1

ISBN : 974-422-126-7
1

:
: 3,000



2541
HIV/
AIDS 2541-2543
3.6, 7.9 10.1
(Disability Adjusted Life Years) 2542

( )

2547

10

12

13

15

16

3 Nitrates

20

22

24

26

1.
2.

3.

Acute coronary syndrome ( ACS) 1-2

Angina pectoris (Rest angina)
20
, (Coronary artery disease = CAD)
(Ischemic heart disease = IHD)

3 50
4-5

6
1.
2.

3.
4.
5.
6.

45 55
(Premature CAD)
(First-degree relative) 55 ; 65
7. Inflammation, Infection, Homocyst(e)ine, Hemostatic factors, Obesity,
Sedentary lifestyle

1. Angina pectoris
2. (Sudden cardiac death)
3. (Acute pulmonary edema)

Angina pectoris (anginal pain) 7

1. ()
(Substernal)

2.
3.

4.

5. 30 15
6.
Walk- through angina
7.
8. Anginal equivalent symptoms Angina

2
1. Stable angina
2. Acute coronary syndrome

1-2

Stable angina ( )5 60
Acute coronary syndrome (ACS)
Angina pectoris 20 ( 80)
( 20)

Heart sound gallop Murmur

Acute coronary syndrome (Pathogenesis of ACS) and Plaque disruption

(Acute coronary syndrome, ACS)
(Atherosclerosis)
(Plaque rupture, disruption) Raw
surface (Platelet aggregation)
(Thrombus formation)
(Partial occlusion)
(Unstable angina)
(Complete occlusion)
(Acute myocardial infarction, AMI)
(Plaques
vulnerability to rupture)8
(1) Lipid-rich core
(2) Macrophage
(3)
(Impaired healing)
(Disruption)
(Fibrous cap)
(Predict)

1. ST elevation acute coronary syndrome
ECG ST segment elevation 2 leads Epicardial

coronary flow 30
Acute ST elevation myocardial infarction (STEMI or Acute transmural MI, Q-wave MI)
2. Non ST elevation acute coronary syndrome
ST segment elevation (non-specific)
ST segment depression / T wave inversion 30
non-ST elevation MI ( NSTEMI, or Non-Q wave MI )
(Unstable angina)

ECG Biochemical markers

ACS
1. Acute myocardial infarction ( Anginal equivalent)
30
1.1 STEMI (ST elevation myocardial infarction)
1.2 NSTEMI (non-ST elevation myocardial infarction)
2. Unstable angina

Differential diagnosis of chest pain due to ST-elevation myocardial infarction9

1. Life-threatening
1.1 Aortic dissection
1.2 Pulmonary embolism
1.3 Perforating peptic ulcer
1.4 Tension pneumothorax
1.5 Boerhaave syndrome (esophageal rupture with mediastinitis)
2. Other cardiovascular and non-ischemic
2.1 Pericarditis
2.2 Atypical angina
2.3 Myocarditis
2.4 Vasospastic angina
2.5 Hypertrophic cardiomyopathy

3. Other non-cardiac
3.1 Gastroesophageal reflux (GERD) and spasm
3.2 Chest wall pain Herpes zoster, Costochondritis
3.3 Pleurisy
3.4 Peptic ulcer disease
3.5 Panic attack
3.6 Biliary or pancreatic pain
3.7 Cervical disc or neuropathic pain
3.8 Somatization and psychogenic pain disorder

1. ECG ECG
()
Hyper-acute myocardial injury T wave Peak T wave
T wave Leads
STEMI ST segment
ST-elevation 0.1 mV Limb lead 0.2 mV Chest lead
2 leads Nitroglycerin
New or presumably new ST-T segment ( 0.02 J point )
(Depression) ( 0.08 J point ) 0.10 mV 2 leads
(Lead II, III, aVF)10
New Q wave Presumably new Q wave Q wave
30 milliseconds 0.20 mV10 ST elevation
T wave inversion Symmetrical
ST depression, T wave change
Ischemic changes
lead 12 lead ECG
Extensive anterior wall Lead V1-V5 V6
Anteroseptal wall Lead V1-4 V1-V3
Anterolateral wall Lead I, aVL V4-V6
Inferior wall Lead II, III, aVF
Posterior wall (Reciprocal change) ST depression
T wave Lead V1-V5 V6 Tall R wave in V1-3 V 1-2 (R/S ratio 1in V1 and
V211)

