STEMI + Hypotension (DDx)

STEMI
1. 3 important Physical Exam

• UL pulses = aortic dissection
• murmur = MR/VSR, AR (dissection)
• auscultation = HF

2. STEMI + Shock, hypotension, DDx? DIR-M (also check AR for Ao Dissection)

• Dysrrhythmia = check the monitor
• Infarct Extension, Cardiogenic Shock = check the ECG
• RV Infarct = check R lead
  
• Mechanical (post-infarct myocardial rupture) emedicine
  1. MR (acute MR/papillary muscle rupture) = apex murmur, flash APO, N heart size, U/S
  2. VSR (acute VSD/VSR) = 3rd-7th day; murmur, U/S Color doppler
  3. LV free wall rupture = 10x more common than MR, VSR
  
  • 40% within 24h, 85% within a week; most common: LATERAL
    
  • Subacute: if epicardium or hematoma seals off the rupture
  • U/S: pericardial effusion + color flow over the epicardium inside the pericardial cavity youtube

3. acute MR/papillary muscle rupture is common in mild MI, why?

• posterior leaflet is supplied by one vessel = RCA
• anterior leaflet is dually supplied by LAD and L circumflex
  = tough infarct, LAD + L circumflex must be occluded, which the patient might not survive after all