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The 4 Ds of STEMI Survival Door ·          EMS personnel should transport a patient with a suspected STEMI directly to a PCI capable hospital ·          Door to needle time is 30 minute ·          Door to balloon time less than 90 minutes ·          High risk patients in cardiogenic shock transferred within 30 minutes Data ·          Time of onset of symptoms ·          Obtain targeted history ·          Obtain 12 lead ·          Obtain VS ·          Review fibrinolytic check list ·          Obtain labs ·          Obtain PCXR...

Absolute Contraindications for Fibrinolytic Therapy* ·          Any prior intracranial hemorrhage ·          Known structural cerebral vascular lesion (eg, AVM) ·          Known malignant intracranial neoplasm (primary or metastatic) ·          Ischemic stroke within 3 months EXCEPT acute ischemic stroke within 3 hours Absolute Contraindications for Fibrinolytic Therapy* ·          Suspected aortic dissection ·          Active bleeding or bleeding diathesis (excluding menses) ·          Significant closed head trauma or facial trauma within 3 months Note:   Contraindications and cautions for fibrinolytic use in STEMI from ACC/AHA 2004 Guideline Update* Relative Contraindications for Fibrinolytic The...

Reperfusion ·          Restores flow in the infarct-related artery ·          Limits infarct size ·          Reduces mortality rates ·          Optimal fibrinolysis restores normal coronary flow in 50% to 60% of subjects ·          PPCI is able to achieve restored flow in >90% of subjects. Note:   The patency rates achieved with PPCI translates into reduced mortality and reinfarction rates as compared to fibrinolytic therapy. This benefit is even greater in patients presenting with cardiogenic shock. PPCI also results in a decreased risk of intracranial hemorrhage and stroke, making it the reperfusion strategy of choice Circulation. 2010; 122: S787-S817 doi: 10.1161/​CIRCULATIONAHA.110.971028 Key to Reperfusion Therapy ·          The k...

Clopidogrel ·          Oral thienopyridine that irreversibly inhibits the adenosine diphosphate receptor on the platelets, resulting in a reduction in platelet aggregation ·          AHA guidelines recommend withholding clopidogrel for 5 to 7 days in patients for whom CABG is anticipated ·          Patients <75 years of age a loading dose of clopidogrel 300 to 600 mg with non-STE ACS and STEMI followed   by maintenance dose of 75mg/day   is recommended ·          Give 300-mg of clopidogrel to ED patients with suspected ACS (without ECG or cardiac marker changes) who are unable to take aspirin ·          Little evidence on the use of a loading dose of clopidogrel in patients aged ≥ 75 years of age with NSTEMI and STEMI treated by PPCI Prasugrel ·     ...

Unfractionated Heparin ·          Prevents thrombus formation over ruptured plaque surface ·          Prevents recurrence of thrombosis ·          Maintains patency of infarct-related artery ·          Prevent mural thrombus formation in patients with large infarctions Unfractionated Heparin Disadvantages ·          Need for IV administration ·          Frequent monitoring of aPTT ·          Unpredictable anticoagulant response patients ·          May stimulate platelet activation, causing thrombocytopenia. Unfractionated Heparin dosage ·          Initial bolus 60u/kg IV (maximum bolus: 4000 units) ·     ...

Myocardial Ischemia with Inverted T waves Myocardial Ischemia with Inverted T waves in I, II, AVF, V3, V4, V5, V6 Anteriolateral Ischemia with inverted T waves Anteriolateral ischemia with inverted T waves in V1-V4, V5-V6 Adjunctive Treatments ·          Beta blockers IV ·          Nitroglycerine IV ·          UF H eparin IV or LMWH ·          Ace Inhibitors Beta blockers ·          Decrease catecholamine levels ·          Reduce discharge from the sinus node ·          Lower blood pressure ·          Reduce myocardial contractility ·          Reduce myocardial oxygen consumption Note: ...

Anatomic regions ·          I, aVL, V5, V6                              High lateral wall ·         V5, V6                                          Low lateral wall ·          II, III, aVF                                     Inferior wall ·          V1-V4                           ...

ECG classification: ST Depression ·          ST depression or T-wave inversion ·          Ischemic ST-segment depression >0.5 mm (0.05 mV) or dynamic T-wave inversion with pain or discomfort is classified as UA/NSTEMI. ·          Nonpersistent or transient ST-segment elevation ≥ 0.5 mm for 20 minutes is also included in this category Note:   Threshold values for ST-segment depression consistent with ischemia are J-point depression 0.05 mV (-0.5 mm) in leads V2 and V3 and -0.1 mV (-1 mm) in all other leads (men and women) ECG classification ·          Nondiagnostic or normal ECG ·          Nondiagnostic ECG with either normal or nonspecific ST-segment or T-wave changes. ·          ST-segment deviation of 0.5 mm or T-wave inversion of ≤ 0....