10

 Right ventricular (RV) infarction ST elevation Lead V1,

V2R-V6R 10 12
Inferior STEMI RV infarction9
ACS ECG LBBB (Left bundle branch block)
Acute MI 9,13
1. ST elevation 0.1 mV Leads with a positive QRS
2. ST depression 0.1 mV Lead V1, V2 or V3
3. ST elevation 0.5 mV Lead with a negative QRS

Differential diagnosis of ST-elevation from ECG9

Pericarditis
Early repolarization
Wolff-Parkinson-White syndrome
Hyperkalemia
Bundlebranch blocks
Brugada syndrome

Differential diagnosis of ST depression/ T wave change from ECG9

Deeply inverted T waves suggestive of a central nervous system lesion or apical hypertrophic
cardiomyopathy
LV hypertrophy with strain
Myocarditis
Bundle branch blocks
Hypertrophic cardiomyopathy
Electrolytes imbalance
Panic attack, hyperventilation syndrome
Cardiac biomarkers Myocardial
cell damage Injury Biochemical markers
Total creatinine kinase (CK), CK-MB, Myoglobin, Troponin-T, Troponin-I, LDH isoenzyme
Acute coronary syndrome
2 Troponin Creatinine kinase
Troponin Troponin-T (cTnT) Troponin-I (cTnI)
Myocardial cell damage Acute coronary syndrome Troponin

11

 Positive Unstable angina, Non-Q MI Q wave MI

Myocardial cell damage Troponin
Troponin 2
6 Myocardial Cell
damage Troponin 3-12 9 (Mean time to peak elevation)
cTnT 12-48 cTnI 24 Troponin
5-14 9 Unstable angina Myocardial
ischemia Troponin 99 percentile 9
Creatinine kinase (CK) Total CK

Isoenzyme CK-MB
Q wave non-Q wave MI
Unstable angina CK CK-MB Biochemical marker
3-12 9 48-72 9
CK Myocardial cell damage
3. CBC with platelet count, Blood chemistry,
Chest X-ray, Echocardiogram, Radionuclide study Coronary angiography

.. 2533
8-1014
(Reperfusion)
(Thrombolytic agent)

(Remodeling)
Cardiogenic shock 5715
40 16-17
Sustained ventricular tachycardia 48
2018

12

 Acute ST elevation myocardial infarction (STEMI,

Q-wave MI)
STEMI
Acute ST elevation myocardial infarction (STEMI)

STEMI

(Thrombolytic therapy)
30 1
25 2-3 18 4-6
9,19
STEMI
2

(Thrombolytic agents)
.. 1980
STEMI 3019-20
3 9
Streptokinase, t-PA, Reteplase

STEMI New left bundle branch block (LBBB) 12

3 75 Class I
75 Class IIa9
(Absolute contraindications) 9
1. (Bleeding diathesis )
2.
3. 3 Acute ischemic stroke
3
4.
5. arteriovenous malformation
6. Aortic dissection

13

7. (Closed-head trauma)
3

(Cautions/Relative contraindications) 9
1. 3

2.
3. CPR (Cardio-pulmonary resuscitation) 10
3
4. 180/110
5.
6. INR 2 (
PT INR 3)
7.
8. Streptokinase 5 ( 2 )
Streptokinase
9.
10. (Active peptic ulcer)
11. ( 2-4 )

75
9

1. Streptokinase: 1.5 30 1
2. Tissue plasminogen activator: 15 , 50
30 35 1 100
3. Urokinase: 3 1
4. Reteplase: 10 30

14

 1
Streptokinase

t-PA

Reteplase

Allergic reaction
(Hypotension most common)

Yes

No

No

90-min. patency rate (%)

50

75

75

TIMI grade 3 flow (%)

32

54

60

Mortality rate (%)

7.3

7.2

7.5

1.
3021
2.
61 60 23
3. 20-30
4.
9,24

1. 0.7
2. 5
0.5
3. 5.8
4. 12.5

15


2 25

(%)

(%)

4.4

6.5

32

7.2

11.9

39

0.1

1.1

91

Acute STEMI
1.
- ST elevation New/presumed new LBBB
- 12 12
- 90 30
-
-
2. Cardiogenic shock 75 STEMI 36 Shock
16
Antiplatelet agents
1. Antiplatelet drugs
1.1. Platelet cyclooxygenase inhibitor
1.2. Thienopyridine group
2. GP ( Glycoprotein) IIb/IIIa receptor antagonist
1. Antiplatelet drugs
1.1. Platelet cyclooxygenase inhibitor
Prostaglandin H-synthase
PGG2 PGH2 Arachidonic acid, PGH2
Thromboxane A2

