Acute MI and STEMI (ALS)

Dr. Katz's Assessment Of This Case

As soon as the crew arrives on the scene, the lead medic immediately calls for a
thorough scene survey and an interview with the grandson. Our patient says that
his symptoms began while he was watching television. He says he has no chest
pain, no shortness of breath, no recent trauma, no numbness, and no history of
similar symptoms in the past.  

He has not been ill recently. Simultaneously, our lead medic initiates the ABCs and
calls for a full set of vital signs and the patient to be placed on a monitor. This is
extremely important in any situation when acute coronary syndrome is possible.

Once you identify a STEMI (ST-elevation MI) on the EKG, it’s time to think “load
and go.” On-scene time is the largest fraction of “pre-hospital time.”
As mortality can be reduced with rapid coronary reperfusion, STEMI patients should
be identified rapidly, with minimum scene times, and rapid transport to the
appropriate receiving facility.  

Armed with an EKG showing an acute STEMI, the crew accurately decides to “load
and go”. The remainder of the SAMPLE history and head-to-toe performed as the
patient is moving towards the back of the ambulance and eventually the treating
hospital. The grandson is briefed about his grandfather’s condition and rides along
to the hospital.

Our Case

You are presented with a 75-year-old man. His grandson calls 911 because he was
having left arm pain, sweating, and nausea for the past 15 minutes. His
vital signs and physical exam are relatively unremarkable, except that he is anxious
and sweating. His symptoms started while he was watching TV. Our patient has no
known medical history. The EKG reveals the most compelling evidence with ST
elevation in leads V3, V4, and V5 with reciprocal T wave inversions inferiorly. We
have now diagnosed an acute anterior wall STEMI (ST-elevation MI).

Summary Of History

Left arm pain, sweating, and nausea. No chest, arm or back pain. No nausea or
vomiting. No shortness of breath. No significant past medical history, except for
smoking 1 pack of cigarettes per day for the past 50 years.

Summary Of Physical Exam Findings

What Is Atherosclerosis?

Atherosclerosis is the main cause of acute coronary syndrome. It is a disorder in

which cholesterol and calcium builds up inside the walls of the blood vessels,
eventually leading to partial or complete blockage of blood flow.

The atherosclerotic process begins in childhood. Common locations for

atherosclerosis formation are the points of turbulent blood flow, typically where a
vessel bifurcates, or where the vessel wall has been damaged. As the streak of fat
enlarges, it becomes a mass of fatty tissue, or atheroma, and eventually calcifies
and hardens into a plaque.
Plaques narrow the vessel, and can eventually rupture causing an acute blockage
and obstruction of the vessel.
 Risk Factors For The Formation Of Atherosclerosis

 Age

 Smoking

 High cholesterol

 Diabetes

 Hypertension

 Family history

What Is Coronary Artery Disease?

A pathologic process caused by atherosclerosis that leads to progressive narrowing

and eventual obstruction of the coronary arteries. What is "acute coronary
syndrome?" A continuum of coronary artery occlusion that all have coronary
atherosclerosis in common.

 Unstable angina

 NSTEMI (Non-ST elevation MI)

  STEMI (ST-elevation MI)

Evolutionary pattern or indicative changes of MI.

How Can I Decrease My Risk For Developing Cardiovascular Disease?

 Quit smoking

 Lower and control hypertension

 Lower total cholesterol level

 Lower LDL cholesterol level

 Increase HDL cholesterol level

 Lower weight, if overweight

 Increase aerobic exercise

Precordial leads (chest leads) look at the heart in the horizontal plane.
©Jones and Bartlett Learning, 2013.

Cardiovascular Disease Statistics In The United States

 #1 killer every year since 1900

 1.3 million cases of myocardial infarctions each year

 In the United States, more than 600,000 die each year from coronary artery
disease (CAD)

o 1/2 die in Emergency Department or before reaching the hospital,

during the first minutes or hours after the initial onset of symptoms

 13% - Six month mortality for NSTEMI

 8% - Six month mortality for unstable angina

  Mortality from coronary artery disease declined 22% in the United States
from 1993 to 2003

 Each year, 5 million patients present to emergency departments with chest

pain

Electrical conduction system of the heart. Impulses that originate in the SA node spread through
the atria and along the internodal pathways to the AV node. From the AV node, they travel down
the bundle of His and right and left bundle branches and into the Purkinje network of
the ventricles.

