✅ STEMI

‼️تنطیمات دستگاه: باید روی سرعت 25mm/sec و ولتاژ 10mm/mv باشه.

پارت سوم ACS/ECG
STEMI
اکثر نکات در اوردر و تصاویر آورده شده اند.

▪️ما یه سری تغییرات نواری داریم که بهشون میگن STE equivalents، یعنی هم‌وزن انسداد عروق کرونر در کسی که درد قفسه سینه یا سایر علائم ACS رو داره ما MI درنظر میگیریمشون.(مثل newly identified LBBB, de winter sign و...). اینها چیزایی هستن که باید حواسمون باشه miss نکنیم.

▪️حواسمون به تعییرات reciprocal هم توی نوار باشه. هروقت توی بیمار علامتدار STD دیدیم، دنبال STE هم بگردیم.(توی بقیه لیدها و یا لیدهای راست و پوستریور)

▪️RV MI

▫️حواسمون به RV MI باشه مخصوصا در افرادی که inf MI کردند( به علت مسیر عروقی که اول قلب راست رو خون میده و بعد بخش تحتانی، پس اگه بالاتر انسداد داشته باشیم میتونه RV MI هم بده. پس در هرفرد با inf mi ما درخواست نوار right هم میکنیم.

▫️چرا مهمه؟ چون منجمنت قلب راست کمی با قلب چپ متفاوته، مثلا نباید tng, duretic, opioid بدیم چون اینجا قلب راست preload dependent هست و با اینا ما پره لود رو کمتر میکنیم( سایر مواردی که توی اوردرها اشاره شده.)

▫️Diagnosis: The diagnosis of RVMI is strongly suspected when hypotension, raised jugular venous pressure
(distended neck veins), and clear lung fields are present in a patient whose 12-lead ECG has findings of
an acute inferior wall infarction as well as ST elevation(>1mm) in lead V4R.

▫️Urgent echocardiography (often at the bedside), including evaluation for RV infarction, should be
performed in patients with an inferior MI and evidence of hemodynamic compromise. In patients
without hemodynamic compromise, this test should not delay referral of such patients to the cardiac
catheterization laboratory for emergency percutaneous revascularization of the culprit vessel

▪️ نوار و تروپ اولیه اگه نرمال باشند رد کننده MI نیستند، پس توی هر فرد مشکوک ما نوار و تروپ سریال چک میکنیم. توالی MI رو هم بهتره بدانیم.

▪️یه سری اصطلاحات داریم مثل Door-to-balloon time, Door-to-needle time, … که یکیش بیشتر برای ما مهمه FMC هست که میگیم اگه کمتر از 120 دقیقه باشه pci میفرستیم(استثنا هم میشه کاردیوژنیک شوک که پایین تر میگم)

▫️First medical contact-to-balloon or -needle time: This is the time between first medical contact
(FMC) with the patient, which may be out of hospital, to first balloon inflation or administration of
fibrinolytic therapy via IV, respectively. FMC typically refers to the time of STEMI diagnosis via
electrocardiogram (ECG).

▪️Echocardiography, computed tomographic angiography, and other imaging studies are not routinely
obtained unless a specific diagnosis is suspected (eg, aortic dissection, pericardial tamponade.


🔹Selecting reperfusion strategy

▪️Approach in most patients – We recommend reperfusion in all patients with (STEMI)

▪️Patients with symptoms less than 12 hours and PCI immediately available:

▫️FMC-to-PCI (ie, balloon inflation) is approximately 120 minutes or less, we recommend primary PCI as soon as possible rather than fibrinolytic therapy.

▫️Patients with symptoms less than 12 hours and PCI delayed >120 minutes (we use a pharmacoinvasive strategy that includes both) :
*Immediate fibrinolysis and
*Routine angiography 6 to 24 hours after fibrinolysis:
In patients who will receive fibrinolysis, we recommend transfer for routine angiography with PCI as needed within 6 to 24 hours immediately after initiation of fibrinolytic therapy rather than using the response to fibrinolytic therapy to determine the need for transfer and angiography

▪️Patients with symptoms between 12-48h
we suggest PCI as soon as possible rather
than fibrinolytic therapy or no attempt at reperfusion

▪️Patients with STEMI presenting more than 48 hours after the onset of symptoms(reperfusion is individualized)

▫️Clinical features that may favor PCI include unclear timing of symptoms onset, relapsing and remitting symptoms, or ongoing cardiogenic shock or other complications related to ischemia (eg, arrhythmias, heart failure).
However, there are few data to support routine PCI in this setting
🔻In patients who present beyond 48 hours after symptom onset, the aggregate data suggest that PCI
and fibrinolysis are not effective.