STEMI 2

ST- ELEVATION
MYOCARDIAL
INFARCTION
(STEMI)
MOTUNRAYO KAY-SALAMI
TEXILA AMERICAN UNIVERSITY
CONTENTS
• Introduction
• Risk Factors/ Etiology
• Pathophysiology
• Clinical Presentation
• Diagnostics
• Differential Diagnosis
• Management
• Complications
• Prevention
Introduction
Acute coronary syndrome (ACS): is the clinical manifestation

of myocardial infarction. It is an umbrella term that describes the suspicion or
confirmed presence of acute myocardial ischemia. It may be further
classified into the following:
 NSTE-ACS: ACS manifesting without ST elevations on ECG.
 NSTEMI: positive myocardial injury biomarkers
 Unstable angina: absence of detectable myocardial injury
biomarkers
 STE-ACS: ACS manifesting with persistent ST elevations on ECG
Myocardial Infarction (MI)
It is defined as acute myocardial injury with clinical and diagnostic

evidence of acute ischemia. It results from myocardial cell necrosis
caused by an imbalance between oxygen supply and demand. An acute
myocardial infarction is subdivided into a non-ST-elevation myocardial
infarction (NSTEMI) and an ST-elevation myocardial infarction (STEMI). It
is further classified into 5 Subtypes:
RISK FACTORS
ETIOLOGY
PATHOPHYSIOLOGY
PATHOPHYSIOLOGY
STEMI
• STEMI is the most severe type of ACS
• The most common etiology is the

rupture of an atherosclerotic plaque
which subsequently occludes a
coronary artery causing transmural
myocardial infarction.
TYPES OF STEMI
1. Anterior STEMI: A blockage in the artery supplies blood to the front

wall of the heart, the left anterior descending (LAD) artery.
2. Inferior or Lateral STEMI: A blockage in the arteries that supply
blood to the bottom walls of the heart. This type of STEMI can be
caused by the blockage of the right coronary artery (RCA) or the left
circumflex coronary artery (LCx)
3. Posterior STEMI: A blockage in the arteries that supply blood to the
back wall of the heart
Clinical Presentation
Classic symptoms of MI
• Acute retrosternal chest pain: dull,
squeezing, pressure, and/or tightness (>15
min) and/or recurrent pain within 1 h
• Commonly radiates to the left chest, arm,
shoulder, neck, jaw, and/or epigastrium
• Precipitated by exertion or stress
• Nausea and vomiting
• Dyspnea
• Epigastric pain (inferior wall MI)
Clinical Presentation
• Atypical presentations: more likely in elderly,

diabetic individuals, and women. Stabbing,
sharp chest pain
• No or minimal chest pain
• “Silent MI” without chest pain is more

common in patients with diabetes, as a
result of polyneuropathy.
Diagnostics
1. History
2. Physical Examination
a. Vitals: Tachycardia, Tachypnea, Hypotension
b. Symptoms of CHF (e.g., orthopnea, pulmonary
edema) or cardiogenic
shock(e.g., hypotension, tachycardia, cold extremities)
c. New heart murmur on auscultation.
3. Investigations
Investigations
1. 12-lead ECG
2. Cardiac Biomarkers
• Cardiac troponin
• CK-MB
• Myoglobin
3. CBC, BMP, Coagulation panel
4. TTE
Investigations
1. Troponin is released from ischemic muscle. Cardiac troponins T and I are

highly sensitive and specific for myocardial damage. Serum levels increase
within 3-12 hours from the onset of chest pain, peak at 24-48 hours, and can
remain high for up to 10 days in the presence of normal creatine clearance.
2. Other cardiac enzymes (e.g. CK-MB) increase within 3-12 hours of the onset
of chest pain.
3. ACS is not the only cause of a raised troponin, and troponin levels must be
interpreted in the clinical context. Other causes of raised troponins include:
• Tachy-/bradyarrhythmia
• Aortic dissection
• Heart failure
• Myocarditis
• Chronic kidney disease
• Sepsis
STEMI ECG Findings
Evolution of STEMI
Types of STEMI
Reciprocal changes in STEMIs
● are the ST depressions (0.1mV) found on
the ECG that are on the opposite side of the
heart of the myocardial infarction.
● Note that the absence of reciprocal changes

does not rule out the presence of a STEMI,
but the presence of reciprocal changes
makes it more likely.
STEMI Differential Diagnosis
□ Left Bundle Branch Block