Young Patients At High Risk For Myocardial Infarction (MI)

 Cocaine abusers

 Insulin-dependent diabetes mellitus (IDDM)

 High cholesterol levels

 Strong family history of cardiac disease

Possible Symptoms Of Myocardial Infarctions (MI)

 Chest or midepigastric discomfort

 Dyspnea (shortness of breath)

 Arm, neck, or upper back pain

 Sweating

 Nausea and/or vomiting

 Lightheadedness

 Palpitations
  Syncope

 EKG changes

 Signs of shock

Atypical Presentations Of MI

 Women

 Elderly

 Diabetics

Pearls Of Wisdom

More men have heart disease than women, but more women die of heart disease.
Why? Women often present with atypical presentations (i.e., nausea, sweating,
lightheaded, etc.) making diagnosis more difficult. Be aggressive in considering
acute coronary syndrome in the female patient population with atypical symptoms.
Sudden cardiac death is always a possibility within the spectrum of the various
acute coronary syndromes. Half of the deaths from acute coronary syndrome occur
before patients reach a hospital. This makes efficient diagnosis and treatment of
acute coronary syndrome so imperative in the prehospital environment.

 Identification of patients with STEMI and triage for early reperfusion therapy

 Relief of ischemic chest discomfort

 Prevention of major adverse cardiac events (MACE) such as death, nonfatal

MI, and the need for urgent post-infarction revascularization

 Treatment of acute, life-threatening complications of acute coronary

syndrome, such as VF/pulseless VT, symptomatic bradycardias, and unstable
tachycardias.
Myocardial infarction (MI) is typically the result of a blockage in one of the coronary
arteries due to an atheroscleroticplaque. The partial or complete blockage of this
coronary blood vessel causes the lack of oxygenated blood to be delivered to a
portion of the heart causing an infarction (death of heart muscle). As time is
muscle, the quicker these patients are treated with either fibrinolytics (clot busters)
or angioplasty, the better. The goal in both treatment modalities is to open the
blocked coronary artery as soon as possible.

Myocardial infarction (MI) is typically the result of a blockage in one of the coronary
arteries due to an atheroscleroticplaque. The partial or complete blockage of this
coronary blood vessel causes the lack of oxygenated blood to be delivered to a
portion of the heart causing an infarction (death of heart muscle). As time is
muscle, the quicker these patients are treated with either fibrinolytics (clot busters)
or angioplasty, the better. The goal in both treatment modalities is to open the
blocked coronary artery as soon as possible.
Caution

Be aware of abnormal heart rhythms. In an ICU setting, between 72% and 100% of
heart attack patients will have an abnormal heart rhythm. Be prepared for
bradycardia, heart blocks, and ventricular fibrillation. MI patients are extremely
vulnerable to lethal heart rhythms and it is always a good idea to have the AED or
defibrillator ready in case it is needed.

What Is A Myocardial Infarction (MI)?

"MI" is another term for "heart attack" and is used to describe irreversible necrosis
(or death) of the heart muscle due to ischemia (lack of oxygen). This is the reason
for the adage that "time is muscle." MI is the result of an occlusion of a coronary
artery by a clot (thrombus), spasm of a coronary artery (cocaine is common cause),
or any reduction in overall blood flow (shock, arrhythmias, pulmonary embolism).
Coronary artery obstruction from clot (thrombus) is the most common reason for
an acute MI.

Load And Go For STEMI

On-scene time is the largest fraction of "pre-hospital time." As mortality can be

reduced with rapid coronary reperfusion, STEMI patients should be rapidly identified
with a 12-lead EKG with accurate interpretation, with minimum scene times, and
rapid transport to the appropriate receiving facility.

Questions To Ask The Suspected MI Patient

 Severity (How bad is your pain on a scale from 1 to 10?)

 Location (Where exactly is your pain located?)

 Radiation (Does the pain radiate to your arm, neck, or back?)