16

Thromboxane A2 (Platelet
aggregation) Aspirin ()
Aspirin
Myocardial infarction The Second International Study of Infarct
Survival (ISIS-221) Aspirin 160 mg 20
35

Acute myocardial infarction Aspirin 160-325 mg

Non-enteric formulation 75-160 mg Enteric
Non-enteric formulation
1.2 Thienopyridine groups
2 Ticlopidine Clopidogrel
Aspirin Aspirin Coronary stenting Ticlopidine
Thrombocytopenic purpura, Granulocytopenia 2.4 Clopidogrel
Granulocytopenia 0.1 Ticlopidine

1. Aspirin
2. 6

Ticlopidine 250 mg bid

Clopidogrel Loading 300 mg 75 mg
2. GP IIb/IIIa receptor antagonist
Coronary angioplasty

Antithrombin
Heparin 2
1. Unfractionated heparin (UFH)
UFH Glycoaminoglycan 3,000 30,000 dalton
Polysaccharide Antithrombin III
Thrombin Factor Xa

17

 Meta-analysis UFH acute myocardial infarction

UA/NSTEMI Aspirin 3326-27
Streptokinase
UFH

Massive anterior wall myocardial

infarction UFH Mild thrombocytopenia 10-20 Severe
thrombocytopenia (platelet count < 100,000) 1-2 4-14
Complete blood count
2. Low Molecular Weight Heparin (LMWH)
LMWH 4,000-5,000 dalton Heparin

( UFH LMWH)
1. Plasminogen activators
2. Unstable angina, NSTEMI
3. Massive anterior wall myocardial infarction

UFH Bolus 60-70 U/kg (Maximum 5,000U) intravenous

12-15 U/kg/hr Partial thromboplastin time (PTT) 1.5-2.5
Control 2-5
Enoxaparin: 1 mg/kg/dose subcutaneous bid 3-7 TIMI 11B trial
Enoxaparin 30 mg intraveneous

Beta-blockers :
Beta-blocker
2 Beta-blocker Heart Attack Trial (BHAT) The Norwegian Multicenter Study
Group 26-39 50-60

(Peripheral vascular disease = PVD)

18

 Beta-blocker
1. HR < 50 /
2. Systolic BP < 90 mmHg
3. Severe heart failure requiring IV diuretics or inotropes
4. Cardiogenic shock
5. Asthma
6. Second or third degree AV block

Initial dose : Atenolol 25 mg 1 ( 12.5-25 mg

)
: Metoprolol 50 mg 2 ( 25 mg
)
Titration : weekly
Target dose : Atenolol 100 mg OD
: Metoprolol 100 mg bid

1.
2. ACEI 1 Beta-blocker
3.

Beta-1 selective agent (Metoprolol or Atenolol 25 mg)

DM, First AV block PVD

Nitroglycerin Nitrates
Nitrates Angina 100
Nitrates Nitric oxide Guanylate cyclase
Cyclic guanosine monophosphate (cGMP)

19

 3 Nitrates
Dose
(mg)

Onset of action
(min)

Duration of action
(min)

2.5-10

5-20

45-120 min

2. Oral ISDN

10-60 t.i.d. to q.i.d.

SR 80-120 OD

15-45
60-90

2-6 h
10-14 h

3. Oral ISMN

20 b.i.d
SR 60-120 OD.

30-60
60-90

3-6 h
10-14 h

1. Sublingual ISDN

ISDN = Isosorbide dinitrate, ISMN = Isosorbide mononitrate

Nitroglycerin
, ,
Methemoglobinemia
Sildenafil
(Life-threatening hypotension) Nitrate (Nitrate-free
interval) 8-12 (Nitrate tolerance)

Statin
(Lipid lowering agents) 4S CARE
Statin 200-308
./. LDL-C 115-174 ./.
24-35 LDL-cholesterol 100 ./. Heart Protection
Study27 Simvastatin 40 mg
24 LDLcholesterol Schwartz MIRACL study26
Atorvastatin 80 mg Acute coronary syndrome

