STEMI

Clinical History
Usual precipitants are vigorous physical activities, emotional stress, or
medical/surgical illness
Similar to angina pectoris but usually more severe and lasts longer
Can occur at rest; does not subside with cessation of activity
Heavy, squeezing, crushing pain; occasionally stabbing or burning
Involves central portion of chest and/or epigastrium
Radiation:
o Arms
o less common sites: abdomen, back, lower jaw, neck; can be as high as
the occipital area but not below the umbilicus
Associated symptoms:
o weakness, sweating, nausea, vomiting, anxiety, and sense of
impending doom
In diabetics, proportion of painless STEMI is greater
In the elderly, STEMI may present as sudden-onset breathlessness
Less common presentations
o Loss of consciousness, confusional state, sensation of profound
weakness, appearance of arrhythmia, evidence of peripheral
embolism, unexplained drop in arterial pressure
Physical Findings
Anxious and restless
Pallor associated with perspiration and coolness of extremities
Substernal chest pain > 30 mins + diaphoresis
Normal pulse rate and BP within 1st hour
o of patients with anterior infarct have sympathetic hyperactivity
o of patients with inferior infarct have parasympathetic hyperactivity
Precordium usually quiet, apical impulse difficult to palpate
3rd and 4th heart sounds, decreased 1st heart sound, splitting of 2nd heart
sound
Carotid pulse decreased in volume
Temperatures up to 38C during first week
Arterial pulse variable
ECG

ST-segment elevation due to total occlusion of an epicardial coronary artery

May evolve Q waves transiently

Cardiac Biomarkers
Cardiac-specific troponin T (cTnT) and Cardiac-specific troponin I (cTnI)
o Rises within 3-6 hours, peaks in 20 hours, may last up to 14 days
o May increase to levels > 20 times higher
o Remain elevated for 7-10 days
Creatinine phosphokinase (CK) and its MB isozyme (CKMB)
o CK rises within 4-8 hours, peaks in 12-24 hours, returns to normal by
48-72 hours

CKMB

Low specificity for STEMI

May be elevated with skeletal muscle disease or trauma
CK activity > 2.5 suggest skeletal source
more specific for STEMI

Cardiac Imaging
2D echo wall motion abnormalities
Radionuclide imaging lack sensitivity and specificity
Hi-res cardiac MRI accurately detects MI
UA/NSTEMI
Clinical History / Physical Findings
Chest pain typically substernal, sometimes epigastric
Radiates to neck, left shoulder, and/or left arm
Anginal equivalents
o Dyspnea and epigastric discomfort
o More common in women
Findings resembling STEMI
o Diaophoresis; pale, cool skin; sinus tachycardia; 3 rd or 4th heart sound;
basilar rales; sometimes hypotension
o If patient has a large area of myocardial ischemia or large NSTEMI
ECG
Unstable angina
In 30-50% of patients:
o ST-segment depression
o transient ST-segment elevation
o T-wave inversion in 30-50% of patients
ST-segment deviation
o important predictor of adverse outcome
o even if only 0.05 mV
T-wave changes
o sensitive for ischemia but less specific
o unless they are new, deep T-wave inversions (> 0.3 mV)
Cardiac Biomarkers
UA/NSTEMI
CKMB
Troponin
o More specific and sensitive marker of myocardial necrosis
o patients who have elevated biomarkers of necrosis (CKMB, Troponin)
are at increased risk for death or recurrent MI
o may be slightly elevated in CHF, myocarditis, or pulmonary embolism
Stress testing