This medical flowchart illustrates the reperfusion strategy selection and timeframes for patients with ST-elevation myocardial infarction (STEMI), based on 2018 ESC/EACTS Guidelines. The algorithm maps the 'Total Ischemia Time' from symptom onset, divided into 'Patient\'s Delay' and 'Health System\'s Delay'. Following a STEMI diagnosis (visualized by ST-segment elevation on ECG), the pathway bifurcates based on hospital capabilities. For hospitals with a catheterization lab (cath lab), the goal for Primary Percutaneous Coronary Intervention (PCI) is <60 minutes to guidewire introduction. For patients at hospitals without a cath lab or via emergency medical services, the decision depends on 'Time to PCI'. If the estimated PCI delay is ≤120 minutes, Primary PCI is preferred with a goal of <90 minutes. If the estimated delay is >120 minutes, immediate fibrinolysis (bolus) is indicated within 10 minutes. The diagram emphasizes minimizing 'Removal System\'s Delay' to ensure optimal myocardial revascularization and clinical outcomes.

Summary : This figure presents a care system pathway for patients experiencing ischemic symptoms suggestive of acute coronary syndrome (ACS), detailing the recommended steps for emergency medical services (EMS), hospital arrival, and reperfusion strategies based on the patient's mode of transportation and hospital capabilities. flowchart: # Nodes : • Start: Patients With Symptoms Suggestive of ACS (rectangle) • Patient calls 911: preferred (rectangle) • EMS obtains prehospital ECG within 10 min of FMC and suspects STEMI (Class 1) (rectangle) • EMS determines destination hospital (rectangle) • Transport to PCI center: Prehospital cath lab activation (Class 1), Direct transport to PCI center for PPCI (Class 1) (rectangle) • Arrive at PCI center (rectangle) • Bypass ED (if feasible) (rectangle) • ED (rectangle) • Cath lab (rectangle) • Goal EMS FMC-to-device ≤90 min (Class 1) (rectangle) • Primary PCI (rectangle) • Notify non-PCI center of STEMI patient en route (rectangle) • Arrive at non-PCI center (rectangle) • Non-PCI center commits to reperfusion strategy (rectangle) • Fibrinolysis strategy: If PPCI not feasible within 120 min of FMC (Class 1), Goal door-to-lysis ≤30 min (rectangle) • Assess patient for reperfusion after lysis (rectangle) • Arrange for immediate transfer to PCI center: If lysis failed or patient unstable, arrange for urgent angiography for rescue PCI (Class 1); If lysis successful and patient stable, arrange for early angiography (Class 1) (rectangle) • PPCI strategy: If PPCI feasible within 120 min of FMC, or lysis contraindicated (Class 1), Activate cath lab for PPCI, Urgent transfer to PCI center (bypass ED, direct to cath lab, if feasible) (rectangle) • Cath lab (rectangle) • Goal FMC-to-device ≤90 min (direct presenters) or ≤120 min (transfers) (Class 1) (rectangle) • Primary PCI (rectangle) • Patient takes own transportation (rectangle) • FMC: arrive at non-PCI center (rectangle) • Door-to-ECG ≤10 min (Class 1), Diagnose STEMI (rectangle) • FMC: arrive at PCI center (rectangle) • Door-to-ECG ≤10 min (Class 1), Diagnose STEMI, Activate cath lab (rectangle) # Connectors : • Arrows indicate progression from symptom onset to EMS or self-transport, then to hospital arrival, diagnosis, and reperfusion strategy. • Branches split based on whether the patient calls 911 or self-transports, and whether the hospital is a PCI or non-PCI center. • Decision points include EMS determination of hospital, non-PCI center commitment to reperfusion strategy, and assessment after fibrinolysis. • Merges occur at the cath lab and primary PCI endpoints. # Layout : • The flowchart is organized into three main vertical pathways: EMS/911 activation, self-transport to non-PCI center, and self-transport to PCI center. • Each pathway includes time-based goals (e.g., ECG within 10 min, FMC-to-device ≤90 min). • Green boxes highlight key actions and time targets. • The chart uses solid arrows for process flow and decision branches. # Analysis : • The figure emphasizes rapid diagnosis and treatment for STEMI, with clear time goals for ECG, lysis, and PCI. • Direct transport to PCI centers and bypassing ED when feasible are prioritized for faster reperfusion. • Non-PCI centers must quickly commit to either fibrinolysis or transfer for PCI, with specific instructions based on patient stability and response. • The workflow is designed to minimize delays and optimize outcomes for ACS patients, regardless of initial hospital type or mode of arrival.