 Duration (How long did the pain last? Is it still there?)

 Modifying factors (What made the symptoms better?)

 Exacerbating factors (What made the symptoms worse?)

 Quality (How would you describe the discomfort?)

 Associated symptoms (Do you have any sweating or nausea?)

OPQRST Approach To Chest Pain/Coronary Syndrome

O - Onset - How did chest pain or symptoms begin? Ever had this before?
P- Provoked - What brought symptoms on? Exertional? Non-exertional? What were
you doing when symptoms started? What makes symptoms better? Worse?
Q - Quality -  What does discomfort feel like? Dull? Pressure? Sharp? Squeezing?
Tightness?
R- Radiate -  Does pain radiate? Arm? Neck? Back? Abdomen?
S - Severity -  How bad is discomfort/pain on a scale from 1-10?
T - Timing -  When did symptoms start? How long did symptoms last? When did it get
worse or better? Constant? Wax and waning?

ABC's

A - Airway is clear without signs of obstruction.

B - Breathing is unlabored, at a rate of 20, O 2  saturation is 94% on room air,
oxygen is immediately applied.
C - Pulses are present and strong. Heart rate is 92 and regular.

The EKG reveals the most compelling evidence with ST elevation in leads V 3 , V 4 ,
and V 5  with reciprocal T wave inversions inferiorly. Our crew has quickly diagnosed
an acute anterior wall STEMI (ST-elevation MI).This is a classic EKG presentation of
an acute anterior wall infarction, which typically involves the left anterior
descending artery.

 What Is Our Patient's Preliminary Diagnosis?

From the information we have been given in this scenario, this patient's diagnosis is
acute anterior wall STEMI.

Why Is This Case Challenging?

Our patient does not have any chest pain, yet his EKG suggests that he is having an
acute MI. The teaching point here is that chest pain is not always present with an
acute myocardial infarction. Not all patients will have the classic symptoms of a
heart attack. In fact, 30% of MI patients will have a silent MI, or atypical symptoms
of MI.

Dr. Katz's Comments

"I have seen patients in the ER present with nothing more than sweating while they
were in the midst of having an acute MI. I have seen many patients die from an MI
without ever having chest pain. Although you should be aware of the classic
symptoms of an MI, equally important is to keep in mind that there are many
exceptions to the rule, and many different clinical presentations of the acute MI
patient."

Treatment Of Acute Coronary Syndromes/MI In The EMS Environment

 Continuous monitoring

 Oxygen

 Aspirin
  Nitroglycerin

o Contraindicated with recent use of sexual enhancing medications:

 Cialis (Tadalafil)

 Viagra (Sildenafil)

 Levitra (Vardenafil)

o Avoid with hypotension and right-sided infarctions

 Morphine

o Avoid with hypotension

 If your patient is found to have a STEMI, transportation should ideally be to a

hospital with emergency angioplasty capabilities. Depending on your area
capabilities, this may not always be possible. Make sure to be familiar with
and follow your local protocols regarding the transport of STEMI patients.

What Does A STEMI Look Like On An EKG?

ST elevation in 2 contiguous leads, often with reciprocal changes.

ST-Elevation

It is critically important for the paramedic to quickly obtain a 12-lead EKG and be

able to recognize the presence of ST-elevation.
 Suggestions to maximize ST-elevation MI identification:

o Frequently review the different ST elevation patterns either in a

textbook or online tutorial. Practice makes perfect when it comes to
EKG interpretation. The more EKGs you review, the better you will be
at identifying that subtle case of ST elevation.

o Perform 12-lead EKGs, if possible, with the patient completely still in a

non-moving environment (i.e., a vehicle not moving). Artifacts are
common when 12-lead EKGs are performed in a moving rescue
vehicle, which can sometimes make identifying subtle ST-elevation
nearly impossible.

 Posterior Wall MI: Don’t forget to always consider and look for a
posterior wall MI. It does not present with ST elevation when
looking at the EKG conventionally! Typical pattern includes tall
and fat R wave, ST depression, and upright T wave in leads
V 1 and V 2 .

o Good trick: If you turn the EKG upside down, and look at the EKG
through the back of the paper, you will see ST elevations in V 1  and
V 2  with an acute posterior wall MI.

