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AMI/ACS Diagnosis: History and Physical
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  1. AMI/ACS Diagnosis:History and Physical

  2. AMI/ACS Diagnosis: History • How do we assess risk in chest pain patients?

  3. AMI/ACS: Risk Assessment • Pain characteristics • Palliative/provocative features • Associated cardiac symptoms • Cardiac history • Cardiac risk factors • Family Hx: early AMI, sudden death

  4. AMI/ACS: Risk Assessment • Low, medium, high risk • Does the patient have an acute coronary syndrome (ACS)? • Is there a ruptured plaque that is occluded by a white or red thrombus?

  5. AMI/ACSHistory • Important clinical tool • Chest pain may not be “classic” • Crushing, heaviness 24% • Burning pain 23% • Pleuritic pain 19% • Reproducible pain 8-15% • Sharp/stabbing pain 5%

  6. Anginal Equivalents • 25-30% of MI’s clinically silent • Diabetic and elderly at risk • Older pts • Less likely to present with CP • Less likely to have diaphoresis, N/V • SOB, dizziness, syncope may be sx

  7. Anginal EquivalentsAtypical Presentations • Back, neck, jaw, abdominal pain • Dyspnea • Diaphoresis • N/V • Syncope • Confusion • Generalized weakness • Dizziness, TIA

  8. AMI/ACSHistory • Associated symptoms • Diaphoresis 80% • Nausea 60% • Belching 47% • Vomiting 39%

  9. Coronary AtherosclerosisRisk Factors • Male gender • Age > 50 • HTN • Diabetes • Hypercholesterolemia • Post menopausal • Family history of atherosclerosis

  10. Coronary AtherosclerosisRisk Factors • Smoking • Cocaine usage • Peripheral Vascular Disease • Obesity • Hyper-triglyceridemia

  11. AMI/ACS History: Prior Cardiac Catheterization • How long of a time does the report of a “negative” cardiac catheterization exclude a likely acute coronary syndrome?

  12. AMI/ACS History: Prior Cardiac Catheterization • Perhaps 6-12 months, unless patient presents with STEMI or unstable • Must determine clean coronaries as opposed to non-occlusive lesions • The latter addresses the 60% lesion that is prone to disruption and STEMI

  13. AMI/ACS Diagnosis Physical Exam • Pleuritic, positional pain • Palpable tenderness • CHF, DVT, PE, AAA • New murmur (valve) • Unequal BP, pulses • Cardiac dysrhythmia

  14. AMI/ACS Diagnosis:EKG

  15. AMI/ACS Diagnosis: EKG • How do we diagnose AMI/ACS? • How soon after triage should the first EKG be performed?

  16. EKG Diagnosis Ischemia or NSTEMI (ACS) • Ischemia or NSTEMI • ST segment depression • Symmetric T wave inversions • Inverted/biphasic T waves • Non-specific ST or T ’s

  17. EKG Diagnosis Acute Myocardial Infarction • Infarction (AMI) • Peaked T waves (earliest finding) • ST segment elevation • Normalization of ST segment • Development of Q waves

  18. AMI/ACS: EKG Localization

  19. AMI/ACS: EKG Localization

  20. I lateral aVR V1 septal V4 anterior II inferior aVL lateral V2 septal V5 lateral III inferior aVF inferior V3 anterior V6 lateral AMI/ACS: EKG Localization

  21. AMI/ACS: Coronary Arteries • Left • Septal wall of LV • Anterior and lateral walls of LV • Inferior wall LV (10%) • Both bundle branches • Right • Inferior wall of LV • Posterior wall of LV (90%) • AV node (90%) • Right ventricle

  22. Anteroseptal MI • ST elevation in V1, V2

  23. Anteroseptal MI • ST elevation in V1, V2

  24. Anterior Wall MI • ST elevation in V2, V3

  25. Anterolateral Wall MI • ST elevation in V2-V6

  26. Anterolateral Wall MI • ST elevation in V4, V5

  27. Inferior Wall MI • ST elevation in II, III, AVF

  28. AMI/ACS Diagnosis: EKG • How do we diagnose true posterior wall AMI? RV AMI?

  29. True Posterior AMI • Initial R waves V1, V2; R/S ratio >1

  30. True Posterior AMI • Initial R waves V1, V2; R/S ratio >1

  31. Right Ventricular AMI • ST elevation in II, III, aVF • Also noted in in V4R to V6R

  32. Right Ventricular AMI • RCA occlusion • Inferior and RV infarction

  33. AMI Diagnosis: EKG • What are the indications for additional EKG leads? Which are done? How? Why?

  34. V1 V3 V4R V8 V9 Lead Placement for aRV and Posterior ECG V2

  35. AMI/ACS: EKG Extra Leads • EKG shows posterior wall AMI • Inferior wall MI with hypotension: ??? RV infarction • Ischemic changes, cardiogenic shock, search for PTCA indications

  36. Lead V4R = diagnostic ST-segment elevation Right-sided 12-Lead ECG: Patient With Inferior ST-Segment Changes

  37. AMI/ACS: EKG Extra Leads • Zalenski extra leads study • Inf AMI, 14% complications • Inf AMI and RV AMI, 26%

  38. EKG Diagnosis AMI/ACS Dx in LBBB • Rules for detecting MI with LBBB •  ST > 1mm and concordant with QRS = 5 pts •  ST > 1mm in V1, V2, or V3 = 3 pts •  ST > 5mm and discordant with QRS = 2 pts • Higher scores more likely MI present with LBBB

  39. EKG Diagnosis AMI/ACS Dx in LBBB

  40. EKG Diagnosis ST Elevation in Pericarditis • Diffuse ST elevation, atypical

  41. AMI/ACSEKG Diagnosis • EKG non-diagnostic in 50% of AMI cases (NSTEMI) • Cardiac enzymes useful • Serial EKGs useful

  42. AMI/ACS Dx: EKG Timing • An EKG should be obtained within 10 minutes of presentation and initial triage