Summary : This flowchart outlines the decision-making and organization of reperfusion strategies for patients with ST-segment elevation myocardial infarction (STEMI) within the first 12 hours of medical contact, focusing on minimizing total ischemic time and system delays. flowchart: # Nodes : • Symptom onset (vertical dashed line, start point) • FMC STEMI diagnosis (vertical dashed line) • PCI centre (rectangle) • Primary PCI (rectangle, red) • Aim FMC-to-wire crossing time <60 mins (rectangle, red) • EMS or non-PCI centre (rectangle) • Can PCI be performed within 120 mins? (diamond) • Immediate transfer to PCI centre (rectangle) • Primary PCI (rectangle, red) • Aim FMC-to-wire crossing <90 mins (rectangle, red) • Immediate fibrinolysis (rectangle) • Aim FMC-to-needle time ≤30 mins (rectangle, red) • Fibrinolysis successful? (diamond) • Early transfer for coronary angiography between 2–24 hours (rectangle, red) • Immediate transfer for rescue PCI (rectangle, red) • If cardiogenic shock, immediate transfer to PCI centre where possible (rectangle, red, spanning bottom of chart) # Connectors : • Arrows indicate flow from symptom onset through diagnosis to either PCI centre or EMS/non-PCI centre. • From PCI centre → Primary PCI → Aim FMC-to-wire crossing time <60 mins. • From EMS/non-PCI centre → Can PCI be performed within 120 mins? – YES: Immediate transfer to PCI centre → Primary PCI → Aim FMC-to-wire crossing <90 mins. – NO: Immediate fibrinolysis → Aim FMC-to-needle time ≤30 mins → Fibrinolysis successful? ▫ YES: Early transfer for coronary angiography between 2–24 hours. ▫ NO: Immediate transfer for rescue PCI. • If cardiogenic shock at any point, immediate transfer to PCI centre where possible. # Layout : • Flow is left-to-right, with vertical swim-lanes for “Pathways and decisions in reperfusion” and “Time delays in reperfusion.” • Patient delay and system delay are indicated as horizontal bars below the main flowchart, contributing to total ischemic time. • Red boxes highlight critical time targets and urgent actions. # Analysis : • The chart emphasizes minimizing delays in reperfusion therapy for STEMI, prioritizing primary PCI when feasible within recommended timeframes. • Decision points focus on the feasibility of PCI within 120 minutes and the success of fibrinolysis, with clear fallback strategies (rescue PCI or early angiography). • Immediate transfer to PCI centre is recommended in cases of cardiogenic shock, regardless of other considerations. • The flowchart visually separates patient delay from system delay, underscoring the importance of rapid system response to reduce total ischemic time.

This composite figure illustrates a percutaneous coronary intervention (PCI) procedure for in-stent restenosis (ISR). Panel 5a consists of two fluoroscopic frames showing balloon angioplasty (POBA) being performed to optimize a previously deployed stent in the Right Coronary Artery (RCA); a radiopaque balloon catheter is visible within the vessel lumen. Panel 5b presents cross-sectional Intravascular Ultrasound (IVUS) images, showing a circular, widely patent lumen with improved stent expansion and wall apposition following the intervention. The bright, circumferential echoes represent the expanded stent struts against the vessel wall. Panel 5c displays the final coronary angiogram, revealing an excellent procedural result with a smooth, unobstructed lumen in the RCA and successful restoration of distal blood flow without signs of residual stenosis or dissection. This sequence demonstrates the use of intravascular imaging to guide and verify successful balloon optimization in complex coronary revascularization cases.

This diagnostic fluoroscopic image captures a Percutaneous Coronary Intervention (PCI) during a 'kissing balloon' dilation procedure. The angiogram displays the bifurcation of the left main coronary artery into the left anterior descending (LAD) and left circumflex (LCx) arteries. Two radiopaque coronary stents with a visible mesh-like morphology are positioned in tandem, extending from the left main artery into the LAD and LCx branches. Two distinct coronary guidewires are seen traversing the length of the stents and extending into the distal vasculature. Notably, two angioplasty balloons are simultaneously inflated at the bifurcation to ensure optimal stent expansion and bifurcation patency. A large-bore catheter (Impella device) is also visible in the cardiac silhouette, providing hemodynamic support. The image demonstrates complex interventional techniques for treating coronary bifurcation lesions, highlighting the use of simultaneous balloon inflation to prevent side-branch occlusion and maintain vessel geometry.

