

ACTIONS/MEDICATIONS

1. Control of cardiac
discomfort

Nitroglycerin, morphine, beta

blockers

2. Rapid identification of
patients who are candidates
for urgent reperfusion
therapy
3. Triage of lower-risk patients
to the appropriate location
in the hospital

ECG
Reperfusion therapy: ST-segment
elevation 2 mm in 2
contiguous precordial leads and
1 mm in 2 adjacent limb leads is
present.

4. Avoidance of inappropriate
discharge of patients with
STEMI

Harrisons Principles of Internal Medicine. 18th ed.

Reperfusion therapy for patients with STEMI. The bold arrows and boxes are the preferred
strategies.

OGara P T et al. Circulation 2013;127:529-555

Copyright American Heart Association

Primary PCI in STEMI

ACC/AHA 201 Guidelines for the Management of ST-Elevation Myocardial Infarction