In this section : Cardiac
Deactivation of Implantable Cardioverter Defibrillator
Extravasation of IV Amiodarone
Anticoagulation for AF, DVT and PE
Patients Returning from Interventional Cardiac Procedure
Cardiology Referrals
STEMI Thrombolysis Protocol
STEMI
Hypertensive Emergencies
Rate Control in AF
Heart Failure
Aortic Dissection
Non ST Elevation MI (NSTEMI)
Suspected Acute Coronary Syndrome
Pericardiocentesis
Pacemakers
Indications for Echocardiography
Bradycardia
Narrow Complex Tachycardia
Anti-Platelet Therapy in Coronary Heart Disease
Management of Acute AF
Rhythm Control in AF
Atrial Fibrillation
Hypertension
Ventricular Tachycardia
Cardiogenic Shock Complicating Acute Coronary Syndrome
Telemetry
STEMI
Last updated 15th January 2024
STEMI
- Diagnosis of STEMI is made by the history and the ECG
- The sequence of ECG changes is hyperacute T waves (rarely seen), then ST elevation followed by Q waves and T wave inversion
- Inferior STEMI requires ST elevation >1mm in two of leads II, III and aVF
- Anterior STEMI requires ST elevation >2mm in two adjacent chest leads
- Posterior STEMI requires ST depression in V1 – V3 instead of elevation usually with an R wave in V1/V2 (ECG looks like an ST elevation MI if viewed from behind)
- The development of an new LBBB in a patient with a typical history is considered equivalent to a STEMI
Inferior STEMI
- ST elevation in leads II, III and aVF
Inferior and Posterior STEMI
- ST elevation III and aVF with ST depression in V1-V2 with an R wave in V1 (ECG looks like an ST elevation MI if viewed from behind)
Anterior STEMI
- ST elevation I, aVL, V1-V5
Management
- Primary PCI shown to be better than thrombolysis which means that if ambulance crew have diagnosed STEMI they will take patient straight to Hairmyres
- The following advice only applies to patients whose STEMI is first diagnosed in A&E or on the wards
- Email ECG to [email protected] and then phone the on call cardiologist at Hairmyres on 01355 584817 (or 01355 584819 if line busy) to discuss whether to arrange emergency transfer to Hairmyres or thrombolyse in Dumfries.
- If taking DOAC or warfarin, advice is likely to be no thrombolysis but give aspirin 300mg and clopidogrel 300mg then emergency transfer to Hairmyres for angio. Avoid ticagrelor and suspend the DOAC/warfarin.
Management if Already on Ticagrelor
- Load with aspirin 300mg, Ticagrelor 180mg & Heparin 5000 units
- Maintain on aspirin 75mg once daily and Ticagrelor 90mg twice daily until transfer to Hairmyres
- If has PCI, patient shoudl have further 6 months Ticagrelor from date of PCI unless otherwise specified by Cardiologist. Aspirin should continue lifelong.
- If medical management only, patient should continue Ticagrelor for the remainder of the course from previous PCI or for 3 months, whichever is longer. Aspirin should continue lifelong.
Absolute Contraindications to Thrombolysis
- Haemorrhagic stroke or stroke of unknown origin at any time
- Ischaemic stroke in the preceding 6 months
- Central nervous system damage or neoplasms
- Recent major trauma/surgery/head injury (within the preceding 3 weeks)
- Gastro-intestinal bleeding within the last month
- Known bleeding disorder
- Aortic dissection
- Has already been given a dose of Ticagrelor
Relative Contraindications to Thrombolysis
- Transient ischaemic attack in preceding 6 months
- Oral anticoagulant therapy
- Within 1 week post-partum
- Non-compressible punctures
- Traumatic resuscitation
- Refractory hypertension (systolic blood pressure >180 mmHg)
- Advanced liver disease
- Infective endocarditis
- Active peptic ulcer
Eligible for Thrombolysis & Thrombolysis Advised
What To Do Next
- This will depend on advice given by Hairmyres Cardiologist
- If thrombolysed then Hairmyres will usually request blue light transfer to their CCU
- If emergency transfer to Hairmyres not agreed then you should discuss whether to give/continue fondaparinux, aspirin & copidogrel in Dumfries
- If the patient stays in Dumfries then angio, which will usually be indicated, will be arranged at the Jubilee.
- Remember to phone the DGRI Cardiac Rehab team on 01387 244264 to notify of admission/transfer.
Suspected ACS
Links
Content Updated by Chris Isles