This composite of three diagnostic fluoroscopic images illustrates a percutaneous coronary intervention (PCI) procedure, specifically demonstrating Left Main (LM) coronary artery stenting using the kissing balloon technique. The left panel shows a coronary angiogram in an RAO Caudal projection (spider view), providing clear visualization of the distal left main bifurcation into the left anterior descending (LAD) and circumflex (LCx) arteries with contrast enhancement. The central panel captures the interventional phase in an LAO Cranial projection, showing a catheter-delivered angioplasty balloon inflated at the bifurcation site; the balloon is identifiable by distinct radiopaque markers, with a distal guidewire curving beyond the tip. The right panel displays the post-stent result in an LAO Cranial projection, demonstrating restored vessel patency and the structural deployment of the stent. These images serve as an educational resource for interventional cardiology, highlighting procedural steps for complex bifurcation lesions and coronary anatomy visualization.

This composite of diagnostic images contains four panels (Fig 8a-d) showing a percutaneous coronary intervention (PCI) procedure for in-stent restenosis (ISR). Panel 8a is a coronary angiogram of the right coronary artery (RCA) displaying a complete occlusion within a previously placed proximal stent. Retrograde collateral vessels are visible, arising from the left coronary artery to supply the distal RCA. Panel 8b illustrates the successful antegrade advancement of a guidewire across the occluded segment into the distal vessel, confirmed via contralateral injection. Panels 8c and 8d demonstrate the therapeutic phase of the procedure, featuring predilatation of the occluded stented segment using non-compliant balloons. The balloons are seen fully inflated across the lesion site to restore luminal patency before further definitive treatment. This series provides a clinical example of managing complex chronic total occlusions within previously stented segments using antegrade techniques and high-pressure balloon angioplasty.

Diagnostic coronary angiography images comparing two clinical scenarios of coronary artery disease. The image is structured into two horizontal rows, each containing three angiographic views (likely RAO/LAO cranial and caudal projections) to visualize the Right Coronary Artery (RCA), Left Anterior Descending (LAD) artery, and Circumflex (LCx) artery. Scenario 1 (top row) demonstrates high-complexity multivessel disease with a total SYNTAX score of 47. Labeled lesions include the mid-RCA, distal RCA, posterolateral branch, distal circumflex, first diagonal, and mid-LAD, showing varying degrees of stenosis and vessel involvement. Scenario 2 (bottom row) illustrates low-complexity disease with a total SYNTAX score of 10, highlighting fewer and less severe lesions in the distal RCA, distal circumflex, and mid-LAD. These comparison images serve as an educational tool for cardiologists to understand coronary lesion scoring based on anatomical location, severity, and complexity to guide revascularization strategies (PCI vs. CABG).

Summary : This image presents a clinical recommendation table for DAPT (dual antiplatelet therapy) adherence in patients with multivessel coronary artery disease (CAD), comparing PCI (percutaneous coronary intervention) and CABG (coronary artery bypass grafting). table: # Recommendation Table for DAPT Adherence : ## Columns : • COR (Class of Recommendation): 2a (yellow background) • LOE (Level of Evidence): B-NR (blue background) • RECOMMENDATION: Textual clinical recommendation ## Recommendation Text : • "In patients with multivessel CAD amenable to treatment with either PCI or CABG who are unable to access, tolerate, or adhere to DAPT for the appropriate duration of treatment, CABG is reasonable in preference to PCI (1-10)." ## Supplementary Information : • Referenced studies supporting the recommendation are summarized in "Online Data Supplement 16." Analysis : • The table provides a specific clinical recommendation (Class 2a, Level B-NR) suggesting CABG over PCI for patients with multivessel CAD who cannot adhere to DAPT, with supporting references available in an online supplement. The structure is typical for guideline tables, with clear separation of recommendation strength, evidence level, and clinical context.

