Acute coronary Acute coronary syndrome syndrome

ManagementManagementDr Pham Duc TuanDr Pham Duc Tuan

A&E dept. FVHospital A&E dept. FVHospital

22/12/0922/12/09

IntroductionIntroduction The spectrum clinical conditions ranging The spectrum clinical conditions ranging

from : from : ST elevation MI ( 1/3 cases )ST elevation MI ( 1/3 cases ) Non ST elevation MI ( 2/3 cases )Non ST elevation MI ( 2/3 cases )

Characterized by the common Characterized by the common physiopathology of disrupted physiopathology of disrupted atherosclerotic plaqueatherosclerotic plaque

Diagnosis of ACSDiagnosis of ACS History of cardiac chest pain: accompanied by SOB , History of cardiac chest pain: accompanied by SOB ,

diaphoresis , palpitation , nausea , lightheadedness- diaphoresis , palpitation , nausea , lightheadedness- radiates to arm , neck , jaw – is worse with exertion- radiates to arm , neck , jaw – is worse with exertion- may improve with NG administrationmay improve with NG administration

Cardiac risk factor : Age ( men >55 , women >65 )-Cardiac risk factor : Age ( men >55 , women >65 )-DM-Smoking-HTN- Hypercholesterolemia – Family DM-Smoking-HTN- Hypercholesterolemia – Family history early of CAD .Approximately one half of all history early of CAD .Approximately one half of all pts with ACS have no established risk factors other pts with ACS have no established risk factors other than age & gender .than age & gender .

Physical examination : vital signs – heart failure . Physical examination : vital signs – heart failure . Atypical presentation : absence of chest pain “ silent Atypical presentation : absence of chest pain “ silent

MI ” , SOB , cardiogenic shock , altered mental MI ” , SOB , cardiogenic shock , altered mental stastus , epigastric pain , fatigue , nausea , stastus , epigastric pain , fatigue , nausea , palpitation ( especially in DM , elderly patients , palpitation ( especially in DM , elderly patients , post operations ) .post operations ) .

Diagnosis of ACSDiagnosis of ACS

Differential diagnosis :Differential diagnosis : Non cardiac life threatening causes : Aortic Non cardiac life threatening causes : Aortic

dissection , PE , Tension pneumothorax dissection , PE , Tension pneumothorax Cardiac causes : pericarditis , tamponade , Cardiac causes : pericarditis , tamponade ,

myocarditis .myocarditis . Common non cardiac causes: GI ( GERD , Common non cardiac causes: GI ( GERD ,

cholecystitis , pancreatitis )- cholecystitis , pancreatitis )- Musculoskeletal ( costeochondritis) – Musculoskeletal ( costeochondritis) – Pulmonary ( Pleurisy , pneumonia )- Pulmonary ( Pleurisy , pneumonia )- Psychiatric ( Panic attacks ) Psychiatric ( Panic attacks )

Diagnosis of ACSDiagnosis of ACSCardiac biomarkersCardiac biomarkers

ST elevation MIST elevation MI

Cardiac biomarkers:Cardiac biomarkers: An elevated level of Troponine An elevated level of Troponine

correlates with increased risk of correlates with increased risk of death , greater elevation predict death , greater elevation predict greater risk of adverse outcome .greater risk of adverse outcome .

They are insensitive during the first 4-6 They are insensitive during the first 4-6 hrs of presentation .hrs of presentation .

Serial marker testing over time Serial marker testing over time improves sensitivity but remains improves sensitivity but remains insensitive in the first 4-6 hrsinsensitive in the first 4-6 hrs

Conditions that cause an Conditions that cause an increased level of increased level of

Troponine I ,T outside ACSTroponine I ,T outside ACS Renal insufficiencyRenal insufficiency PEPE MyopericarditisMyopericarditis Decompensated HFDecompensated HF Coronary spasmCoronary spasm Critical illness ( including burns & sepsis )Critical illness ( including burns & sepsis ) Cardiac contusion , trauma, surgeryCardiac contusion , trauma, surgery Electrocardioversion/ defibrillationElectrocardioversion/ defibrillation Electrophysiological procedures Electrophysiological procedures

( including arrhythmia ablation ( including arrhythmia ablation procedures )procedures )

STEMISTEMI

ECG :ECG : The 12 lead ECG is central to the triage of The 12 lead ECG is central to the triage of

pts with chest discomfort . pts with chest discomfort . A 12 lead ECG should be performed & A 12 lead ECG should be performed &

shown to an experienced EP within 10 mins shown to an experienced EP within 10 mins of ED arrival of all pts with chest discomfort of ED arrival of all pts with chest discomfort . .

