What is the management for a patient with ST elevation in leads V2, V3, V4, and V5 indicating an acute anterior wall myocardial infarction?

Management of ST Elevation in V2, V3, V4, and V5

Immediate primary percutaneous coronary intervention (PCI) is the recommended reperfusion strategy for patients with ST elevation in leads V2, V3, V4, and V5, which indicates an acute anterior wall myocardial infarction. 1

Initial Assessment and Diagnosis

• ST elevation in V2-V5 indicates an anterior wall myocardial infarction, typically due to occlusion of the left anterior descending coronary artery 2, 3
• Diagnosis requires ST elevation in at least two contiguous leads with the following thresholds:
  • Men ≥ 40 years: ≥0.2 mV in V2-V3
  • Men < 40 years: ≥0.25 mV in V2-V3
  • Women (all ages): ≥0.15 mV in V2-V3
  • All other leads (including V4-V5): ≥0.1 mV regardless of gender or age 2

Immediate Management

1. Reperfusion Strategy

   • Primary PCI is the preferred reperfusion strategy if it can be performed within 120 minutes of STEMI diagnosis 1
   • Patients should be transferred directly to the catheterization laboratory, bypassing the emergency department 1
   • If primary PCI cannot be performed within 120 minutes, fibrinolytic therapy should be initiated within 12 hours of symptom onset 1

2. Antithrombotic Therapy

   • Aspirin: Administer oral or IV (if unable to swallow) as soon as possible 1
   • P2Y12 inhibitor: Administer before or at the time of PCI 1
     • Preferred agents: Prasugrel or ticagrelor 1, 4
     • Alternative: Clopidogrel (if prasugrel or ticagrelor are contraindicated or unavailable) 1
   • Anticoagulation: Unfractionated heparin (enoxaparin or bivalirudin may be alternatives) 1

3. If Fibrinolysis is Chosen

   • Initiate as soon as possible, preferably in pre-hospital setting 1
   • Use a fibrin-specific agent (tenecteplase, alteplase, or reteplase) 1
   • Administer clopidogrel in addition to aspirin 1
   • Provide anticoagulation with enoxaparin (preferred) or unfractionated heparin 1
   • Transfer to a PCI-capable center immediately after fibrinolysis 1

Special Considerations

• Anterior wall MI carries a higher risk of complications including heart failure, cardiogenic shock, and ventricular arrhythmias due to the larger area of myocardium affected 1, 5
• Lower left ventricular ejection fraction is commonly seen with anterior wall MI involving leads V2-V5 3, 5
• Routine echocardiography during hospital stay is recommended to assess left ventricular function and detect complications 1

Post-Acute Management

• Dual antiplatelet therapy (DAPT) with aspirin plus ticagrelor or prasugrel (or clopidogrel if these are not available) for 12 months 1
• Consider proton pump inhibitor in patients at high risk of gastrointestinal bleeding 1
• Beta-blockers are indicated in patients with heart failure and/or reduced left ventricular ejection fraction 1
• Cardiac rehabilitation is recommended for all patients 1
• Smoking cessation counseling and support should be provided 1

Potential Pitfalls

• Rarely, ST elevation in V2-V3 may represent isolated right ventricular infarction rather than anterior wall MI 6, 7
• Pulmonary embolism can occasionally present with ST elevation in precordial leads, mimicking anterior STEMI 8
• Always confirm the diagnosis with coronary angiography and consider alternative diagnoses if the angiogram does not show occlusion of the left anterior descending artery 6, 7
• In patients with left bundle branch block, ST elevation diagnosis is more challenging but still possible; concordant ST elevation is one of the best indicators of ongoing MI 2

Algorithm for Management

1. Confirm STEMI diagnosis with 12-lead ECG showing ST elevation in V2-V5 2
2. Administer aspirin and a P2Y12 inhibitor immediately 1
3. Determine if primary PCI can be performed within 120 minutes 1
   • If yes: Transfer directly to catheterization laboratory for primary PCI 1
   • If no: Administer fibrinolytic therapy and transfer to a PCI-capable center 1
4. Perform echocardiography to assess left ventricular function 1
5. Monitor for complications (heart failure, arrhythmias) 1
6. Implement secondary prevention measures after stabilization 1