 Right ventricular infarction: - often associated with inferior wall

MI. Right-side leads should always be obtained with inferior wall
 MI. Right-sided infarction will classically show ST elevation in
lead V 4 R.

Site Of MI And Associated Leads EKG Changes Are Seen

Inferior - II, III, aVF

Anteroseptal - V 1  to V 3
Anterolateral - V 4  to V 6
Extensive anterior wall - V 1  to V 6 , 1 and aVL
Posterior wall - V 1  and V 2  (tall R waves with ST depression, (i.e., reciprocal
changes))

Treatment of MI In The Hospital

 Angioplasty: The gold standard for STEMI treatment. An interventional

cardiologist places a wire into the femoral artery and feeds the wire into
the aorta. Dye is then injected allowing visualization of the coronary
arteries and determination if there is a blockage. A blockage can then be
opened by placing a balloon in the blocked area and inflating it. A stent is
often placed at the site of the blockage to maintain the involved area opened.
Most authorities would agree that if angioplasty can be done immediately, it
is a better option than fibrinolysis.

 Fibrinolysis: Intravenous clot busting drug (i.e., tPA®, retavase®, TNKase®,

streptokinase) – currently much less common due to the availability of
angioplasty capabilities.

Anterior Wall Myocardial Infarction

In our patient’s scenario, the EKG shows ST elevation in leads V1, V2, and V3 with
reciprocal ST depresion inferiorly (II, III, aVF). This is a classic EKG presentation of
an acute anterior wall infarction, which typically involves the left anterior
descending artery.

What Happened To Our Patient?

Our patient felt better with the oxygen, aspirin, and nitroglycerin administered by
our crew. He was taken to a hospital where he had emergency angioplasty. Once
the cardiologist injected the dye to visualize the coronary arteries, the patient was
found to have a 99% blockage in the left anterior descending artery. The patient
had the vessel opened and a stent placed. His door-to-balloon time was 30
minutes, and the patient was discharged from the hospital 3 days later, very
appreciative of all of the life-saving professionals that cared for him.  

Remember, quickly obtaining a 12-lead EKG, keeping your EKG interpretation skills

sharp, minimizing on-scene times once a STEMI has been identified, and closely
monitoring you patient on the way to the appropriate hospital can be life-saving.

Misdiagnosed Heart Attacks

Misdiagnosed heart attack is one of the most common causes of malpractice
litigation for emergency room physicians. The reason for this is probably due to the
high number of atypical presentations for heart attack. Acute MI patients do not
always present with the classic symptoms and the lesson here is to be thorough
with your history-taking skills. Do the patient’s symptoms get worse with exertion?
Do they improve with rest? Does the patient have risk factors for coronary artery
disease? Is the patient complaining of sweating? As always, your ability to approach
each patient thoroughly and methodically will assist you in narrowing the
possibilities to explain your patient’s symptoms.

Documentation

Diagnosing and treating a STEMI is serious business, and a task that the public
expects from its ALS providers. Your documentation should reflect the seriousness
of that task.  What are the patient’s symptoms, when did they start? What are your
patient’s signs?  Are they diaphoretic, pale, hypotensive? Does your charting
accurately reflect the picture you were presented? Does your charting have
accurate times, i.e., time on scene, time the initial and subsequent EKGs were
obtained, time the hospital was called notifying them of a suspected STEMI? How
about scene time? Were any delays on scene adequately documented? How did the
patient’s clinical situation change while they were in your care? Did the pain or
symptoms get better or worse? Is this clearly documented?  Was more than one
EKG obtained? Are these EKG interpretations properly documented? Was a right-
sided EKG obtained? Adequately and systematically documenting your patient’s
symptoms, vitals, scene times, and actions is always important, but especially
important in the STEMI patient.

