How about if the chest pain is resolved, but there is still ST elevation? That was assessed in this study by Schomig et al. Lastly, when is it too late for emergent PCI? Never, if there is persistent chest pain. Hazard of 90-day mortality and a 90% relative increase in the hazard ofĭeath, shock, and CHF." Thus, another study shows that the ECG is a better marker of "acuteness" of the ECG than is time of symptom onset. Onset was significantly associated with a 78% relative increase in the Multivariable adjustment, baseline Q-wave but not time from symptom More recently, Armstrong et al. showed that Q-waves on the baseline ECG are an independent marker of worse clinical outcome and, importantly, "after These patients had larger final infarct size, but equal benefit from thrombolytic therapy. Raitt et al. found in a subgroup of 432 first MI patients whose ECG was recorded within the first hour after onset of chest pain that pathologic Q-waves were already present, and this was particularly true for anterior MI patients. Q-waves are often seen in the first hour after pain onset. Unless there are important contraindications to reperfusion (i.e., high bleeding risk), then either tPA or PCI are indicated. Moreover, the chest pain is less than 12 hours. The Q-waves are the only indicator of prolonged ischemia. In this case, the ST segments are high, the T-waves are large, and there is no T-wave inversion. Absence of T-wave inversion all indicators of high acuity.Īt the bottom, I have reprinted a section that I wrote on "Acuteness" that comes from a chapter on reperfusion thereapy that I wrote with Bill Brady. The best indicator of MI "Acuteness" is the ECG, with these as indicators of high acuteness:Ĥ. Many MIs have dynamic occlusion and reperfusion of the infarct-related artery and the pain can go on for days without any significnat necrosis. There are many STEMI, however, which will benefit beyond 12 hours of chest pain: the time onset of chest pain is not necessarily the time of onset of irreversible ischemia. The FTT collaborative group meta-analysis confirmed this, and the benefit at various time points after pain onset is best described in the paper by Boersma (see Table below). Time window for thrombolytics: The GISSI and the LATE trial both established that late thrombolysis, up to 12 hours after onset of chest pain, is beneficial for STEMI. Question 2 is answered extensively below. Let's answer question 1: The T-waves are too tall for LV aneurysm! You can use this LV Aneurysm Rule to Determine whether there is acute STEMI or ST elevation due to LV aneurysm. Do these Q-waves imply that the STEMI is too far progressed for benefit from tPA? How do we know these QS-waves do not represent LV aneurysm?Ģ. There is diagnostic ST elevation with large T-waves. BP was 250/120, and after placement on an IV nitroglycerine drip, BP declined to 170/90. A 50 year old hypertensive presented with 9 hours of central crushing chest pain.
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