Download Acute Coronary Syndrome - UC Irvine`s Department of Medicine

Acute Coronary Syndrome
MINI LECTURE
KELVIN NGUYEN
2016 UPDATE: RYAN BURRIS
OBJECTIVES
 Understand the definition of ACS
 Be able to explain the differences between UA,
NSTEMI, and STEMI
 Know how to risk stratify UA/NSTEMI
 Be familiar with the basic management of ACS
Acute Coronary Syndrome
Definition: a group of 3 different diagnoses: UA, NSTEMI,
STEMI which share a common pathology: obstruction of
coronary arteries.
Acute Coronary Syndrome
Definition: a group of 3 different diagnoses: UA, NSTEMI,
STEMI which share a common pathology: obstruction of
coronary arteries.
Chest pain is the most common symptom
Acute Coronary Syndrome
Definition: a group of 3 different diagnoses: UA, NSTEMI,
STEMI which share a common pathology: obstruction of
coronary arteries.
Chest pain is the most common symptom
Chest pain caused by coronary occlusion often feels like a
sub-sternal pressure which can radiate to the left arm or
angle of the jaw.
Chest Pain
 Suspicious Chest Pain can be put into 3 different
categories

Typical (3/3 criteria)
Chest Pain
 Suspicious Chest Pain can be put into 3 different
categories


Typical (3/3 criteria)
Atypical (2/3 criteria)
Chest Pain
 Suspicious Chest Pain can be put into 3 different
categories



Typical (3/3 criteria)
Atypical (2/3 criteria)
Non-cardiac (1/3 criteria)
Review Slide
 The 3 Criteria are:
Review Slide
 The 3 Criteria are:
 1. the presence of substernal chest pain
 2. discomfort that was provoked by exertion or emotional
stress
 3. relieved by rest and/or nitroglycerin.
Acute coronary syndrome
 Based on ECG and cardiac enzymes, ACS is classified
into:

STEMI: ST elevation, elevated cardiac enzymes
Acute coronary syndrome
 Based on ECG and cardiac enzymes, ACS is classified
into:


STEMI: ST elevation, elevated cardiac enzymes
NSTEMI: ST depression, T-wave inversion, elevated cardiac
enzymes
Acute coronary syndrome
 Based on ECG and cardiac enzymes, ACS is classified
into:



STEMI: ST elevation, elevated cardiac enzymes
NSTEMI: ST depression, T-wave inversion, elevated cardiac
enzymes
Unstable Angina: Non specific or no EKG changes, normal
cardiac enzymes
Acute coronary syndrome
Now to review the different acute
coronary syndromes in more
detail
Unstable Anginal Chest Pain
 New onset angina
Unstable Anginal Chest Pain
 New onset angina
 Occurs at rest and prolonged, usually lasting >20
minutes
Unstable Anginal Chest Pain
 New onset angina
 Occurs at rest and prolonged, usually lasting >20
minutes
 Increasing angina: Pain that occurs more frequently,
lasts for longer periods or is increasingly limiting the
patients activity
Unstable Angina
 EKG
 May present with nonspecific ST segment changes that do not
meet criteria for NSTEMI or STEMI
Unstable Angina
 EKG
 May present with nonspecific ST segment changes that do not
meet criteria for NSTEMI or STEMI
 Troponin
 normal
NSTEMI
 EKG:
ST depressions (0.5 mm at least) or T wave
inversions ( 1.0 mm at least) without Q waves in
2 contiguous leads with prominent R wave or R/S
ratio >1.

NSTEMI
 EKG:
ST depressions (0.5 mm at least) or T wave
inversions ( 1.0 mm at least) without Q waves in
2 contiguous leads with prominent R wave or R/S
ratio >1.
 Troponins:
Elevated

STEMI
 EKG:
Q
waves , ST elevations, hyper acute T waves;
followed by T wave inversions.
STEMI
 EKG:
Q
waves , ST elevations, hyper acute T waves;
followed by T wave inversions.
 Troponins:
 Elevated
STEMI EKG
 STEMI:


Q waves , ST elevations, hyper acute T waves; followed by T wave
inversions.
Clinically significant ST segment elevations:
 > than 1 mm (0.1 mV) in at least two anatomical contiguous leads
 or 2 mm (0.2 mV) in two contiguous precordial leads (V2 and V3)
STEMI EKG
 STEMI:
 Q waves , ST elevations, hyper acute T waves; followed by T wave
inversions.
 Clinically significant ST segment elevations:




> than 1 mm (0.1 mV) in at least two anatomical contiguous leads
or 2 mm (0.2 mV) in two contiguous precordial leads (V2 and V3)
Note: LBBB and pacemakers can interfere with diagnosis of MI on EKG
Right sided or inferior infarctions on the EKG may reflect right
ventricular dysfunction. Be careful to not decrease these patients’
preload!
Cardiac Enzyme Details
 Troponin is primarily used for diagnosing MI
because it has good sensitivity and specificity.

