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STEMI Equivalents … an opportunity to save myocardium Susan P. Torrey, MD, FAAEM, FACEP

STEMI Equivalents … an opportunity to save myocardium Susan P. Torrey, MD, FAAEM, FACEP Associate Professor of Emergency Medicine Tufts University School of Medicine. Disclosures. None Nada Niente. We all know what to do with this…. STEMI Equivalents. Critical left main disease

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STEMI Equivalents … an opportunity to save myocardium Susan P. Torrey, MD, FAAEM, FACEP

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  1. STEMI Equivalents …an opportunity to save myocardium Susan P. Torrey, MD, FAAEM, FACEP Associate Professor of Emergency Medicine Tufts University School of Medicine

  2. Disclosures • None • Nada • Niente

  3. We all know what to do with this…

  4. STEMI Equivalents • Critical left main disease • Isolated posterior MI • Wellens’ syndrome • Persistent hyperacute T waves (de Winters)

  5. Case 1. 70-yo farmer with chest pain

  6. Critical Left Main Artery Disease • Wellens described association with: • ST-segment depression ≥8 leads • ST-segment elevation in lead aVR • Especially if ST-elevation in aVL

  7. Another critical left main stenosis

  8. A recent case - EMS EKG

  9. EKG in the ED

  10. 90% left main occlusion

  11. Case 2. 48-yo man with chest pain

  12. Isolated posterior wall MI • Posterior MI usually with inferior MI • 5% MIs - isolated posterior wall • Isolated posterior wall MI • ST-segment depression V1-3 • As MI evolves: • Upright T waves V1-3 • Tall R waves V1-2

  13. Acute inferior – posterior MI

  14. ST-segment depression in V1-3 With flipped EKG  ST elevation “inverted reflection” ST-depression in V1-3

  15. A recent case – circ stent

  16. Evolving posterior MI with tall R-V2

  17. Case 3. 65-yo woman with 90 mins severe substernal chest pain earlier

  18. Wellens’ warning • Left anterior descending (LAD) • Associated with changes V2-4 • Deeply inverted T waves • Biphasic T waves • Change from initial normal EKG • During pain-free interval • Normal enzymes

  19. Wellens’ syndrome

  20. Wellens’ syndrome, type 2

  21. Wellens’ original description - 1982 • 18% of admitted unstable angina • If NOT revascularized  75% large anterior MI …within weeks

  22. 60-year-old man with chest painearlier in the day

  23. ECG from 1 month prior

  24. Previous EKG Presentation

  25. One week later…

  26. 4. 60-year-old man with chest pain

  27. de Winter’s sign • Persistent hyperacute T’s • ST-segment depression • Proximal LAD occlusion • 2% of anterior MIs de Winter NEJM 2008

  28. In conclusion… Remember these STEMI equivalents

  29. In conclusion… • Critical left main occlusion • ST-depression ≥ 8 leads • ST-elevation aVR

  30. In conclusion… • Critical left main occlusion • Isolated posterior MI • ST-depression in V2-3 • Evolving tall R in V1-2

  31. In conclusion… • Critical left main occlusion • Isolated posterior MI • Wellens’ warning • Inverted or biphasic T waves V2-3

  32. In conclusion… • Critical left main occlusion • Isolated posterior MI • Wellens’ warning • de Winter’s sign • Persistent hyperacute T waves • ST depression

  33. ESC STEMI Guidelines Europ H J 33:2569, 2012 • Specifically address: • Isolated posterior infarction • Left main coronary obstruction

  34. Cardiol Clin 30:591-599, 2012

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