Presentation is loading. Please wait.

Presentation is loading. Please wait.

Leanna R. Miller, RN, MN, CCRN-CSC, PCCN-CMC, CEN, CNRN, CMSRN, NP Education Specialist LRM Consulting Nashville, TN.

Similar presentations


Presentation on theme: "Leanna R. Miller, RN, MN, CCRN-CSC, PCCN-CMC, CEN, CNRN, CMSRN, NP Education Specialist LRM Consulting Nashville, TN."— Presentation transcript:

1 Leanna R. Miller, RN, MN, CCRN-CSC, PCCN-CMC, CEN, CNRN, CMSRN, NP Education Specialist LRM Consulting Nashville, TN

2 Place Your Phone & Beeper on Silence!!!

3 Objectives – Evaluate common abnormalities that mimic myocardial infarction. – Identify the criteria for pericarditis and evidence – based interventions. – Differentiate between pulmonary embolus and myocardial infarction using diagnostic criteria. ST Segment Changes: Identifying MI Mimics

4  Acute Coronary Syndromes – Unstable Angina – Non ST segment Elevation MI (NSTEMI) – ST segment Elevation MI (STEMI) ST Segment Changes: Identifying MI Mimics

5

6  Acute Coronary Syndromes – Clinical Symptoms typical atypical ST Segment Changes: Identifying MI Mimics

7  Acute Coronary Syndromes – Diagnostics Echocardiography Lab – ABGs – H & H – enzymes ST Segment Changes: Identifying MI Mimics

8  Acute Coronary Syndromes – Diagnostics ECG (12 or 15 lead) – T wave inversion – ST segment elevation – Q wave – reciprocal ST segment depression ST Segment Changes: Identifying MI Mimics

9

10 SITEINDICATIVERECIPROCAL SeptalV 1, V 2 None AnteriorV 2, V 3, V 4 None AnteroseptalV 1, V 2, V 3, V 4 None LateralI, aVL, V 5, V 6 II, III, aVF AnterolateralI, aVL, V 3, V 4, V 5, V 6 II, III, aVF InferiorII, III, aVFI, aVL, V 2, V 3 PosteriorNoneV 1, V 2

11 ST Segment Changes: Identifying MI Mimics

12 Variation to ST – Segment Elevation ST Segment Changes: Identifying MI Mimics

13

14 High acute risk factors for progression to myocardial infarction or death – recurrent chest pain at rest – dynamic ST-segment changes: ST-segment depression > 0.1 mV or transient ( 0.1 mV – elevated Troponin-I, Troponin-T, or CK-MB levels ST Segment Changes: Identifying MI Mimics

15 High acute risk factors for progression to myocardial infarction or death – hemodynamic instability within the observation period – major arrhythmias (ventricular tachycardia, ventricular fibrillation) – early post-infarction unstable angina – diabetes mellitus ST Segment Changes: Identifying MI Mimics

16

17

18

19

20

21

22  Acute Pericarditis Introduction – causes physical discomfort – predisposition to tachydysrhythmias ST Segment Changes: Identifying MI Mimics

23  Acute Pericarditis ECG Criteria – ST segment elevation – PR segment depression – T wave flattening or inversion – atrial dysrhythmias ST Segment Changes: Identifying MI Mimics

24  Acute Pericarditis ST segment elevation – not isolated or discrete segments – upward concavity – may be notching at the junction of QRS and ST segment – no reciprocal ST segment depression ST Segment Changes: Identifying MI Mimics

25  Acute Pericarditis PR interval – interval between end of P wave and beginning of QRS may be depressed – most often seen in lead II and V leads may be only ECG finding ST Segment Changes: Identifying MI Mimics

26  Acute Pericarditis T wave flattening or inversion – no T wave inversion during acute phase – uncomplicated pericarditis: negative T waves only occur in leads which usually have negative T waves (aVR & V 1 ) ST Segment Changes: Identifying MI Mimics

27  Acute Pericarditis Atrial dysrhythmias – SVT in postoperative open heart patient – treat with low dose steroids ST Segment Changes: Identifying MI Mimics

28

29  Acute Pericarditis Complications (pericardial effusion) – dampening of electrical output – low voltage in all leads – ST segment & T wave changes ST Segment Changes: Identifying MI Mimics

30  Acute Pericarditis Complications (pericardial effusion) – freely rotating heart produces electrical alternans ST Segment Changes: Identifying MI Mimics

31  Dressler’s Syndrome Introduction – postmyocardial infarction syndrome – autoimmune process ST Segment Changes: Identifying MI Mimics

32  Dressler’s Syndrome Clinical Presentation – low – grade fever – chest pain (worsens with deep breath; lessens with sitting up and leaning forward) – pericardial friction rub ST Segment Changes: Identifying MI Mimics

33  Dressler’s Syndrome 12 – lead ECG – diffuse ST segment elevation across the precordial leads ST Segment Changes: Identifying MI Mimics

34  Dressler’s Syndrome Treatment – corticosteroid administration – monitor for complications (effusion) ST Segment Changes: Identifying MI Mimics

35  Pulmonary Embolus Introduction – sudden massive PE produces ECG changes – must get 12 – lead to rule out MI ST Segment Changes: Identifying MI Mimics

36  Pulmonary Embolus ECG Findings – RVH with strain – RBBB pattern in V 1 – large S wave in Lead I; large Q wave in Lead III (S 1 Q 3 pattern) ST Segment Changes: Identifying MI Mimics

