3. STEMI Definition

4.  In the absence of LBBB or LVH  New ST elevation at the J point in at least 2 contiguous leads of:  2 mm (0.2 mV) in men or 1.5 mm (0.15 mV) in women in leads V2–V3 and/or  of 1 mm (0.1 mV) in other contiguous chest leads or the limb leads  ST depression in 2 precordial leads (V1–V4) may indicate transmural posterior injury

5. STEMI Definition  Caveats  Most cases of LBBB at time of presentation are “not known to be old” because of ECG is not available for comparison.  New or presumably new LBBB at presentation occurs infrequently  Interfere with ST-elevation analysis, and  Should not be considered diagnostic of acute MI in isolation  Baseline ECG abnormalities other than LBBB (LVH, Brugadda, V paced) obscure STEMI assessment

6. Jain et al. Am J Cardiol 2011;107: 1111–1116

7. 7 Hospitalizations in the U.S. Due to Acute Coronary Syndromes (ACS) Acute Coronary Syndromes* 1.57 Million Hospital Admissions - ACS UA/NSTEMI † STEMI 1.24 million Admissions per year.33 million Admissions per year Heart Disease and Stroke Statistics – 2007 Update. Circulation 2007; 115:69-171. *Primary and secondary diagnoses. †About 0.57 million NSTEMI and 0.67 million UA.

8. STEMI Epidemiology

9. STEMI Facts  In hospital and 1 year mortality continue to decline  Reperfusion therapy  Earlier recognition  “Time is myocardium”  Target Areas For Improvement  Women, Non-whites, Diabetics, Elderly, CKD/ESRD

10. STEMI Timeline

11. STEMI Guidelines – Cath Activation

12. STEMI Guidelines

13. Platelets Role in Thrombosis Reproduced with permission from Cannon CP. Atherothrombosis slide compendium. Available at: www.theheart.org. Aggregation 3 1 Activation 2 Adhesion

14. Pathways to Clot Formation White HD. AM J Cardiol 1997; 80:2B-10B Schafer A. J Clin Invest 1986; 78:73-79 DeJong MJ, et al. Critical Care Nursing Clin of N Am 1999; 11:355-371

15. STEMI Guidelines - Fibrinolytic

19. STEMI Guidelines - Hypothermia

20. STEMI Guidelines - Anticoagulation

22. An Electrical Beat

23. Many faces of normal ST segments

24. Pathologic ST segments

25. ECG

40. THANK YOU University of California Davis Medical Center