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Slide 1 - Diagnosing Myocardial Infarction Kimberly A. Dovin, MD, PGY3 Case Conference February 18, 2004
Slide 2 - MI: Old Definition Requires 2 of 3: Typical Sx Enzyme rise Typical EKG (Q waves)
Slide 3 - MI: Defined 2000 Acute, evolving or recent MI Requires 1 of 2: Typical rise and gradual fall (troponin) or more rapid rise and fall (CK-MB) of markers of myocardial necrosis with >= 1 of: Symptoms Q waves EKG c/w ischemia S/p coronary artery intervention Pathologic findings of AMI
Slide 4 - MI: Defined 2000 Established MI One or more of - new Q waves on EKG - pathologic findings of healed/healing MI
Slide 5 - Symptoms of MI Chest, epigastric, arm, wrist, jaw pain or discomfort w/ exertion or at rest Usually lasts 20 min, but may be less Associated sx: dsypnea, diaphoresis, nausea, vomiting, light-headedness With or without chest discomfort
Slide 6 - Biochemical markers Troponin: High sensitivity, high specificity for myocardial tissue CK-MB: less tissue specific, but better specificity for irreversible injury Myoglobin: for rapid diagnosis
Slide 7 - Biochemical Markers II
Slide 8 - Biochemical Markers III
Slide 9 - Non MI Causes of Troponin Elevation Tachycardia PE w/ Right Vent infarct Cardiac failure w/ myonecrosis Cardiac surgery Myocarditis Renal failure
Slide 10 - EKG Findings: Ischemia Patients with ST segment elevation: New elevation at the J point in 2+ contiguous leads >= 0.2mV in V1-3 >= 0.1mV in all others Patients without ST segment elevation: ST segment depression T wave abnormalities
Slide 11 - EKG Findings: Established MI ANY Q waves in V1-3 Q wave >= .03s in I, II, aVL, aVF, V4-6
Slide 12 - Coronary Angiogram Observer variability Discordance betw severity of lesion and physiologic effects Greater stenosis vs more unstable plaques? 2-D picture of a 3-D problem Diffuse disease may limit estimation of “abnormal segments” Missed lesions
Slide 13 - “ It is now clear that any amount of myocardial damage, as detected by cardiac troponins, implies an impaired clinical outcome for the patient.” “A review of currently available data demonstrates no discernible threshold below which an elevated value for cardiac troponin would be deemed harmless.”
Slide 14 - Bibliography Elliott Antman MD, Jean-Pierre Bassand MD, Werner Klein MD, Magnus Ohman MD, Jose Luis Lopez Sendon MD, Lars Rydén MD, Maarten Simoons MD and Michal Tendera MD Myocardial infarction redefined––a consensus document of The Joint European Society of Cardiology/American College of Cardiology committee for the redefinition of myocardial infarction Journal of the American College of Cardiology Volume 36, Issue 3 , September 2000, Pages 959-969 John K French and Harvey D White Clinical implications of the new definition of myocardial infarction Heart 2004;90:99-106 Steven E. Nissen MD, FACC Pathobiology, not angiography, should guide managementin acute coronary syndrome/non–ST-segment elevation myocardial infarction*1 The non-interventionist's perspective Journal of the American College of Cardiology Volume 41, Issue 4, Supplement 1 , 19 February 2003, Pages S103-S112