 Let's take a closer look at the end-stemmy myocardial infarction. The end-stemmy is a subendothelial infarct. That is the inner one-third of the myocardium. This area is very susceptible to ischemia because the nutrients and the oxygen must pass through the entire portion of the muscular ventricle to get to the subendocardium. So a small reduction in blood flow to that area can easily infarct the subendothelial layers. Upon EKG we will see an ST depression. So you can see that here in V4 and V5. That ST depression is below the lines of the normal EKG. Treatment for an end-stemmy includes many different medications. First and foremost we will anti-coagulate with something like heparin. We will also give anti-platelet therapy like aspirin and this will be a full-dose aspirin which is about a 325 milligram, not the baby aspirin 81 milligrams. We will also use ADP receptor inhibitors like clopidogrel, also known as plavix. And then we will use beta blockers, ACE inhibitors and statins to reduce the preload and the afterload on the heart as well as tend to issues with hyperlipidemia. We can symptomatically control the patient with nitroglycerin and morphine but this does not reduce risk of mortality. The reason we use morphine along with nitroglycerin is because nitroglycerin vasodilates and it does not distinguish between coronary arteries and other arteries in the body. Major vasodilation in the cerebral flow can cause migraine headaches so we use morphine to help reduce the risk of migraine headaches. Let's discuss stemmies or ST elevation MIs. These are caused by a transmural infarction so the blood flow is cut off and the tissue dies through the entire myocardium of the heart. This is the full thickness muscular wall that is involved. On EKG you can see an ST elevation, hence the name STEMI, and we can also see pathologic Q waves. You see that here in 2 and 3 where we have the ST elevations and then also the pathologic Q waves in 3 as well as AVF. Stem for STEMI is the same as the end STEMI so we are going to use heparin, aspirin, clopidogryl, beta blockers, ACE inhibitors, statins, we can treat symptomatically with nitroglycerin and morphine but specifically we are going to do a PCI or percutaneous coronary intervention where we go find the clot, destroy the clot, remove the clot or open up the arteries to allow blood flow to continue through the heart.