1.3 Case Presentation - STEMI Mimickers - Dr. Isabella Sp.jp(1)
Transcript of 1.3 Case Presentation - STEMI Mimickers - Dr. Isabella Sp.jp(1)
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Isabella Lalenoh, MD, FIHA
S
TEMI MimickersWhat Can We Learn From ECG Findings
6th Surabaya Cardiology Update
Shangri-La Hotel Surabaya
September 12, 2015
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A rapid diagnosis of ST –segment elevation myocardial
infarction (STEMI) is mandatory for optimal treatment
Important as early initiation of primary
percutaneous coronary intervention (PCI)
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Wrong transport destination. Unnecessarily bypassing non-PCIhospitals damages continuity of care, burdens families,
antagonizes facilities.
Wrong treatment. Nitro? Aspirin? Fibrinolytics? Getting it rightaffects field and hospital treatment.
Missed alternate diagnoses. Some non-MI diagnoses are alsocritical – think aortic dissection, hyperkalemia, etc. “Call it STEMI”
is not always “playing it safe.”
False positive STEMI diagnoses
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Case
• 19 yo Male
• CC : Chest pain since 4 hours before admision
Sharp quality, middle-left chest, non radiating
• Other symptoms : fever with flu-like symptoms from1 week before admision
• Risk factors: DM -, HT -, Non Smoker, Family history -
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Physical exam:
• BP: 120/80, HR: 112 bpm, RR: 28 x/mnt, SO2:
99% (O2 binasal)
• Temp ax.: 38.5 C
• Heart: S1/S2 normal, no murmur or gallop
• Lung: no ronchi / wheezing
Case
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ECG
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• The patient was immediately referred for
angiogram. The angiogram, however, revealed
the absences of thrombus and significant
stenosis and ruled out coronary artery
disease
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CMR
ACUTE PERI-MYOCARDITIS
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NON ISCHAEMIC CAUSES – How common?
Brady et al ., Cause of ST segment abnorm ali ty in ED chest
pain pat ients (Am J Emerg Med 2001 Jan;19(1):25-8)
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Retrospective review of ED charts over 3-month period
• Looked at 902 adults with cc “chest pain”
• Looked for STE in contiguous leads, >1mm
limb leads, >2mm pre cordials
• Compared final diagnoses, MI vs. other
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Results
Only 15% of STE patients had MI!
85% had non-MI diagnosis
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THE MIMIKERS – What were they?
• Left Ventricular Hypertrophy — 25%• Left Bundle Branch Block — 15%
• AMI — 15%
• Benign Early Repolarization — 12%
• Right Bundle Branch Block — 5%
• Nonspecific BBB — 5%
• Ventricular aneurysm — 3%
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Pericarditis — 1%• Undefined/unknown — 17%
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In other words:
Anyone can recognize ST elevation
STEMI recognition and diagnosisrequires distinguishing MI from non-
ischemic causes
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What are our tools for addressing this?
• Clinical correlation. Any suspicious ECG findings
should be matched against patient presentation andphysical exam.
• History and risk factors. Does history supports MI – smoker, diabetic, hypertensive, aspirin use, etc?
• Old ECGs. Extremely valuable tool when availablefor establishing baseline.
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Serial ECGs. Repeat 12-leads may reveal dynamicchanges with time/treatment.
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More signs that point to MI
• Changes on serial ECGs. ACS is a dynamicprocess of supply/demand imbalance;consecutive 12-leads should reveal ongoingchanges. Mimics are typically electricallystable.
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One of the best tools for distinguishing STEMI vs.mimics!
Early and continuous prehospital ECGs can playa crucial role in eventual care!
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Summary
The shape of the ST-segment elevation, the leadsinvolved, other features of the EKG, the clinical setting,
and most important, awareness of the conditions that
mimic infarction can help differentiate the conditions
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