16 4
Statin Acute coronary syndrome 25
Double-blind, Randomized placebo-controlled trial26 LDLcholesterol < 100 mg/dL

20

Angiotensin converting enzyme inhibitor (ACEI)

GISSI-328 lisinopril 24 . NSTEMI
12 6 HOPE Study29
Ramipril 10 ./ ,
22 ACEI
, ,
(Left ventricular ejection fraction < 40%)
CABG (Coronary artery bypass graft)

1. Failed PTCA
2. Cardiogenic shock with coronary anatomy suitable for CABG
3. Repair mechanical defect
VSD ( Ventricular septal defect)
MR ( Mitral regurgitation)
Free wall rupture
Ventricular aneurysm with intractable VT (Ventricular tachycardia) or pump failure
4. Persistent or recurrent ischemia refractory to medical therapy and coronary anatomy suitable
for CABG
Left main disease
Triple vessels disease especially poor LV function
Multiple vessels disease with complex lesion
Double vessels disease with proximal LAD lesion

21

Patient with ischemic pain type 20 min

ECG 12 leads

ST elevation or

ST depression or

New LBBB

T ware inversion

Normal, nonDx.

ASA 160-325 mg chewable and swallow

+
Cardiac biomarkers (Troponin and/or CK-MB)

ST elevation / new LBBB

Initial anti-ischemic therapy < 12 hours
Assess contraindications to thrombolysis

Eligible

Thrombolysis
(the best < 3 hrs
from the initial symptoms)
or
Primary PCI

22

Not eligible

Primary PCI

Not a candidate
for reperfusion Tx

Heparin infusion or LMWH,

Beta blocker, Nitrate, ACEI
Stain

Non-ST elevation M I (NSTEMI)

ASA, Heparin or LMWH, Beta-blocker, Nitrate, ACEI, Statin
Unstable angina (UA)
ASA, Beta blocker, Nitrate, ACEI, Statin (if severe adding heparin/ LMWH)
Asthma Diltiazem Beta blocker NSTEMI/UA

23


1. Management of acute coronary syndromes in patients presenting without persistent ST-segment
elevation. The Task Force on the Management of Acute Coronary Syndromes of the European
Society of Cardiology. European HJ 2002; 23,1809-1840.
2. ACC/AHA 2002 Guideline Update for the Management of Patients With Unstable Angina and
Non-ST-segment Elevation Myocardial Infarction. A Report of the American College of
Cardiology / American Heart Association Task Force on Practice Guidelines.
3. Badimon L, Fuster V, Corti R, Badimon JJ. Coronary thrombosis : local and systemic factors. In
Hursts The Heart. 11th edition, 2004.
4. Marcus ML: The Coronary Circulation in Health and Disease. New York, Mc Graw-Hill 1983
5. Gould KL, Lipscomb L : Effects of coronary stenoses on coronary flow reserve and resistance.
Am J Cardiol 1974, 34:50.
6. Executive Summary of the Third Report of the National Cholesterol Education Program (NCEP)
Expert panel on detection evaluation and treatment of High Blood Cholesterol in Adults (Adult
Treatment Panel III). JAMA 2001; 285 2486-97.
7. O, Rourke RA,Schlant RC, Douglas JS Jr. Diagnosis and Management of Patients with Chronic
Ischemic Heart Disease in 10th Edition Hursts The Heart 2001, 1207-1236.
8. Falk E, Shah PK, Fuster V. Atherothrombosis and Thrombosis prone Plaque. In 11th edition Hursts
The Heart 2004.
9. ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction.
Antman et al, 2004 (www.acc.org).
10. Rude RE, Poole WK, Muller JE, et al. Electrocardiographic and clinical criteria for recognition of
acute myocardial infarction based on analysis of 3,697 patients. Am J Cardiol 1983;52: 936 -942.
11. Chamroth L Posterior wall myocardial infarction. In:The 12 -leads Electrocardiogram. Book 1 (of 2).
Boston: Blackwell 1989; 176-180.
12. Alexander RW, Pratt CM, Ryan TJ, Roberts R. ST-segment-elevation myocardial infarction : clinical
presentation, diagnostic evaluation, and medical management. In 11th edition Hursts The Heart 2004.
13. Sgarbossa EB, Pinski SL, Barbagelata A, et al. Electrocardiographic diagnosis of evolving acute
myocardial infarction in the presence of left bundle branch block. New Eng J Med 1996; 334: 481-487.
14. Virmani R, Burke AP. Pathology of myocardial ischemia, infarction, reperfusion and sudden death.
In 11th edition Hursts The Heart 2004.
15. Hasdai D, Topol EJ, Califf RM, et al. Cardiogenic shock complicating acute coronary syndrome. Lancet
2000; 356: 749-756.

