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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: 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