A quarter of these patients will be diagnosed with acute coronary syndromes, but among those, nearly half will have nondiagnostic electrocardiograms. Anterior STEMI on ElectrocardiogramĬhest pain is the second most common complaint in emergency departments, with 6.4 million visits annually in the United States. HEART Score for Suspected Acute Coronary Syndromesįigure 1. Clinical Features of Type 1 and Type 2 Myocardial Infarction American Heart Association/ American College of Cardiology Classes of Recommendation and Levels of Evidence Risk Management Pitfalls for Management of NSTEMI in the Emergency DepartmentĬlinical Pathway for Risk Stratification for STEMI and NSTEMI in the Emergency DepartmentĬlinical Pathway for Management of NSTEMI in the Emergency Department.Ischemia-Guided Strategy Versus Early-Invasive Management StrategyĬopeptin as a Biomarker for Acute Coronary Syndromes Left Bundle Branch Block and Sgarbossa Criteria What is the best ED management when you don’t know whether the patient’s further treatment strategy is going to be early-invasive or ischemia-guided? Is there new evidence on treatment strategies – analgesia, antiplatelets, anticoagulation? Risk stratification scores: HEART, GRACE, TIMI: Which is best for the ED? What is the latest evidence on the value of high-sensitivity troponin assays? How has the modified Sgarbossa criteria increased sensitivity for identifying MI? What is the sensitivity of serial ECGs in detecting an occluding lesion? What are the different causes of STEMI and NSTEMI? Type 1 MI versus type 2?īesides chest pain, what is the likelihood that other symptoms, such as nausea, dyspnea, and diaphoresis, are pointing to MI? Are these related to age, ethnicity, and sex? What are the ECG criteria that differentiate STEMI and NSTEMI? For the emergency clinician, it is critical to make the correct diagnosis, fast: STEMI, NSTEMI, unstable angina (or is it pulmonary embolism or just heartburn?). In hospitalized NSTEMI patients with high risk of clinical events, early PCI is associated with improved 28-day survival.Ĭoronary delayed early percutaneous revascularization.Up to 25% of patients who present to the ED with chest pain are diagnosed with acute coronary syndromes (ACS). By 1-year of follow up, there was no significant difference in mortality with respect to early vs. After accounting for potential confounders, early PCI was associated with a 58% reduced 28-day mortality (OR = 0.42 95% CI: 0.21-0.84) for the entire population, and 57% reduced mortality (OR = 0.43 95% CI: 0.21-0.88) for high risk patients. The 28-day and 1-year mortality were 2% and 5%, respectively. Most were white (79%), male (68%), with mean age 61 years. Associations between early versus late PCI and mortality were analyzed using multivariable logistic regression adjusted for demographics, hospitalization year, TIMI score, and comorbidities.įrom 1987 to 2012, 6,746 patients were hospitalized with NSTEMI and underwent PCI. Patients were stratified into low (TIMI score 2-4), and high risk (TIMI score 5-7, or presence of cardiogenic shock, ventricular fibrillation, or cardiac arrest). We limited our study to patients undergoing early (<24 hr of the event onset), or late (≥24 hr) percutaneous coronary intervention (PCI). NSTEMI was classified using a validated algorithm. The ARIC Study has conducted hospital surveillance of acute myocardial infarction (MI) since 1987. The real-world effectiveness of this strategy is unknown. A delayed invasive strategy (24-72 hr) is considered reasonable for low risk patients. Current guidelines recommend early invasive intervention (<24 hr) for high risk patients with non-ST-segment elevation myocardial infarction (NSTEMI).
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