24

16. Mark DB, Naylor CD, Hlatky MA, et al. Use of medical resources and quality of life after acute
myocardial infarction in Canada and the United States. N Eng J Med 1994; 331:1130-1135.
17. Califf RM, Bengtson JR. Cardiogenic shock. N Eng J Med 1994;330: 1724-1730.
18. Eldar M, Sievner Z, Goldbourt U, et al. Primary ventricular tachycardia in acute myocardial infarction:
clinical characteristics and mortality. The SPRINT Study Group. Ann Intern Med 1992; 117: 31-36.
19. Greenbaum AB et al, An update on acute myocardial infraction from recent clinical trials, Current
Opinion in Cardiology 12: 418
20. Gruppo Italiano per to Studio della Streptochinasi nell'Infarto Miocardico (GISSI), Effectiveness
of intravenous thrombolytic treatment in acute myocardial infarction. Lancet 1986; 1: 39720
21. The Second International Study of Infarct Survival Collaboration Group, Randomized trial of
intravenous streptokinase, oral aspirin, both,or neither among 17,187 cases of suspected acute
myocardial infarction.ISIS -2. Lancet 1988;2: 349
22. The Fibrinolytic Therapy Trialists (FTT) Collaborative Group, Indications for fibrinolytic therapy
in suspected acute myocardial infraction: Collaborative overview of early mortality and major
morbidity results form all randomized trials of more than one thousand patients. Lancet 343: 311
23. The TIMI Study Group, The thrombolysis in myocardial infraction (TIMI) trial, N Engl J Med
1985; 312: 932
24. Weaver WD et al, Early treatment with thrombolytic therapy: Results from the Myocardial Infraction,
Triage and Intervention Pre-Hospital Trial. JAMA 1993;270: 1211
25. Weaver WD et al, Comparison of primary coronary angioplasty and intravenous thrombolytic therapy
for acute myocardial infarction: A quantitative review. JAMA 1997; 278: 2093
26. Schwartz GG. Effects of atorvastatin on early recurrent ischemic events in acute coronary syndromes:
The MIRACL study: A randomized controlled trial. JAMA 2001; 285:1711
27. Stenestrand U. Early statin treatment following acute myocardial infraction and 1-year survival. JAMA
2001; 285: 430
28. GISSI-3, Gruppo Italiano per lo Studio della Streptochinasinell'Infarto Miocardico. Effects of lisinopril
and transdermal glycerol trinitrate singly and together on 6-week mortality and ventricular function
after acute myocardial infraction. Lancet 1994;343:1115
29. The Heart Outcomes Prevention Evaluation Study Investigators: Effects of an angiotensin-converting
enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients. N Engl J Med 2000; 342:145.

25

26


27

NSR 100/min
ST segment elevation > 4 mm (0.4 mV) in Lead V3-5 and
ST elevation > 1 mm in aVL indicative of acute myocardial injury of
antero-lateral wall
ST segment depression in Lead II, III, aVF were from reciprocal
change, inferior wall myocardial ischemia.
q wave (q 1 0.04 )
Q wave (q 1 0.4 ) Lead V3 V3
V5 aVL Acute STEMI
Specific Serial EKG 1/2
q/Q wave Lead(s) STEMI.
EKG (ECG) Significant ST segment
elevation ST segment depression significantly
ST segment elevation STEMI

28


29

30

STEMI

ST segment elevation 1 mm (1 ) in Lead V2-V6, I, aVL

with Q wave in lead aVL, V3-V4 (small q wave in Lead I,V5-V6) were
indicative of acute extensive anterior wall STEMI.
ST segment depression in Lead II, III, aVF were suggestive of
acute inferior wall myocardial ischemia, reciprocal change.