A normal ECG doesn’t preclude the A normal ECG doesn’t preclude the diagnosis of ACS . Serial assessments diagnosis of ACS . Serial assessments improve sensitivity & specificity for improve sensitivity & specificity for detecting ACS .detecting ACS .

Hyperacute Anterior MIHyperacute Anterior MI

Difficult ECG Difficult ECG interpretationsinterpretations

ST elevation in absence of AMI : early ST elevation in absence of AMI : early repolarization , LVH , pericarditis , repolarization , LVH , pericarditis , myocarditis , LV aneurysm , hypertrophic CM myocarditis , LV aneurysm , hypertrophic CM , ventricular paced rhythms , LBBB , , ventricular paced rhythms , LBBB , hypothermiahypothermia

ST depression in absence of ischemia : ST depression in absence of ischemia : hypokalemia , digoxin effect , cor pulmonale , hypokalemia , digoxin effect , cor pulmonale , LVH , LBBBLVH , LBBB

T waves inversion without ischemia : CNS T waves inversion without ischemia : CNS hemorrhage , mitral valve prolapse , hemorrhage , mitral valve prolapse , pericarditis , PE , LVH , RBBB , LBB pericarditis , PE , LVH , RBBB , LBB

STEMISTEMI

ECG criteria for diagnosis of MI in ECG criteria for diagnosis of MI in the presence of LBBB.the presence of LBBB. ST elevation of ≥ 1mm in leads with ST elevation of ≥ 1mm in leads with

positive QRSpositive QRS ST depression ≥ 1mm in leads V1 to V3ST depression ≥ 1mm in leads V1 to V3 ST elevation > 5mm in leads with a ST elevation > 5mm in leads with a

negative QRSnegative QRS

NSTEMINSTEMI

Presentation :Presentation : Rest angina : prolonged (>20 min ) Rest angina : prolonged (>20 min )

discomfort during lack of physical discomfort during lack of physical activity activity

New onset angina: newly diagnosed New onset angina: newly diagnosed severe discomfort causing marked severe discomfort causing marked limitation of physical activity limitation of physical activity

Worsening angina : intense prolonged Worsening angina : intense prolonged with less strenous activity with less strenous activity

High risk patients with High risk patients with NSTEMINSTEMI

Refractory ischemic chest painRefractory ischemic chest pain Recurrent/ Persistent ST deviationRecurrent/ Persistent ST deviation Ventricular tachycardiaVentricular tachycardia Hemodynamic instabilityHemodynamic instability Signs of pump failure Signs of pump failure Positive cardiac biomarkersPositive cardiac biomarkers TIMI ≥ 5TIMI ≥ 5 Early invasive strategies.Early invasive strategies.

NSTEMINSTEMI TIMI Risk Score : Risk StatusTIMI Risk Score : Risk Status

0 or 1 0 or 1 Low Low 22 3 Intermediate 3 Intermediate 44 5 High5 High 6 or 76 or 7

NSTEMINSTEMI

ECG : ST depression consistent with ECG : ST depression consistent with high risk UA/NSTEMIhigh risk UA/NSTEMI

Non diagnostic or Normal ECGNon diagnostic or Normal ECG 10% of ACS pts may present with 10% of ACS pts may present with

normal ECGnormal ECG Repeating the ECG at 5-10 minsRepeating the ECG at 5-10 mins

NSTEMINSTEMI

Initial general therapyInitial general therapy

Aspirine: 160-325mgAspirine: 160-325mg Nitroglycerine: No apparent impact Nitroglycerine: No apparent impact

on mortality in pts with ACS.on mortality in pts with ACS. Indication : ongoing chest discomfort , Indication : ongoing chest discomfort ,

HTN , pulmonary congestion .HTN , pulmonary congestion . CI: hypotension , severe bradycardia < CI: hypotension , severe bradycardia <

50bpm, tachycardia > 100 bpm , RV 50bpm, tachycardia > 100 bpm , RV infarction .infarction .