Summary : This table presents recommendations for patients with complex coronary artery disease (CAD) who require revascularization, comparing coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) based on disease complexity and supporting evidence. table: # Columns : • COR (Class of Recommendation): 1 (green), 2a (yellow) • LOE (Level of Evidence): B-R (randomized) • RECOMMENDATIONS: Detailed clinical guidance for each scenario # Rows : • Row 1: – COR: 1 (green) – LOE: B-R – Recommendation: In patients who require revascularization for significant left main CAD with high-complexity CAD, it is recommended to choose CABG over PCI to improve survival (references 1,2). • Row 2: – COR: 2a (yellow) – LOE: B-R – Recommendation: In patients who require revascularization for multivessel CAD with complex or diffuse CAD (e.g., SYNTAX score >33), it is reasonable to choose CABG over PCI to confer a survival advantage (references 2-5). # Design Encodings : • COR is color-coded: green for 1, yellow for 2a. • LOE is consistently B-R (randomized evidence). • Recommendations are text-based, with reference numbers in parentheses. # Analysis : • The table prioritizes CABG over PCI for patients with high-complexity or multivessel CAD, especially when left main disease or high SYNTAX scores are present. • Stronger recommendation (Class 1) is given for left main CAD with high complexity, while a reasonable (Class 2a) recommendation is given for multivessel or diffuse CAD. • Both recommendations are supported by randomized evidence (B-R).

A clinical photograph illustrating the standardized placement of a 12-lead electrocardiogram (ECG) on a neonate. The image shows several electrodes secured to the newborn's skin using clear adhesive gel tabs (Philips brand). The electrode distribution follows neonatology guidelines to minimize motion artifacts: the four limb leads are positioned on the right and left shoulders and the right and left iliac crests, rather than the distal extremities. The precordial leads (V1-V6) are arranged across the anterior chest wall. Each electrode consists of a transparent plastic clip housing, a tapered brown connector with color-coded bands (including red, yellow, green, blue, and purple) for lead identification, and white cabling. The clinical context demonstrates the procedural adaptations required for neonatal cardiac monitoring, such as using torso placement for limb leads to improve signal-to-noise ratio in active infants.

This composite educational graphic illustrates the procedural setup and resulting data for a standard 12-lead electrocardiogram (ECG/EKG). Panels (a) and (b) are clinical photographs demonstrating correct electrode placement on a male torso. The limb leads are positioned as RA (right arm/shoulder) and LA (left arm/shoulder) on the upper chest, with RL (right leg) and LL (left leg) on the lower abdomen. The precordial leads (V1-V6) follow the standard anatomical arc across the chest: V1 and V2 at the fourth intercostal space (right and left of the sternum), V4 at the fifth intercostal space (mid-clavicular line), and V3, V5, and V6 completing the transverse sequence toward the left axilla. Panel (a) includes an inset showing the experimental use of conductive carbon nanotube yarns (SWNT-CYs) connected via alligator clips to the electrodes. Panel (c) displays the resulting 12-lead ECG waveforms on a standard grid, labeled I, II, III, aVR, aVL, aVF, and V1-V6. Each lead shows distinct P-waves, QRS complexes, and T-waves, representing different electrical vectors of cardiac depolarization and repolarization.

This procedural clinical photograph demonstrates the concurrent placement of a standard 12-lead electrocardiogram (ECG) and a Polar H10 heart rate sensor chest strap on a male subject. The image illustrates proper anatomical positioning for clinical and exercise physiology monitoring. The six precordial leads (V1-V6) are visible across the chest: V1 (4th intercostal space, right sternal border), V2 (4th intercostal space, left sternal border), V3 (midway between V2 and V4), V4 (5th intercostal space, mid-clavicular line), V5 (anterior axillary line), and V6 (mid-axillary line). The leads utilize standard color-coding (Red, Yellow, Green, Brown, Black, Violet). Limb leads are positioned at the shoulders (RA/LA) and the lower ribcage/abdominal area (RL/LL) to facilitate movement during testing. The Polar H10 chest strap is situated inferior to the pectoral muscles, intersecting the mid-precordial electrode line. This visual serves as an educational reference for electrode application in comparative heart rate variability (HRV) studies, highlighting the spatial relationship between traditional medical grade ECG sensors and wearable consumer fitness technology.

