What you need to know

Acute Coronary Syndrome

• • • • • •

Identify who has ACS ( hx /PE/ ECG/labs) STEMI vs UAP/NSTEMI Risk stratify the rest General measures Specific tx modalities( PCI for STEMI) Mx complications( arrhythmias/pump failure)

ACS 1 May 2011

ACS 1 May 2011

Case Scenario
• 55/m/ hpt/DM/smoker • 1 hr of anterior compressive chest pain + diaphoresis • Radiating to jaw • BP: 150/100 PR 85 sats 95% RR: 15 • H/L- NAD • How do you approach this patient?

Acute Coronary Syndrome
• The spectrum of clinical conditions ranging from: – unstable angina – NSTEMI – STEMI • characterized by the common pathophysiology of a disrupted atheroslerotic plaque

ACS 1 May 2011

ACS 1 May 2011

Definition of Coronary Artery Disease

Clinical Presentation of ACS
-Classical features -Angina equivalent - dyspnea (LV failure) - arrhythmia, faint, tiredness -Autonomic features -Atypical chest pain - musculoskeletal, pleuritic features etc

CAD

IHD

Acute coronary syndrome

All patients with coronary artery atherosclerosis

Cardiac disease as a result of myocardial ischemia (imbalance between oxygen requirements and supply)

1. Unstable angina 2. Non-ST elevation MI 3. ST elevation MI

ACS 1 May 2011

ACS 1 May 2011

1

epigastrium Associated sighs: diaphoresis. back. tight Unrelieved by rest or GTN Radiation of pain Associated signs : diaphoresis. rapid or prolonged exercise  Class II : Slight limitation of ordinary activity  Class III : Mark limitation of ordinary physical activity  Class IV : At rest ACS 1 May 2011 Unstable Angina . impending doom Pulmonary edema Cardiogenic shock ACS 1 May 2011 ACS 1 May 2011 2 . shortness of breath.1994 ACS 1 May 2011 Definition of AMI Necrosis of a portion of heart muscle due to inadequate blood supply Based on history Pain > 15 minutes Crushing. jaw. tachyarrhythmia Pain > 15 mins crushing. death Diagnosis: Clinical Investigations ACS 1 May 2011 ACS 1 May 2011 Complications of UA. chocking.Unstable Angina Rest Angina New-onset Angina Increasing Angina Occurrence of angina  Class I : Strenuous. shortness of breath. tight. neck. anxiety Feeling of impending doom. substernal Unrelieved by rest or nitroglycerin Radiation to arms. anxiety. AMI Evolving AMI Congestive heart failure Malignant arrhythmia bradyarrhythmia.Definition • angina at rest (> 20 minutes) • new-onset (< 2 months) exertional angina (at least CCSC III in severity) • recent (< 2 months) acceleration of angina (increase in severity of at least one CCSC class to at least CCSC class III) Canadian Cardiovascular Society Classification Agency for Health Care Policy Research .

focus on eligibility for fibrinolytic therapy • Obtain initial serum cardiac marker levels • Evaluate initial electrolyte and coagulation studies • Request. shock. Aspirin) EMS personnel can perform immediate assessment and treatment (“MONA”). unstable bradyarrhythmia or tachyarrhythmia Reduce subsequent heart failure. Oxygen. VF. or new LBBB ( STEMI ) • • ACS 1 May 2011 ACS 1 May 2011 Assess Initial 12-Lead ECG Findings • ST elevation or new or presumably new LBBB: strongly suspicious for injury • ST-elevation AMI • ST depression or dynamic T-wave inversion: strongly suspicious for ischaemia • High-risk unstable angina/ non–ST-elevation AMI • Nondiagnostic ECG: absence of changes in ST segment or T waves • Intermediate/low-risk unstable angina Classify patients with acute ischaemic chest pain into 1 of the 3 groups above within 10 minutes of arrival. repeat the ECG 15 min to 30 min later 2 adjacent leads with > 1mm ST segment elevation.g. focus on eligibility for fibrinolytic therapy Obtain blood sample for initial cardiac marker levels Initiate electrolyte and coagulation studies ST depression > 0. targeted history and physical exam. review portable chest x-ray (<30 minutes) Immediate general treatment • Oxygen at 4 L/min • Aspirin 160 to 325 mg • Nitroglycerin SL or spray • Morphine IV (if pain not relieved with nitroglycerin) Memory aid: “MONA” greets all patients (Morphine. use checklist (yes-no). including initial 12lead ECG and review for fibrinolytic therapy indications and contraindications. VT. Assess initial 12-lead ECG ACS 1 May 2011 ACS 1 May 2011 Items of Immediate Assessment (<10 min) Based on ECG • • • • • Check vital signs with automatic or standard BP cuff Determine oxygen saturation Obtain IV access Obtain 12-lead ECG Obtain a brief. targeted history and perform a physical examination.Ischemic Chest Pain Algorithm The first healthcare providers to encounter the ACS pt can have a big impact on pt’s outcome Reduce myocardial necrosis Prevent and treat major complications e. Nitroglycerin. ACS 1 May 2011 ACS 1 May 2011 3 . pulm edema.5 mm or dynamic T inversion ( UA or NSTEMI ) “Normal” ECG does not rule out AMI When in doubt. death Chest pain suggestive of ischaemia Immediate assessment (<10 minutes) • Measure vital signs (automatic/standard BP cuff) • Measure oxygen saturation • Obtain IV access • Obtain 12-lead ECG (physician reviews) • Perform brief.

