=====Cardiac Ischaemia=====
{{ :wiki:cardiovascular:cuh_acs-2018---pdf_.pdf |CUH ACS guidleine 2018}}\\
*[[wiki:cardiovascular:myocardial_ischaemia#non-ischaemic_ST_elevation|Non-ischaemic ST elevation]] is seen in 15% population, especially young men
*abnormal ST elevation:
*Leads V2,3 >0.2mV in men >40y and >0.25mV in men <40y (>0.1mV in all other leads)
*Leads V2,3 >0.15mV in women (>0.1mV in all other leads)
*usually convex or straight
[{{ :wiki:cardiovascular:acs_croydon.png?200| **//Croydon ACS protocol//**}}]
====STEMI====
*ST elevation reflects transmural ischaemia
*criteria for STEMI in patients with LBBB = **modified Sgarbossa criteria** (≥3 points 90% specificity for STEMI)
*//**5 points**//: ≥1 lead with ST elevation ≥1mm, concordant with the vector of the QRS complex
*//**3 points**//: ≥1 lead of V1-V3 concordant ST depression ≥1 mm
*//**2 points**//: ≥1 lead with discordant ST elevation ≥25% of depth of preceding S wave (Leads V1-3)
[{{ :wiki:cardiovascular:modified_sgarbossa-criteria-lbbb-paced-rhythm.png?300| **Modified Sgargossa Criteria for MI in LBBB: ≥3 points** }}]
====NSTEMI====
*patients determined to have symptoms consistent with ACS and troponin elevation but without ECG changes consistent with STEMI
*may have transient ST elevation, ST depression, or new T wave inversion
*differs from Unstable angina in that cardiac markers are elevated
**[[wiki:cardiovascular:ecgs:#deWinterbookmark|de Winter T waves]] are associated with LAD occlusion and sometimes considered STEMI equivalent
====MINOCA (MI with non obstructive coronary arteries)====
[[https://www.icrjournal.com/articles/what-interventionalist-needs-know-about-mi-non-obstructive-coronary-arteries]]\\
*not a benign diagnosis: outcomes similar to those of patients with acute MI and obstructive coronary disease up to 1 year
====Acute Coronary Syndrome====
| **New York functional classification of angina:**\\ //in patients with cardiac disease// ||
^Class I |• no limitation of physical activity |
^Class II |• slight limitation of physical activity\\ • comfortable at rest but ordinary activity causes symptoms |
^Class III |• marked limitation of physical activity\\ • comfortable at rest but less than ordinary activity causes symptoms |
^Class IV |• inability to carry on any physical activity without discomfort\\ • may have symptoms at rest |
====Spontaneous Coronary Artery Dissection (SCAD)====
*SCAD may be a cause of up to 1% to 4% of ACS cases overall
*occurs overwhelmingly in women and may be the cause of ACS in up to 35% of MIs in women ≤50 years of age
*most common cause of pregnancy-associated MI (43%)
[[https://www.ahajournals.org/doi/10.1161/CIR.0000000000000564|Circulation 2018 - SCAD review]]\\
====Non-ischaemic ST elevation====
//usually// concave pattern
*associated with LVH
*secondary to conduction defect eg LBBB, non-specific intracardiac conduction delay, WPW
*Early repolarization pattern
*Spontaneously reperfused STEMI
*Aneurysm/old myocardial infarction
*[[wiki:cardiovascular:pericarditis|Pericarditis]]/myocarditis
*Brugada pattern
*Takotsubo<@anno:[10;;anno_dylan]>
A sudden, transient cardiac syndrome that involves dramatic LV apical akinesis and mimics acute coronary syndrome (ACS)\\ **Requires all 4 of the following:**\\ ♦ Transient hypokinesis, dyskinesis, or akinesis of the LV midsegments, +/- apical involvement; the regional wall-motion abnormalities extend beyond a single epicardial vascular distribution, and a stressful trigger is often, but not always, present\\ ♦ Absence of obstructive CAD or angiographic evidence of acute plaque rupture\\ ♦ New ECG abnormalities (either ST-segment elevation and/or T-wave inversion) or modest elevation in troponin\\ ♦ Absence of phaeochromocytoma or myocarditis (apical ballooning) syndrome, AKA 'broken heart syndrome'
*Hyperkalaemia, Hypercalcaemia
----
===Early repolarisation===
*especially young, athletic afro-Caribbean males and Hispanics
*often disappears with hyperventilation & tachycardia
*usually early V leads
====MI localisation ECG patterns====
