BEDSIDE ASSESSMENT OF PATIENTS WITH...

BEDSIDE ASSESSMENT OF PATIENTS WITH STEMI

Prof. Maria Dorobantu, PhD, FESC, FACCEmergency Hospital of Bucharest, Romania

Presenter Disclosures

There are no conflicts/ grants/ disclosures for this presentation.

Ecocardiographic assessment

Positive diagnosis

Differential diagnosis

Hemodynamic assessment

Reperfusion treatment efficacy

Complications

3.Metabolic impairment

4. Abnormal wall motionDiastolic dysfunction

6. Pain

5.ECG changes

7.Myocardial injury markers

8.Necrosis

2. Perfusion heterogeneity

1. Reduced coronary flow

Sb=80-90%; Sp=80-90% for nontransmural MI

Sb=90-95%; Sp=89% for transmural MI

New definition of AMI

Detection of rise and/or fall cardiac biomarkers (preferably troponin) with at least one value above the 99 th percentile of the upper reference limit together with evidence of ischemia with at least one of the following:

Symptoms of ischemia

ECG changes of new ischemia (new ST-T changes or new LBBB)

Development of pathological Q waves in the ECG

Imaging evidence of new loss of viable myocardium or new regional wall motion abnormality

ESC-ACCF-AHA-WHF Universal Definition of Myocardial Infarction 2007

Positive diagnosis

Complications

LBBB with ischemia LBBB without ischemia

- Apex and anterior wall

- Abnormal LV geometry- Loss of thickness- Dissyncronism-

- No apex and anterior wall- Normal geometry- Multiphasis contraction- Dissyncronism +

Aortic dissection

Pulmonary embolism

Myopericarditis

Wang K, Asinger RW, Marriott HJ. ST-segment elevation in conditions other than acute myocardial infarction. N Engl J Med 2003; 349:2128-35.

Gu YL, Silvas T, van der Horst ICC, Zijlstra F, Conditions mimicking acute ST-elevation myocardial infarction in patients reffered for primary percutaneous intervention, Neth Heart J 2008; 16(10):325-331.

Costantini M,Tritto C, Licci E, et al. Myocarditis with ST-Elevation Myocardial Infarction presentation in young man. A case series of 11 patients. Int J Cardiol 2005;101:157-8.

Positive diagnosis

Complications

LVD and LVS volumes

Left ventricular ejection fraction

Diastolic transmitral inflow and left atrium intracapillary pressure

Cardiac output

Right ventricular function

E/E´rate

DABAGHI SF, ROKEY R, RIVERA JM, SALIBA WI, MAJID PA: Comparison of echocardiographic assessment of cardiac hemodynamics in the intensive care unit with right-sided cardiac catheterization. Am J Cardiol 1995; 76(5): 392-395.

MCGOWAN JH, CLELAND GF: Reliability of reporting left ventricular systolic function by echocardiography:a systematic review of 3 methods. Am Heart J 2003; 146: 388-397.

Positive diagnosis

Complications

Larson DM, Menssen KM, Johnson RK, et al. False positive ST elevation in patients undergoing direct percutaneous coronary intervention. Circulation2006;114:II-346.

Van T’ Hof AWJ, Zijlstra F, The success of primary angioplasty: Beyond TIMI flow, Acute Card Care 2009, 11(2): 66-68

Positive diagnosis

Complications

Ventricular remodeling

Intracavitary thrombosis

Ischaemic mitral regurgitation

Prognosis in Ischemic MR

Quantitative Echocardiography

Mayo Clinic 303 pts with AMI & IMR vs 191 pts with AMI no IMR 5 y mortalityERO > 20mm2 - risc 2,23 (p<0.003) ERO < 20mm2 - risc 1,65 (p<0.049)

Grigioni &c Circ 2001 103

Pericardial effusion

Mechanical complicationsRupture of IVS

Mechanical complicationsRupture of papillary muscle

Mechanical complicationsRupture of free wall

Conclusions

Echocardiography is a safe and easy to perform non-invasive method for patients with STEMI, to be used at bedside.

Echocardiography represents a very important diagnostic tool in difficult cases.

All patients with acute myocardial infarction must be evaluated by echocardiography for hemodynamic and complications’ assessment.

BEDSIDE ASSESSMENT OF PATIENTS WITH...

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