37

38

39  Ventricular Aneurysm Introduction (etiology) – myocardial infarction – congenital – cardiomyopathy – inflammatory – idiopathic ST Segment Changes: Identifying MI Mimics

40  Ventricular Aneurysm Introduction – infereolateral wall of LV – symptoms include CHF & exercise – induced syncope (VT) ST Segment Changes: Identifying MI Mimics

41  Ventricular Aneurysm ECG Findings – persistent ST segment elevation – small q wave in II, III, & aVF – sustained VT with RBBB morphology ST Segment Changes: Identifying MI Mimics

42

43

44

45  Ventricular Aneurysm Treatment – surgical resection – antidysrhythmics – anticoagulants – treat heart failure – ablation therapy ST Segment Changes: Identifying MI Mimics

46

47  Left Bundle Branch Block (LBBB) QRS duration > 0.12 second absence of septal q waves and S wave in I, aVL, & V 5 – 6 (+ complex usually notched) broad QS or rS in V 1 – 3 (- complex) ST Segment Changes: Identifying MI Mimics

48  Left Bundle Branch Block (LBBB) S – T, T wave changes in leads I, aVL & V 5 – 6 (T wave opposite QRS) delayed intrinsicoid deflection over left ventricle (V 6 ); normal over V 1 ST Segment Changes: Identifying MI Mimics

49  Left Bundle Branch Block (LBBB) hypertensive heart disease aortic stenosis degenerative changes of the conduction system coronary artery disease ST Segment Changes: Identifying MI Mimics

50

51

52

53

54

55 LBBB with Acute Myocardial Infarction ST Segment Changes: Identifying MI Mimics

56 Left Ventricular Hypertrophy ST Segment Changes: Identifying MI Mimics

57

58 Left Ventricular Hypertrophy ST Segment Changes: Identifying MI Mimics

59 Brugada Syndrome – autosomal dominant inheritance (SCN5A) gene – sodium channel involvement in 25% of the patients – Asian populations (58%) – high incidence of polymorphic ventricular tachycardias ST Segment Changes: Identifying MI Mimics

60 Brugada Syndrome – found in right precordial leads – prominent J wave – ST – segment elevation in the absence of structural heart disease – three types ST Segment Changes: Identifying MI Mimics

61 Brugada Syndrome – Type I: ST – segment elevation is triangular and T waves may be inverted in V 1 – V 3 – Type II: downward displacement of ST – segment (does not reach baseline) – Type III: middle part of ST segment touches baseline ST Segment Changes: Identifying MI Mimics

62

63 Brugada Syndrome ST Segment Changes: Identifying MI Mimics

64 LBBB Infarction Resemblance –ST segment elevation in the negatively deflected leads, (V 1 – V 3 ) –QS complexes in the negatively deflected leads, (V 1 – V 3 ) Recognition –Wide QRS –QS in V 1 ST Segment Changes: Identifying MI Mimics

65 Ventricular Rhythms Infarction Resemblance –ST segment elevation in the negatively deflected leads, (V 1 – V 3 ) –QS complexes in the negatively deflected leads, (V 1 – V 3 ) Recognition –Wide QRS following pacer spike –Negative V 1 (RV paced) ST Segment Changes: Identifying MI Mimics

66 LVH Infarction Resemblance –ST segment elevation in the negatively deflected leads, (V 1 – V 3 ) Recognition –Choose deepest S wave from V 1 and V 2 –Choose tallest R wave from V 5 and V 6 –Add deflections of tallest R wave and deepest S wave –Suspect LVH if total is > 35 ST Segment Changes: Identifying MI Mimics

67 Pericarditis Infarction Resemblance –ST segment elements in multiple leads Recognition –ST segment elevation not in anatomical grouping –PR segment deprewsion –Notching of the J point ST Segment Changes: Identifying MI Mimics

68 Acute Pulmonary Emboli Infarction Resemblance –RVH with strain pattern –RBBB pattern in V 1 –S 1 Q 3 on frontal plane Recognition –Patient is symptomatic with atypical cardiac pain –Elevates BMP –r/o with spiral CT/angiogram ST Segment Changes: Identifying MI Mimics

69 Ventricular Aneurysm Infarction Resemblance –High risk for ventricular dysrhythmias (VT with RBBB pattern) –Inferolateral MI –Persistent ST segment elevation –Small q wave in II, III, aVL Recognition –Structural abnormality on ECHO –CHF & exercise – induced syncope (VT) ST Segment Changes: Identifying MI Mimics

70 Brugada Syndrome Infarction Resemblance –Ventricular dysrhythmias (polymorphic VT) –ST segment elevation in right precordial leads Recognition –Autosomal dominant –Asian culture –No structural abnormality noted on ECHO ST Segment Changes: Identifying MI Mimics

71 Prominent J with ST segment elevations – septal MI – RV cardiomyopathy – pericardial effusion – hypercalcemia ST Segment Changes: Identifying MI Mimics

72 Prominent J with ST segment elevations – hyperkalemia – acute pulmonary embolism – subarachnoid hemorrhage – tricyclic antidepressant intoxication ST Segment Changes: Identifying MI Mimics

73

74 In Conclusion – is the patient having a MI? – a variety of conditions can mimic infarction  ST segment changes ST Segment Changes: Identifying MI Mimics


Download ppt "Leanna R. Miller, RN, MN, CCRN-CSC, PCCN-CMC, CEN, CNRN, CMSRN, NP Education Specialist LRM Consulting Nashville, TN."

Similar presentations


Ads by Google