31

32

ST segment elevation in Leads V3-V5 0.5 mV (5 ) with

ST segment elevation in Lead V6 = 0.1 mV and T wave upright in
V1-V6 were probable from acute extensive anterior wall STEMI
superimposed with LBBB (or LBBB superimposed with acute extensive
anterior wall STEMI).
ST segment elevation in Lead II, III aVF were from acute inferior
wall myocardial injury which is early acute STEMI.
ECG ST segment elevation in Lead V4-V6 ST
segment blend Ascending limb T wave
Acute pericarditis Fine crepitation LV
failure, Cardiogenic shock

NSR, QRS = 0.12 seconds, LBBB


33

34

Q wave in Leads V1-V6 with ST segment elevation > 1 mm and

QS in V1-V5 were indicative of acute extensive anterior wall STEMI.
Q wave in Leads II, III aVF with probable ST segment elevation
(scale ) from probable acute inferior wall STEMI.
Significant Q wave (Q > 0.04 seconds) Leads II,
III, aVF, V1-V6 ST segment Leads
(Blend) Ascending limb of T wave T wave
Acute pericarditis

NSR


35

36

QS in Leads V2-V4, I, aVL (small q wave in V5-6) with ST

segment elevation in V1-V5, I, aVL and inverted T wave were
indicative of acute extensive anterior wall STEMI.

NSR (Normal sinus rhythm)


37

ST segment elevation > 3 mm (0.3 mV) in Lead II, III , aVF with
q/Q wave indicative of acute inferior wall STEMI .
ST segment elevation 1 mm in V6 suggestive of early acute injury
at lateral wall.
ST segment depression > 2 mm in Lead I, aVL, V1-V4 were from
extensive anterior wall (anteroseptal, anterior and anterolateral wall)
myocardial ischemia; reciprocal change.
PR = 0.23-0.24 seconds were from first degree AV block

Acute STEMI

38


39

PR = 0.24 seconds was from first degree AV block.

QRS = 0.12-0.13 seconds with tall R wave in V1-V3 were form
RBBB.
ST segment elevation > 1.5 mm in Leads II, III, aVF with Q ware
were indicative of acute inferior STEMI.
ST elevation in Leads V4-V6 with q/Q wave in V5-V6 and T wave
upright in Lead V2-V3 in the presenting of RBBB, which all of these
were probable from acute exertive anterior wall STEMI.
AMI STEMI Inferior Extensive
anterior wall ( Right coronary artery = RCA;
Left anterior descending artery = LAD)
First degree AV block RBBB Bifascicular block
Complete heart block Temporary pacemaker prophylaxis, ( Trans-venous External-pacing).

40


41

42

ST segment elevation in Lead II, III, aVF > 2 mm with q/Q wave indicative of acute
inferior wall STEMI. Tall R wave in V1-V3 (R:S > 1) highly suggestive of acute posterior
wall MI.
ST segment depression in V4-V5, I, aVL were from antero-lateral wall myocardial
ischemia, left ventricular hypertrophy (LVH), reciprocal change.
LVH from voltage criteria in Lead V5
ST segment elevation Leads II, III, aVF T wave
T wave Q wave 0.04 seconds Lead III, aVF
Posterior wall infarction, ST segment depression
STEMI
ST elevation ST segment T wave
T wave Q wave Differential diagnosis Early acute pericarditis
Pericardial rub; Serial ECG 1/2 hr AMI, ECG ,
Therapeutic Dx. Isosorbide dinitrate ECG ; Indomethacin 25 mg
45 ( Significantly) ECG

Admit


43

NSR
QS in Leads II, III, aVF with ST segment elevation and inverted
T waves were indicative of acute inferior wall STEMI.
ST segment elevation in Leads V3R and V4R with T waves
inversion were probable from acute right ventricular (RV) wall
infarction.

44


45

46

Symmetrical inverted T wave in Leads V2-V6, I, aVL were suggestive

of subendocardial ischemia, non-STEMI (to R/O intracerebral
hemorrhage : unlikely)


47

ST segment depression horrizontally at the J junction more than 1 mm

in Leads V3-V5-V6 and I were suggestive of antero-lateral wall
myocardial ischemia, Non-STEMI.

48


49

50

NSR, axis = +120 segment elevation in Leads II, III, aVF, V4-V6
were from acute pericarditis.
ST segment Segment
Horrizontal T wave
Acute STEMI
Observe Vital signs
Tachycardia,
Isosorbide dinitrate
ECG Contraindication in therapeutic
diagnosis Indomethacin (25 mg) po 1 capsule ( ,
Antacid) 45-60
ECG ( Acute STEMI STT waves )
** ASD ASD 2-3
Post operative acute pericarditis

51

52