Acute Coronary Syndrome: Dr. Suhaemi, SPPD, Finasim
Acute Coronary Syndrome: Dr. Suhaemi, SPPD, Finasim
Acute Coronary Syndrome: Dr. Suhaemi, SPPD, Finasim
SYNDROME
Inferior Wall MI
Anterior Wall MI
(Left Ventricle) =
Left Anterior
Descending Artery
Blockage
Lateral Wall MI
Lateral Wall =
Circumflex Artery
Blockage
Objectives
Define & delineate acute coronary syndrome
Review Management Guidelines
Unstable Angina / NSTEMI
STEMI
Scope of Problem
(2004 stats)
CHD single leading cause of
year of having it
Hypertension
Diabetes Mellitus
Dyslipidemia
Family Historyevent in
Non-ST-Segment
Elevation MI
(NSTEMI)
ST-Segment
Elevation MI
(STEMI)
ACS PATHOPHYSIOLOGY
Diagnosis of Acute MI
STEMI / NSTEMI
At least 2 of the
following
Ischemic symptoms
Diagnostic ECG
changes
Serum cardiac marker
elevations
Diagnosis of Angina
Typical anginaAll three of the following
Substernal chest discomfort
Onset with exertion or emotional stress
Relief with rest or nitroglycerin
Atypical angina
2 of the above criteria
Unstable
Angina
Non occlusive
thrombus
Non specific
ECG
Normal cardiac
enzymes
NSTEMI
Occluding thrombus
sufficient to cause
tissue damage & mild
myocardial necrosis
ST depression +/T wave inversion on
ECG
Elevated cardiac
enzymes
STEMI
Complete thrombus
occlusion
ST elevations on
ECG or new LBBB
Elevated cardiac
enzymes
More severe
symptoms
Acute Management
Initial evaluation &
stabilization
Efficient risk
stratification
Focused cardiac care
Evaluation
Efficient & direct history
Occurs
simultaneously
Initial labs
and tests
12 lead ECG
Obtain initial
cardiac enzymes
electrolytes, cbc
lipids, bun/cr,
glucose, coags
CXR
Emergent
care
IV access
Cardiac
monitoring
Oxygen
Aspirin
Nitrates
History &
Physical
Establish
diagnosis
Read ECG
Identify
complications
Assess for
reperfusion
Focused History
Aid in diagnosis and
rule out other causes
Palliative/Provocative
factors
Quality of discomfort
Radiation
Symptoms associated
with discomfort
Cardiac risk factors
Past medical history especially cardiac
Reperfusion questions
Timing of presentation
ECG c/w STEMI
Contraindication to
fibrinolysis
Degree of STEMI risk
Targeted Physical
Examination
Vitals
Cardiovascular
system
Respiratory
system
Abdomen
Neurological
status
increase risk
Hypotension
Tachycardia
Pulmonary rales, JVD,
pulmonary edema,
New murmurs/heart sounds
Diminished peripheral
pulses
Signs of stroke
ECG assessment
ST Elevation or new LBBB
STEMI
ST Depression or dynamic
T wave inversions
NSTEMI
Non-specific ECG
Unstable Angina
ST Depression or Dynamic T
wave Inversions
ST-Segment Elevation MI
New LBBB
Cardiac markers
Troponin ( T, I)
Very specific and more
sensitive than CK
Rises 4-8 hours after
injury
May remain elevated for
up to two weeks
Can provide prognostic
information
Troponin T may be
elevated with renal dz,
poly/dermatomyositis
CK-MB isoenzyme
Rises 4-6 hours after injury
Mortality at 42 Days
8
7
6.0 %
6
5
4
3
2
1
1.0 %
831
3.4 %
3.7 %
148
134
1.7 %
174
50
67
0
0 to <0.4 0.4 to <1.0 1.0 to <2.0 2.0 to <5.0 5.0 to <9.0
Cardiac troponin I (ng/ml)
9.0
Risk Stratification
YES
STEMI
Patient?