CK-MB is more useful in certain situations such as post
reperfusion MI or if troponin test is not available
Cardiac Enzyme Details
 Troponin is primarily used for diagnosing MI
because it has good sensitivity and specificity.

CK-MB is more useful in certain situations such as post
reperfusion MI or if troponin test is not available
 Other conditions can cause elevation in troponin
such as renal failure or heart failure
Cardiac Enzyme Details
 Troponin is primarily used for diagnosing MI
because it has good sensitivity and specificity.

CK-MB is more useful in certain situations such as post
reperfusion MI or if troponin test is not available
 Other conditions can cause elevation in troponin
such as renal failure or heart failure
 Troponins are trended every 6-8 hours until they
peak
Now for a review of the different
acute coronary syndromes
Acute coronary syndrome
 Based on ECG and cardiac enzymes, ACS is classified
into:
Acute coronary syndrome
 Based on ECG and cardiac enzymes, ACS is classified
into:

STEMI: ST elevation, elevated cardiac enzymes
Acute coronary syndrome
 Based on ECG and cardiac enzymes, ACS is classified
into:


STEMI: ST elevation, elevated cardiac enzymes
NSTEMI: ST depression, T-wave inversion, elevated cardiac
enzymes
Acute coronary syndrome
 Based on ECG and cardiac enzymes, ACS is classified
into:



STEMI: ST elevation, elevated cardiac enzymes
NSTEMI: ST depression, T-wave inversion, elevated cardiac
enzymes
Unstable Angina: Non specific or no EKG changes, normal
cardiac enzymes
Risk Stratification: TIMI score
 NSTEMI or unstable angina are risk stratified:


Age>=65
>= 3 CAD risk factors:






HTN, hyperlipidemia, diabetes, smoker, family hx of early MI
Documented CAD with >=50% stenosis
ST segment deviation
≥ 2 aginal episodes in past 24 hours
Aspirin use in the past week (marker for more severe case)
Elevation of cardiac enzymes
 Stratify risk based on number of variables
 Risk:

0-2: Low
3-4: Intermediate
5-7: High risk
Risk Stratification: GRACE risk model
 Superior predictive power
 Risk factors include:







Age
Systolic blood pressure
Presence of ST segment deviation
Cardiac arrest during presentation
Serum creatinine concentration
Presence of elevated serum cardiac biomarkers
Heart rate
Management of low risk Chest Pain
 EKG normal or non-specific changes with
intermediate or low risk:



Telemetry
Rule out ACS with 3 sets of troponins and EKG
Consider pre-discharge stress test
NSTEMI & Unstable Angina Management








Telemetry
Aspirin
Beta blocker
Nitrates
Heparin (UFH or LMWH)
ACE-I/ARB
Statin
Antiplatelet agent: Consider ticagrelor over clopidogrel.

When Cangrelor becomes available at UCI, this will be preferable
in many situations
STEMI Management
 STEMI patients usually go straight to the cath lab
from the ED. Goal: door to balloon 90 minutes.
 Initial management for STEMI:

Otherwise similar to NSTEMI
Case
 60 year old male with history of DM2 for 20 years,
HTN, HLD who presented to the ED with 4 hour
onset of chest pain which was described as in the
substernal chest without radiation. The pain seemed
to improve when he sits down and worsening when
he walked upstairs.
 VS: T 36.9, HR: 95, BP: 84/56, RR 22, O2 sat. 99%
RA.
 ECGs are shown as followed
 What will you do?
 What’s your diagnosis?
 What should be done now?
Summary
 ACS is comprised of UA, NSTEMI, and STEMIs
Chest pain is categorized based on location and relation to
exertion
 ACS is categorized based on troponin levels and EKG
 Risk stratification for UA/NSTEMI can be done by the GRACE or
TIMI score
 ACS management medications include: Aspirin, Beta Blocker,
Nitrates, Heparin, Ace-I, Statin, an anti-platelet agent
 Door to balloon time for STEMI should be less than 90 minutes

References



2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency
Cardiovascular Care. Circulation 2005;112:IV-89-IV-110
2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction : A Report of
the American College of Cardiology Foundation/American Heart Association Task Force on Practice
Guidelines. Circulation 2013, epublished April 29th 2013 and print published june 4th 2013.
Herman LK, et al. Comparison of frequency of inducible myocardial ischemia in patients presenting to
emergency department with typical versus atypical or nonanginal chest pain. Am J Cardiol. 2010
105:1561-4.
 www.uptodate.com:


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Overview of the acute management of unstable angina and acute non-ST elevation myocardial infarction
Initial evaluation and management of suspected acute coronary syndrome in the emergency department
Criteria for the diagnosis of acute myocardial infarction