The different infarct patterns are named according to the leads with maximal ST elevation:
*Septal = V1-2
*Anterior = V2-5
*Anteroseptal = V1-4
^localisation ^ST elevation ^Reciprocal ST depression ^coronary artery |
^Anterior MI |V1-V6 but especially V2-5\\ +/- high lateral leads I & aVL |None |LAD |
^Lateral MI |I, aVL, V5, V6\\ • uncommonly isolated\\ • usually as anterolateral |II,III, aVF |LCX or obt marginal |
^Anterolateral MI |V3-V6, I + aVL\\ extensive includes V1,2 | | |
^Septal MI |V1-V2, loss of septum Q in leads V5,V6 |none |LAD-septal branches |
^Anteroseptal MI | V1-V4 | | |
^Inferior MI |II, III, aVF |I, aVL |RCA (80%) or RCX (20%) |
|:::|{{:wiki:cardiovascular:84_acute_inf_stemi.jpg?200|}} | |:::|
^Posterior MI |V7, V8, V9 |high R & ST depression V1-V3 > 2mm (mirror view) |RCX |
|:::|{{:wiki:cardiovascular:posterior-mi-posterior-leads-765x363.png?200|}} |{{:wiki:cardiovascular:posterior-mi-765x365.png?200|}}|:::|
^Right Ventricle MI |V1, V4R |I, aVL |RCA |
^Atrial MI |PTa in I,V5,V6 |PTa in I,II, or III |RCA |
====Atrial ischaemia/infarction====
==Liu’s criteria for diagnosing atrial ischaemia / infarction include:==
*Major criteria
*PR elevation >0.5 mm in V5 & V6 with reciprocal PR depression in V1 & V2
*PR elevation >0.5 mm in lead I with reciprocal PR depression in leads II & III
*PR depression >1.5 mm in the precordial leads
*PR depression >1.2 mm in leads I, II, & III
*Minor criteria:
*Abnormal P wave morphology: eg M-shaped, W-shaped, irregular or notched
====Posterior MI====
-**//ST depression (not elevation) in the septal & anterior precordial leads (V1-V4)//***. This occurs because these ECG leads will see the MI backwards; the leads are placed anteriorly, but the myocardial injury is posterior.
-A R/S wave ratio greater than 1 in leads V1 or V2.
-ST elevation in the posterior leads of a posterior ECG (leads V7-V9). Suspicion for a posterior MI must remain high, especially if inferior ST segment elevation is also present.
-ST elevation in the inferior leads (II, III and aVF) if an inferior MI is also present.
----
====HEART score====
^ |HEART score| |
^History |• Highly suspicious\\ • Moderately suspicious\\ • Slightly suspicious ^2\\ 1\\ 0 |
^ECG |• Significant ST depression\\ • Non-specific repolarisation change/LBBB/PM\\ Normal ^2\\ 1\\ 0 |
^Age |• ≥65\\ • 45-65\\ • <45 ^2\\ 1\\ 0 |
^Risk factors |• **Hx of atherosclerosis** or ≥3 risk factors eg\\ ↑chol, diabetes, smoker, +ve FHx, BMI>30, PHx-MI,PCI,CABG,CVA,TIA,PVD\\ • 1-2 risk factors\\ no risk factors ^2\\ \\ 1\\ 0 |
^Troponin |• ≥3x normal\\ • 1-3x normal limit\\ • normal ^2\\ 1\\ 0 |
===SYNTAX score===
*a scoring system used to determine intervention strategies - PCI vs CABG
{{ :wiki:cardiovascular:syntax_score_coronaries.png?300|}}
*The SYNTAX score is the sum of the points assigned to each individual lesion identified in the coronary tree with >50% diameter narrowing in vessels >1.5mm diameter.
*The coronary tree is divided into 16 segments according to AHA classification, with scores of 1 or 2 attributed to each relevant lesion and then weighted for calculation.
*Higher scores represent greater risk for PCI and therefore more indicative of need for CABG
https://www.cathlabdigest.com/articles/What-SYNTAX-Score-and-How-Should-We-Use-It
==References include:==
[[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4209433/| St elevation - ischaemia vs non-ischaemia 2014]]\\
[[https://emedicine.medscape.com/article/1513631-overview|Takotsubo cardiomyopathy]]\\
https://the-breach.com/introducing-the-modified-sgarbossa-criteria/\\
https://epmonthly.com/article/stemi-in-the-presence-of-lbbb/\\
[[https://www.ncbi.nlm.nih.gov/books/NBK513228/|NSTEMI 2020]]\\
[[http://medreviews.com/sites/default/files/2017-02/RICM152_131.pdf|global T inversion review]]\\
[[https://academic.oup.com/eurheartj/article/40/3/237/5079081|4th universal definition of Myocardial infarction 2018]]\\
[[https://www.ahajournals.org/doi/full/10.1161/circulationaha.106.624924|Circulation: Localisation of MI's - New terminology 2006]]\\