#EuSEM2018 – Day 3

& today has been all about the Heart (New MI definition, Think Aorta, Failure) + some disaster med for my own interest

4th universal Definition of MI

Whats New?

  • ECG criteria
    • ST Elevation (Will this effect who we send for PPCI? – we need to find out)
      • NEW 1mm Elevation in 2 contiguous leads (Chest OR Limb)
      • Except V2–V3
        • ≥ 2mm in men ≥ 40 years
        • ≥ 2.5 mm in men < 40 years
        • ≥ 1.5 mm in women regardless of age
    • Non ST Elevation
      • New horizontal or downsloping ST-depression ≥ 0.5 mm in 2 contiguous leads
      • and/or T inversion > 1 mm in 2 contiguous leads with prominent R wave or R/S ratio > 1
  • Now 6 types of MI defined – types 1 and 2 we need to think about in ED
    • Type 1 – Our traditional Plaque rupture which – ACS treatment
    • Type 2  – Oxygen supply mismatch (shock, arrhythmia, sepsis, dissection, atheroma, etc.) – Treat the cause
    • Type 3 – Sudden cardiac death, presumed MI but no tests done
    • Type 4  – Proceedure induce (a) PPCI, (b) Stent
    • Type 5 –  CABG induced
  • “Myocardial injury” definition – Trop >99th gentile with out acute myocardial ischaemia.

4th universal definition of MI – there is also an app look for ESC



  • The Trop 99th Centile is good for diagnosis NOT prognosis  
    • MI defined as Trop >99th Centile (chosen originally to avoid false +ve’s all other tests based on 95th Centile)
    • Trop > 85th Centile – heralds increased all cause mortality
  • High-Sensitivity Trop (We don’t have it!!! – but it’s coming)
    • LoD (limit of detection) – you can rule out poor prog ACS if the initial trop is below the LoD & you have the right test (but need 2-3 hrs from pain to taking that sample)
    • Risk scores & LoD rule out – risk scores with this strategy don’t improve sensitivity but do reduce the numbers you can discharge early.
    • Above LoD look at delta (i.e.change) – In an MI this should change either increase or decrease depending on where you are on the curve (Beware – you might be near the peak and 2 results may not show much change)

    • Increased mortality? – Swedish registry data has indicated increased all cause mortality – Is that over diagnosis and investigation or lack of thinking as we think we have ruled things out?

Acute Heart Failure

  • As you might expect TIME MATTERS
    • Mortality increased by 1%/hour IV treatment not started
    • Treatment after 12hrs from onset makes little difference
  • GTN/Vasodilators – are a mainstay
  • Diuretics – Frusemide >160mg has been shown to increase mortality
  • NIV – consider if RR>25, SaO2 <90% (can reduce respiratory distress, reduce intubation, but no effect on mortality)
  • BNP >845 shows increased mortality – we have it available
  • Look for CHAMP and treat
    • aCs
    • Hypertension
    • Arrhythmia
    • acute Mechanical (rupture/trauma)
    • Pe

ESC Heart failure guidance

Think Aorta

  • In Type A dissection – mortality increases by 1%/hr they don’t get to theatre
  • 1:3 dissections initially treated as something else
  • 1:2 dissections – not on initial differential
  • D-Dimer not good enough
  • Get a CT!!!!

Aortic Dissection Guide

PE – Pulmonary Embolis

  • PERC – Can be used in low risk as a rule out – used in USA >10yrs validated france and belgium
  • Age related D-Dimer cut off in over 50’s (Age x 10)
  • Dutch have suggested using cut off of 1000 -Unless the following triggered on wells (hemoptysis, signs of deep vein thrombosis and ‘PE most likely’)

PE Guide


  • PATCH – If patients with ‘Unexplained Syncope’ have cardiac monitoring 1:10 are found to have a significant arrhythmia.



  • Evidence of delayed problems downstream from event – PTSD in earthquakes and MI’s  post-terror attack.

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