Morphine SulphateMorphine Sulphate

Reperfusion therapiesReperfusion therapies

FibrinolyticsFibrinolytics Percutaneous Coronary Intervention :Percutaneous Coronary Intervention :

Superior to fibrinolytics in combined end Superior to fibrinolytics in combined end points of deah , stroke & reinfarction in many points of deah , stroke & reinfarction in many studies ( with skilled providers at a skilled PCI studies ( with skilled providers at a skilled PCI facility )facility )

Preferred in patient with STEMI , symptoms Preferred in patient with STEMI , symptoms duration ≤ 12hs , door to balloon time ≤90 duration ≤ 12hs , door to balloon time ≤90 mins.mins.

Preferred in patients with CI of fibrinolytics , Preferred in patients with CI of fibrinolytics , cardiogenic shock , HF .cardiogenic shock , HF .

Adjunctive therapiesAdjunctive therapies Clopidogrel : oral loading dose 300 mg Clopidogrel : oral loading dose 300 mg B Adrenergic Receptor BlokersB Adrenergic Receptor Blokers Low Molecular Weight Heparin : Enoxaparin Low Molecular Weight Heparin : Enoxaparin

( Lovenox )( Lovenox ) NSTEMI 1mg/kg SC bid CrCl <30ml/min 1mg/kg qdNSTEMI 1mg/kg SC bid CrCl <30ml/min 1mg/kg qd STEMI: STEMI:

• <75ys 30mg single bolus plus 1mg/kg SC then 1mg/kg SC q12h <75ys 30mg single bolus plus 1mg/kg SC then 1mg/kg SC q12h • <75ys CrCl <30ml/min 30mg single bolus then 1mg/kg then <75ys CrCl <30ml/min 30mg single bolus then 1mg/kg then

1mg qd1mg qd• ≥ ≥ 75ys 0.75mg/kg SC q12h ( no initial bolus )75ys 0.75mg/kg SC q12h ( no initial bolus )• ≥≥75ys CrCl <30ml/min 1mg SC qd75ys CrCl <30ml/min 1mg SC qd

Glycoprotein IIB/IIIA InhibitorsGlycoprotein IIB/IIIA Inhibitors ACE InhibitorACE Inhibitor StatinsStatins

ComplicationsComplications Cardiogenic shock , LV failure , CHFCardiogenic shock , LV failure , CHF RV infarction : should be suspected in RV infarction : should be suspected in

inferior and or/ posterior MI.inferior and or/ posterior MI. Mechanical complications: rupture of free Mechanical complications: rupture of free

wall , IV septum , papillary muscle .wall , IV septum , papillary muscle . Arrythmias : Arrythmias :

VF&VT : majority of early death , highest in VF&VT : majority of early death , highest in the first 4 hrs , lidocaine plays no role in the first 4 hrs , lidocaine plays no role in prophylaxis .prophylaxis .

AFAF Bradyarrythmias : sinus bradycardia, AV block Bradyarrythmias : sinus bradycardia, AV block

ConclusionsConclusions

Once the pts with ACS contacts with the health care Once the pts with ACS contacts with the health care system. Health care providers must focus on support system. Health care providers must focus on support of cardiopulmonary function , rapid transport , early of cardiopulmonary function , rapid transport , early classification based on ECG characteristics . classification based on ECG characteristics . Patients with STEMI require prompt reperfusion , the Patients with STEMI require prompt reperfusion , the

shorter the interval from onset to reperfusion , the greater shorter the interval from onset to reperfusion , the greater the benefit .the benefit .

Patients with NSEMI require risk stratification , appropriate Patients with NSEMI require risk stratification , appropriate monitoring & therapy .monitoring & therapy .

Health care providers can improve survival rates, Health care providers can improve survival rates, myocardial function of ACS patients by providing myocardial function of ACS patients by providing skilled , efficient , coordinated out of hospital & in skilled , efficient , coordinated out of hospital & in hospital care hospital care