□ Hyperkalemia
□ Early Repolarization
□ Pericarditis
□ TCA use
□ Takotsubo Cardiomyopathy
Management
1. ABCDE assessment
2. Rapid recognition of a STEMI.
3. ACS assessment
4. Immediate revascularization
• Percutaneous Coronary Intervention: coronary angiography with
balloon dilatation and stent implantation. First medical contact (FMC)
to PCI time is ideally ≤ 90 minutes. It should not exceed 120 minutes.
• Fibrinolytic therapy in STEMI: These act to ”lyse” or dissolve blood
clots. Examples are: Tenecteplase, Alteplase, Teteplase, and
Streptokinase.
• Antiplatelet therapy and anticoagulation
• Emergency CABG surgery: not routine
Other medical management:
● GTN
● Aspirin
● Morphine
● Beta blockers
● Oxygen
● ACE Inhibitors
● Secondary Prevention
medications:
● Statins
● Beta Blocker
● ACEI/ Sartan
● SGLT-2 Inhibitors
● Low dose Aspirin
● PPIs- Omeprazole
Prevention
1. Lifestyle modifications
○ Smoking cessation
○ A healthy, plant-based diet
○ Regular physical activity and exercise
2. Management of comorbidities, e.g. treatment of
hypertension
3. Low-dose aspirin is beneficial for certain high-
risk groups.
References
● Robert A Byrne, Xavier Rossello, J J Coughlan, Emanuele Barbato, Colin Berry, Alaide Chieffo, Marc J Claeys,
Gheorghe-Andrei Dan, Marc R Dweck, Mary Galbraith, Martine Gilard, Lynne Hinterbuchner, Ewa A Jankowska,
Peter Jüni, Takeshi Kimura, Vijay Kunadian, Margret Leosdottir, Roberto Lorusso, Roberto F E Pedretti, Angelos G
Rigopoulos, Maria Rubini Gimenez, Holger Thiele, Pascal Vranckx, Sven Wassmann, Nanette Kass Wenger, Borja
Ibanez, ESC Scientific Document Group , 2023 ESC Guidelines for the management of acute coronary syndromes:
Developed by the task force on the management of acute coronary syndromes of the European Society of Cardiology
(ESC), European Heart Journal, Volume 44, Issue 38, 7 October 2023, Pages 3720–3826,
https://doi.org/10.1093/eurheartj/ehad191
● Navdeep S. STEMI. 2023. https://www.saem.org/about-saem/academies-interest-groups-affiliates2/cdem/for-
students/online-education/m3-curriculum/group-electrocardiogram-(ecg)-rhythm-recognition/stemi#top
● Nickson C. STEMI Management. Dec 2020. https://litfl.com/stemi-management/
● Burns E. and Buttner R. Type of STEMI. 2023. https://litfl.com/anterior-myocardial-infarction-ecg-library/
• https://litfl.com/right-ventricular-infarction-ecg-library/
• https://litfl.com/inferior-stemi-ecg-library/
• https://litfl.com/lateral-stemi-ecg-library/
• https://litfl.com/posterior-myocardial-infarction-ecg-library/
● de Winter RJ, Verouden NJ, Wellens HJ, Wilde AA. A new ECG sign of proximal LAD occlusion. N Engl J Med. 2008
Nov 6;359(19):2071-3
● https://next.amboss.com/us/article/Yq0nCS
● https://ecgwaves.com/topic/ecg-st-elevation-segment-ischemia-myocardial-infarction-stemi/

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ST- ELEVATION

Acute coronary syndrome (ACS): is the clinical manifestation

It is defined as acute myocardial injury with clinical and diagnostic

• The most common etiology is the

1. Anterior STEMI: A blockage in the artery supplies blood to the front

• Atypical presentations: more likely in elderly,

• “Silent MI” without chest pain is more

1. Troponin is released from ischemic muscle. Cardiac troponins T and I are

● Note that the absence of reciprocal changes

□ Left Bundle Branch Block

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