This diagnostic image displays two 12-lead electrocardiograms (ECGs) labeled Panel A and Panel B, presented on standard grid paper for clinical comparison. Panel A shows a 12-lead ECG demonstrating sinus rhythm with normal P-wave morphology. The QRS complexes exhibit nonspecific intraventricular conduction disturbances, characterized by widened or slurred morphologies in certain leads, notably the precordial leads V1-V6. Panel B shows a subsequent ECG from the same patient. Comparison between the two panels reveals subtle variations in waveform amplitude and ST-segment baseline, though both lack overt ST-segment elevation. The precordial leads (V1-V6) show a typical progression of R-wave amplitude, while lead aVR shows the expected global inversion of P, QRS, and T waves. This comparison is used in cardiology to monitor electrical changes during acute coronary syndromes, such as Non-ST Segment Elevation Myocardial Infarction (NSTEMI), where conduction disturbances may be present despite the absence of classic ST-elevation.

This composite educational illustration combines an anatomical diagram of the human heart with a diagnostic Electrocardiogram (ECG) tracing to demonstrate cardiac physiology. On the left, a coronal cross-section of the heart identifies the Aorta, Right Atrium, Left Atrium, Right Ventricle, and Left Ventricle. The right side features a detailed ECG waveform analysis set against a standard measurement grid (1 square = 0.04 sec / 0.1 mV). The tracing identifies key electrophysiological components: the P wave (atrial depolarization), QRS complex (ventricular depolarization), and T wave (ventricular repolarization). Critical diagnostic intervals and segments are explicitly labeled, including the PR interval, PR segment, QRS interval, ST segment, ST interval, QT interval, and the RR interval (representing the heart rate). This comparison chart and pathophysiology diagram serve as an introductory resource for understanding the correlation between cardiac anatomy and the electrical signals recorded during a cardiac cycle, suitable for basic to intermediate medical education.

This diagnostic image is a 12-lead electrocardiogram (ECG) demonstrating acute ST-segment elevation myocardial infarction (STEMI). The tracing reveals a sinus rhythm with significant ST-segment elevation in the inferior leads (II, III, and aVF) and the anterior precordial leads (V1 through V4), highlighted by red arrows. Notably, there is reciprocal ST-segment depression in the high lateral leads (I and aVL). The anterolateral leads (V5 and V6) show T-wave inversions. These findings indicate widespread myocardial ischemia or injury involving multiple vascular territories, specifically the inferior and anterior walls. The clinical significance of this ECG suggests acute occlusion of major coronary arteries, such as the right coronary artery (RCA) and left anterior descending (LAD) artery, requiring urgent intervention. This visual is an educational example of multi-territory STEMI and the identification of reciprocal changes in a clinical cardiology context.

This diagnostic image is a 12-lead electrocardiogram (ECG) demonstrating signs of an acute ST-elevation myocardial infarction (STEMI). The tracing reveals significant ST-segment elevation in the anterior leads (V1-V4) and inferior leads (II, III, and aVF), with black arrows highlighting specific areas of elevation. In lead V2 and V3, the ST-segment shows an upward-sloping, concave morphology, while lead V4 displays a more pronounced, 'tombstone' appearance merging into hyperacute T-waves. Reciprocal ST-segment depression is visible in the lateral leads, specifically I and aVL. The rhythm is sinus, and the heart rate is approximately 75-80 beats per minute. The ECG is clinically significant for multi-territory ischemia, correlating with proximal left anterior descending (LAD) artery occlusion and multi-vessel coronary artery disease. This visual is an essential educational resource for medical students and clinicians for identifying acute coronary syndromes and understanding the distribution of myocardial injury across various cardiac walls.

This diagnostic image is a 12-lead electrocardiogram (ECG) demonstrating an acute inferior ST-elevation myocardial infarction (STEMI). The tracing reveals significant convex ST-segment elevation in the inferior leads (II, III, and aVF), characteristic of an injury pattern often involving the right coronary artery or left circumflex artery. Accompanying these findings are prominent reciprocal ST-segment depressions in the anterior precordial leads (V1 through V6) and high lateral lead aVL. The rhythm appears to be a normal sinus rhythm with a regular rate. No significant ST-segment deviations are noted in leads I and aVR. This ECG serves as a classic educational example of an inferior STEMI with reciprocal changes, illustrating the electrical changes associated with acute transmural myocardial ischemia in the inferior wall of the heart.