Glossary

Acute Coronary Syndrome  : Term used to describe any group of clinical symptoms

consistent with acute myocardial ischemia.
Arteries  : The muscular, thick-walled blood vessels that carry blood away from the
heart.
Atherosclerosis  : A disorder in which cholesterol and calcium build up inside the walls
of the blood vessels, forming plaque, which eventually leads to partial or complete
blockage of blood flow.
Bundle Of His  : The portion of the electric conduction system in the interventricular
septum that conducts the depolarizing impulse from the atrioventricular junction to
the right and left bundle branches.
Conduction  : The movement of a wave of depolarization through the nodes,
pathways, and bundles of the cardiac conduction system.
Coronary Arteries  : The blood vessels of the heart that supply blood to its walls.
Depolarization  : The rapid movement of electrolytes across a cell membrane that
changes the cell's overall charge. This rapid shifting of electrolytes and cellular
charges is the main catalyst for muscle contractions and neural transmissions.
Diabetes Mellitus  : Disease characterized by the body's inability to sufficiently
metabolize glucose. The condition occurs either because the pancreas doesn't
produce enough insulin or the cells don't respond to the effects of the insulin that's
produced.
Drug  : Substance that has some therapeutic effect (such as reducing inflammation,
fighting bacteria, or producing euphoria) when given in the appropriate
circumstances and in the appropriate dose.
Femoral Artery  : The main artery supplying the thigh and leg.
Goals  : The end points toward which intervention efforts are directed. A statement
of changes sought in an injury problem, stated in broad terms.
Illicit  : In relation to drugs, illegal drugs such as marijuana, cocaine, and LSD.
Infarction  : Death (necrosis) of a localized area of tissue caused by the cutting off of
its blood supply.
Intravenous  : Within a vein.
Ischemia  : Tissue anoxia from diminished blood flow to tissue, usually caused by
narrowing or occlusion of the artery.
Ischemic  : One of the two main types of stroke; occurs when blood flow to a
particular part of the brain is cut off by a blockage (eg, a clot) inside a blood vessel.
Lead  : Any one of the conductors, composed of two or more electrodes, in the ECG
that shows the electrical conduction in the heart.
Mortality  : Deaths caused by injury and disease. Usually expressed as a rate,
meaning the number of deaths in a certain population in a given time period divided
by the size of the population.
Necrosis  : The death of tissue, usually caused by a cessation of its blood supply.
Occlusion  : Blockage, usually of a tubular structure such as a blood vessel or IV
catheter.
Palpation  : Physical touching for the purpose of obtaining information.
P-R Interval  : The period between the beginning of the P wave (atrial depolarization)
and the onset of the QRS complex (ventricular depolarization), signifying the time
required for atrial depolarization and passage of the excitation impulse through the
atrioventricular junction.
Reperfusion  : The resumption of blood flow through an artery.
Risk Factors  : Characteristics of people, behaviors, or environments that increase
the chances of disease or injury. Some examples are alcohol use, poverty, or
gender.
Signs  : Indications of illness or injury that the examiner can see, hear, feel, smell,
and so on.
Sympathetic Nervous System  : Subdivision of the autonomic nervous system that
governs the body's fight-or-flight reactions by inducing smooth muscle contraction
or relaxation of the blood vessels and bronchioles.
Symptoms  : The pain, discomfort, or other abnormality that the patient feels.
Term  : Used to describe an infant delivered at 38 to 42 weeks of gestation.
Triage  : To sort patients based on the severity of their conditions and prioritize
them for care accordingly.

References

1. Coven, D.L., et al. (2012, December 14) emedicine.medscape.com. “Acute

Coronary Syndrome” Retrieved from http://emedicine.medscape.com/.

2. Garcia, T. B. and Holtz, N. E. (2001). 12-lead ECG, The Art of Interpretation.

India: Jones and Bartlett Publishers.

3. Pollak, A. N. (ed.) (2013). Nancy Caroline’s Emergency Care in the Streets

(7th ed.). Burlington, MA: Jones and Bartlett Publishers.
4. Sinz, E. and Navarro, K. (eds.) (2011). Advanced Cardiovascular Life
Support, Provider Manual. American Heart Association.

5. Tintinalli, J. E. (2011). Emergency Medicine (7th ed.). New York: McGraw-

Hill.

6. Zafari, A. M., et al. (2012, December 14) emedicine.medscape.com.

“Myocardial Infarction” Retrieved from http://emedicine.medscape.com/.