Rebellion in EM 2018: STEMI Equivalents by Tarlan Hedayati, MD

The 1^stannual Rebellion in EM Clinical Conference took place in San Antonio, TX on May 11^th– 13^th, 2018.  If you missed out in 2018, the Rebellion is coming back June 28^th – 30^th, 2019.  Stay up to date as we plan the conference for this upcoming year at www.rebellioninem.com.

The Missions of Rebellion in EM:

1. Decrease Knowledge Translation: With 100s of journals and thousands of publications every year, it takes time for research to disseminate to clinical practice. Discussion of current literature and its application to practice is the key to facilitating safe best practices.
2. Create a Community of Practice: It requires many to take care of the few www.bestintime.me. Patient care is a team sport that starts pre-hospital, continues through the ED, and finally into the hospital.
3. Improve Patient Care: Decrease suffering and improve patient oriented outcomes

“Learning is always rebellion…every bit of new truth discovered is revolutionary to what was believed before.” -Margaret lee Runbeck-

This talk was recorded live on the first day of Rebellion in EM 2018 in San Antonio, TX. The title of the talk, “STEMI Equivalents: High Risk ECGs that Should go to the Cath Lab,” by Tarlan Hedayati, MD (@chitwngurl) In this talk Tarlan discusses some STEMI equivalents all providers should be aware of, including, LBBB, Wellen’s Syndrome, De Winter’s T Waves, ST Elevation in aVR, and OHCA with ROSC.

[embedyt] http://www.youtube.com/watch?v=6P-0wOvhsK8[/embedyt]

Tarlan Hedayati, MD
Associate Program Director
Assistant Professor
Cook County Emergency Medicine
Chicago, IL
Twitter: @chitwngurl

STEMI Hard Definition:

• New ST elevation at the J Point in 2 or more contiguous leads > 1mm or ST depression in V1 – V3 (Posterior MI)

ECG “Families”

ACS Categories

• STEMI –> Go to Cath Lab
• NSTEMI –> Medical Management, but some may go to Cath Lab
• “SOLAR” STEMI (Term Created by Mike Abernathy) –> Not really a STEMI, but the ECG & patient are acting like a STEMI, have high risk features, that we would treat like a STEMI if it was regular business hours

Left Bundle Branch Block (LBBB) [1] [2]

• Used to be a STEMI equivalent
• Which LBBBs should we consider high risk to consult cardiac interventionalist/activate the cath lab for:
  • Hemodynamically Unstable
  • Concordance (1mm elevation or 1mm depression in V1 – V3)
  • Discordance (Use the modified Sgarbossa-Smith Modification)

Any Ratio >0.25 is positive for STEMI

Wellen’s Waves [3]

• Signifies a proximal LAD lesion
• Wellen’s Waves + History of Chest Pain + Normal/Minimally Elevate Troponin = 86% PPV LAD lesion

Wellen’s Type A

Wellen’s Type B

ST Elevation in aVR [4] [5]

• Can mean left main ischemia/occlusion, proximal LAD ischemia/occlusion, or multivessel disease
• Other things can cause this pattern: Pulmonary embolism, aortic dissection
• In patients with ST elevation in aVR, ask your cardiologist if they want dual anti-platelet therapy (DAPT) because this could be a sign of multivessel disease which means patient may need CABG

De Winter’s Hyperacute T Waves [6]

• ST depression + peaked T waves
• Subset of hyperacute T waves tagheuerex
• Signifies proximal LAD occlusion

OHCA with ROSC: [7]

• Patients with unfavorable resuscitation features are not good candidates for cath lab
  • Unwitnessed arrest
  • Initial rhythm non-VF/VT
  • No bystander CPR
  • >30min to ROSC
  • Ongoing CPR
  • pH < 7.2
  • Lactate > 7
  • Age > 85 years
  • End Stage Renal Disease
  • Non-cardiac causes (i.e. traumatic arrest)

Clinical Take Home Point:

• How do you remember the STEMI equivalents? àHOW BaD
  • HATW – Hyperacute T Waves
  • OHCA – Out of Hospital Cardiac Arrest without unfavorable resuscitation features
  • Wellen’s Waves – wellen’s waves + history of chest pain + normal/minimally elevated troponin
  • BBB – Left Bundle Branch Block with concordance or Sgarbossa-Smith modification for discordance > 0.25
  • aVR ST Elevation with diffuse depressions – LM ischemia/occlusion, proximal LAD ischemia/occlusion, or 3 vessel disease
  • De Winter’s T Waves – ST depression + peaked T waves

Also Be Sure to Checkout our YouTube Channel

References:

1. Meyers HP et al. Validation of the Modified Sgarbossa Criteria for Acute Coronary Occlusion in the Setting of Left Bundle Branch Block: A Retrospective Case-Control Study. Am Heart J 2015. PMID: 26678648
2. Cai Q et al. The Left Bundle-Branch Block Puzzle in the 2013 ST-Elevation Myocardial Infarction Guideline: From Falsely Declaring Emergency to Denying Reperfusion in a High-Risk Population. Are the Sgarbossa Criteria Ready for Prime Time? Am Heart J 2013. PMID: 24016487
3. Hanna EB et al. ST-Segment Depression and T-Wave Inversion: Classification, differential Diagnosis, and Caveats. Cleve Clin J Med 2011. PMID: 21632912
4. Kosuge M et al. Predictors of Left Main or Three-Vessel Disease in Patients Who Have Acute Coronary Syndromes with Non-ST Segment elevation. Am J Cardiol 2005. PMID: 15904646
5. Barrabes JA et al. Prognostic Value of Lead aVR in Patients with a First Non-ST Segment elevation Acute Myocardial Infarction. Circ 2003. PMID: 12885742
6. de Winter RJ et al. A New ECG Sign of Proximal LAD Occlusion. NEJM 2008. PMID: 18987380
7. Rab et al. Cardiac Arrest: A Treatment Algorithm for Emergent Invasive Cardiac Procedures in the Resuscitated Comatose Patient. JACC 2015. PMID: 26139060

For More on This Topic Checkout:

• REBEL EM: Five ECG Patterns You Must Know
• REBEL EM: Modified Sgarbossa Criteria – Part Deux
• REBEL EM: Is ST-Segment Elevation in Lead aVR Getting Too Much Respect? With Amal Mattu
• REBEL EM: Beyond ACLS: From CPR to Cath – The New ACC/AHA Cardiac Arrest Algorithm

Post Peer Reviewed By: Anand Swaminathan, MD (Twitter: @EMSwami) and Salim R. Rezaie, MD (Twitter: @srrezaie)