increased thrombus burden & microvascular embilization. an early. Hence may need serial testing I lateral II inferior III inferior ACS 1 May 2011 aVR aVL lateral aVF inferior V1 septal V2 septal V3 anterior V4 anterior V5 lateral V6 lateral ACS 1 May 2011 Troponin elevation correlates with increased risk of adverse outcome.AMI Localization Based on biomarkers Cardiac enzymes e.g. normal level does not exclude AMI Pts with normal or non-diagnostic ECG with symptoms of ACS usually are at low risk or intermediate risk Aims: to risk stratify with diagnostic tests and to provide appropriate Rx e. cardiac biomarkers. troponin T or I Insensitive during the first 4-6 hrs of presentation. TMX. or primary PCI Aims:rapidly identify pts with STEMI quickly screen them for indications or contraindications for reperfusion therapy ACS 1 May 2011 ACS 1 May 2011 4 . increased risk of death As it takes time for biomarkers to appear. sestaMIBI scan ACS 1 May 2011 ACS 1 May 2011 Immediate General Treatment • • • • Oxygen at 4 L/min Aspirin 300mg Nitroglycerin SL Morphine IV (if pain not relieved with nitroglycerin) Pts with STEMI usually have complete occlusion of an epicardial coronary artery Mainstay of treatment is reperfusion Rx fibrinolytics.g. CK-MB. stress echo.

Streptokinase .APSAC (anisoylated plasminogen-streptokinase activator complex) Eligibility Criteria for Thrombolytic Therapy C ntraindications Active internal bleeding Suspected aortic dissection Significant head injury within 3 months Intracranial neoplasm or hemorrhage or AVM Stroke < 3 months History bleeding diathesis ACS 1 May 2011 ACS 1 May 2011 Eligibility Criteria for Thrombolytic Therapy Relative Contraindications Recent trauma or major surgery < 3 months Traumatic or prolonged (>10 mins) CPR Pregnancy Severe HT (BP >180/110 mmHg) Recent internal bleeding > 1 month Active peptic ulcer disease Stroke > 3 months Current use of warfarin Significant liver or renal dysfunction ACS 1 May 2011 ACS 1 May 2011 Pts with UA or NSTEMI usually have critical but incomplete occlusion of an epicardial coronary artery Mainstay of treatment is not fibrinolysis.2 mV in > 2 adjacent chest limbs Thrombolysis Raised cardiac enzymes + ve Normal cardiac . or early invasive strategies Symptoms & signs of ACS & suggestive ECG Symptoms & signs of ACS Pain Rx: Rx: nitrate.ve enzymes UAP Sx < 3 hrs & PCI delay > 60 mins No contraindication & PCI delay > 90 mins PC I Sx < 3 hrs & PCI delay < 60 mins Sx > 3 hrs & PCI delay < 90 mins Cardiogenic shock within 36 hrs Early invasive Delayed invasive.Thrombolytic Agents • Currently available .1 mV in > 2 adjacent limb leads > 0. But optimized medical therapy. or conservative STEMI ACS 1 May 2011 NSTEMI heparin heparin Gp IIb/IIIa heparin Gp IIb/IIIa heparin Gp Iib/IIIa ACS 1 May 2011 5 . morphine Antiplatelets Rx Other or normal ECG STEMI NSTEMI / UAP 12 lead ECG ST elevation > 0.Recombinant tissue plasminogen activator (r-TPA) .

aerosol spray.V.Initial general therapy (1) M O N A Morphine Oxygen Nitrates ( S/L. VF Asystole. heart blocks Bradyarrhythmia Tachyarrhythmia narrow complex broad complex Management of pump complications/valve rupture Case scenario: • 55/m/ hpt/DM/smoker • 1 hr of anterior compressive chest pain + diaphoresis • Radiating to jaw • BP: 150/100 PR 85 sats 95% RR: 15 • H/L.) Aspirin Initial general therapy (2) Clopidogrel b-blockers Heparin (unfractionated. low-molecular-weight) Glycoprotein IIb / IIIa ACE inhibitors Statins ACS 1 May 2011 ACS 1 May 2011 Initial general therapy (3) Management of rhythm disturbances VT.NAD • How do you approach this patient? ACS 1 May 2011 ACS 1 May 2011 What Does This 12-Lead ECG Show? I II III aVR aVL aVF V1 V2 V3 V4 V5 V6 What Does This 12-Lead ECG Show? I II III aVR aVL aVF V1 V2 V3 V4 V5 V6 II II ACS 1 May 2011 ACS 1 May 2011 6 . I.

What Does This 12-Lead ECG Show? I II III aVR aVL aVF V1 V2 V3 V4 V5 What Does This 12-Lead ECG Show? I II aVR aVL aVF V1 V2 V3 V4 V5 V6 V6 III II II ACS 1 May 2011 ACS 1 May 2011 What Does This 12-Lead ECG Show? I II III aVR aVL aVF V1 V2 V3 V4 V5 V6 II ACS 1 May 2011 7 .