ST-segment myocardial infarction (STEMI) is a time-sensitive emergency that requires swift and seamless integration of prehospital and emergency department resources in order to achieve early diagnosis and reperfusion therapy. This issue reviews the current literature on emergency department management of STEMI, including recognition of more subtle diagnoses on electrocardiogram, identification of STEMI mimics, an update on treatment therapies, and strategies to achieve more effective management of STEMI across gender and age groups.
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Following are the most informative references cited in this paper, as determined by the authors.
1. Thygesen K, Alpert JS, Jaffe AS, et al. Fourth universal definition of myocardial infarction (2018). Eur Heart J. 2019;40(3):237-269. (Guideline) DOI: 10.1093/eurheartj/ehy462
4. O’Gara PT, Kushner FG, Ascheim DD, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2013;127(4):e362-e425. (Evidence-based guideline) DOI: 10.1161/CIR.0b013e3182742c84
8. Anderson JL, Adams CD, Antman EM, et al. ACC/AHA 2007 guidelines for the management of patients with unstable angina/non–ST-elevation myocardial infarction. Circulation. 2007;116(7). (Guideline) DOI: 10.1161/CIRCULATIONAHA.107.181940
35. Ibanez B, James S, Agewall S, et al. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: the Task Force for the Management of Acute Myocardial Infarction in Patients Presenting With ST-Segment Elevation of the European Society of Cardiology (ESC). Eur Heart J. 2018;39(2):119-177. (Evidence-based guideline) DOI: 10.1093/eurheartj/ehx393
40. Tabas JA, Rodriguez RM, Seligman HK, et al. Electrocardiographic criteria for detecting acute myocardial infarction in patients with left bundle branch block: a meta-analysis. Ann Emerg Med. 2008;52(4):329-336. (Systematic review and meta-analysis; 11 studies, 2100 patients) DOI: 10.1016/j.annemergmed.2007.12.006
57. American College of Emergency Physicians Clinical Policies Subcommittee on Reperfusion Therapy for Acute STEMI, Promes SB, Glauser JM, et al. Clinical Policy: emergency department management of patients needing reperfusion therapy for acute ST-segment elevation myocardial infarction. Ann Emerg Med. 2017;70(5):724-739. (Clinical Policy) DOI: 10.1016/j.annemergmed.2017.09.035
76. Wenger N. “STEMI at Elderly Age: Expert Analysis.“ 2016. Accessed December 10, 2020. (ACC expert anaylsis)
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Keywords: STEMI, myocardial infarction, acute coronary syndromes, ACS, electrocardiogram, ECG, EMS, diaphoresis, troponin, left bundle branch block, LBBB, posterior, Inferobasal, Sgarbossa, PCI, reciprocal, oxygen, aspirin, opioids, P2Y12, nitroglycerin, thrombolytic, fibrinogen, heparin, cocaine
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Dr. Ashoo is a practicing emergency physician, board-certified in emergency medicine and clinical informatics. Join him as he takes you through the January 2021 issue of Emergency Medicine Practice: Evaluation and Management of ST-Segment Elevation Myocardial Infarction in the Emergency Department
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The Sgarbossa criteria score is used to diagnose acute myocardial infarction in patients with prior left bundle branch block.
It is often difficult to identify a myocardial infarction (MI) in patients with existing left bundle branch block (LBBB). Approximately 1 in 200 patients with MI have LBBB. The use of the Sgarbossa criteria is a well-accepted approach for determining which patients with LBBB are having an MI.
A Sgarbossa score of ≥ 3 is 90% specific for MI, but is not sensitive (36% sensitivity). Therefore, a score ≥ 3 should be acted upon, but a lower score cannot be used to rule out MI. Clinicians should maintain a high index of suspicion if the patient’s clinical presentation is consistent with MI.
Graham Walker, MD
Sgarbossa et al developed and validated the Sgarbossa criteria in 1996, based on a set of electrocardiographic criteria for the diagnosis of acute MI in patients with chest pain and LBBB. The Sgarbossa criteria cannot rule out MI in patients with existing LBBB. Smith et al modified the Sgarbossa criteria by adjusting the component of excessively discordant ST-segment elevation (Smith 2012). This modification has been referenced by Dr. Sgarbossa (Cai 2013) and should be included in the Sgarbossa criteria.
Elena Sgarbossa, MD
Marshall Frank, DO, MPH, FACEP; Carson Sanders, BS, NRP, CCEMT-P; Bryan P. Berry, MD, BCEM, FACEP
James Morris, MD, MPH; Douglas L. Robinson, DO, MS; Andrew Schmidt, DO, MPH
January 1, 2021
February 1, 2024
4 AMA PRA Category 1 Credits™, 4 ACEP Category I Credits, 4 AAFP Prescribed Credits, 4 AOA Category 2-A or 2-B Credits.
Date of Original Release: January 1, 2021. Date of most recent review: December 10, 2020. Termination date: January 1, 2024.
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