Based on initial
Evaluation, ECG, and
Cardiac markers
NO
UA or NSTEMI
- Evaluate for Invasive vs.
conservative treatment
- Directed medical
therapy
Fibrinolysis indications
ST segment elevation >1mm in two contiguous
leads
New LBBB
Symptoms consistent with ischemia
Symptom onset less than 12 hrs prior to
presentation
(primary
or metastatic)
Ischemic stroke within 3 months EXCEPT acute ischemic
stroke within 3 hours
Suspected aortic dissection
Active bleeding or bleeding diathesis (excluding menses)
Significant closed-head or facial trauma within 3 months
PCI available
Door to balloon < 90min
Door to balloon minus
door to needle < 1hr
Fibrinolysis
contraindications
Late Presentation > 3 hr
High risk STEMI
Killup 3 or higher
STEMI dx in doubt
Comparing outcomes
Comparing outcomes
Medical Therapy
MONA + BAH
Morphine (class I, level C)
Analgesia
Reduce pain/anxietydecrease sympathetic tone,
systemic vascular resistance and oxygen demand
Careful with hypotension, hypovolemia, respiratory
depression
Unstable angina/NSTEMI
cardiac care
based upon:
Risk of actual ACS
TIMI risk score
ACS risk categories per AHA guidelines
Low
High
Intermediate
Findings indicating
HIGH likelihood of ACS
Findings indicating
INTERMEDIATE
likelihood of ACS in
absence of highlikelihood findings
Findings indicating
LOW likelihood of ACS
in absence of high- or
intermediate-likelihood
findings
History
Probable ischemic
symptoms
Recent cocaine use
Physical
examination
Extracardiac vascular
disease
Chest discomfort
reproduced by palpation
ECG
Fixed Q waves
Abnormal ST segments or
T waves not documented
to be new
T-wave flattening or
inversion of T waves in
leads with dominant R
waves
Normal ECG
Serum cardiac
markers
Normal
Normal
Intermediate Risk
ACS
Moderate to high likelihood
of CAD
Non-diagnositic ECG
Non-elevated cardiac
markers
Age < 70 years
Low
risk
Intermediate
risk
High
risk
Chest Pain
center
Conservative
therapy
Invasive
therapy
months
TnI/T)
Surveillence in hospital
Serial ECGs
Serial Markers
Secondary Prevention
Disease
HTN, DM, HLP
Behavioral
smoking, diet, physical activity, weight
Cognitive
Education, cardiac rehab program
Secondary Prevention
disease management
Blood Pressure
Lipids
LDL < 100 (70) ; TG < 200
Maximize use of statins; consider fibrates/niacin first
Diabetes
A1c < 7%
Secondary prevention
behavioral intervention
Smoking cessation
Cessation-class, meds, counseling
Physical Activity
Goal 30 - 60 minutes daily
Risk assessment prior to initiation
Diet
DASH diet, fiber, omega-3 fatty acids
<7% total calories from saturated fats
Medication Checklist
after ACS
Antiplatelet agent
Antihypertensive agent
Beta blocker*
ACE-I*/ARB
Aldactone (as appropriate)
REPERFUSION STRATEGY
FIBRINOLYTICS
AVAILABLE FIBRINOLYTICS:
STREPTOKINASE 1.5mu infusion over 30min (1hour ACLS)
rtPA accelerated infusion over 1.5hrs
- 15mg IV bolus, 0.75mg/kg over 30 min, 0.5mg/kg over 1hr
ANISTREPLASE 30 U IV over 5 min
TENECTEPLASE 30 TO 50 MG
RETEPLASE 10 U IV bolus, ffd. 10U IV after 30 min
Prevention news
From 1994 to 2004 the death rate from
coronary heart disease declined 33%...
But the actual number of deaths declined
only 18%
Getting better with treatment
But more patients developing disease
need for primary prevention focus
Summary
ACS includes UA, NSTEMI, and STEMI
Management guideline focus
Question
&
Answer