The following two podcasts from EMCrit, #146 [Who Needs an Acute PCI with Steve Smith (Part I)] and #147 [Who Needs an Acute PCI with Steve Smith (Part II)], are outstanding. You can’t listen to them too often. And, as always, don’t skip the outstanding content and commentary on #146 shownotes and #147 shownotes.
You will want to review, download, and save the three resources that Drs. Smith and Weingart provide [And you definitely want to visit Dr. Smith’s ECG Blog: Instructive ECGs in Clinical Context-you will return again and again.]
ECGs Prompting Activation/Consultation of PCI Team [one page PDF]
Who Needs the Cath Lab/Cards Consult? – A guideline from the Steve Smith’s EKG Blog and the EMCrit Podcast. [Full Text PDF]. This sixteen page document is actually detailed notes of lectures 146 and 147. Here is the Introduction:
A guideline from the Steve Smith’s EKG Blog and the EMCrit Podcast
Activate the Lab for unambiguous STEMI (only clear STEMIs have a 90 minute CMS mandate)
Get Cardiology or Interventional Consultation for more complicated cases: difficult ECGs, subtle ST elevation, ST depression with ongoing symptoms, STEMI “Equivalents”.
This requires a systematic approach, with buy-in from Cardiology that they will respond immediately to such requests for help. What do they get out of it? Fewer false positive activations and more activations for the subtle cases that need it.
Know that the ACC/AHA guidelines for NonSTEMI recommend < 2 hour cath for: 1) refractory ischemia 2) ischemia with hemodynyamic or electrical instability
Proviso: Many cardiologists do not understand these subtle ECG findings or pseudo-STEMI patterns. You must be a strong advocate! If you are worried, get serial ECGs, compare with an old ECG, and get a high quality contrast echocardiogram exam. Persistent occlusion of a significant epicardial coronary artery will nearly always have a wall motion abnormality if the echo quality is good, is done with contrast, and is read by an expert.
The EKG In Acute Reperfusion Therapy: An Evidence Based Manual of Reperfusion Therapy [Full Text PDF]. This is the complete 2002 textbook, which along with the 16 page PDF lecture notes above, is made available at no charge by Dr. Smith! [Thank you, sir]