1.3 case presentation - stemi mimickers - dr. isabella sp.jp(1)

8/18/2019 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

http://www.google.co.id/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&ved=0CAcQjRxqFQoTCOrhxrb678cCFVIkjgodJ-UHNQ&url=http://openi.nlm.nih.gov/detailedresult.php?img%3D2526426_jkms-23-350-g003%26req%3D4&psig=AFQjCNGWry7ZCKPodC8SKGSJ_IMFpmD0Mg&ust=1442094385860397http://www.google.co.id/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&ved=0CAcQjRxqFQoTCOrhxrb678cCFVIkjgodJ-UHNQ&url=http://openi.nlm.nih.gov/detailedresult.php?img%3D2526426_jkms-23-350-g003%26req%3D4&psig=AFQjCNGWry7ZCKPodC8SKGSJ_IMFpmD0Mg&ust=1442094385860397


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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)

•

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%

•

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.

•

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.

•

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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1.3 case presentation - stemi mimickers - dr. isabella sp.jp(1)

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