coronary syndrome
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Acute Coronary SyndromeAcute Coronary Syndrome
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Life-threatening Causes of
Chest Pain Myocardial infarct
Unstable angina
Thoracic aortic dissection Pulmonary embolus
Tension pneumothorax
Oesophageal rupture
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Differential Diagnosis?
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NSTEMI
Presentation
Working Dx
ECG
Cardiac
Biomarker
Final DxNQMI Qw MI
UA
Unstable
Angina
Ischemic Discomfort
Acute Coronary Syndrome
Myocardial Infarction
ST ElevationNo ST Elevation
Non-ST ACS
Libby P. Circulation 2001;104:365, Hamm CW, Bertrand M, Braunwald E, Lancet 2001; 358:1533-1538; Davies MJ. Heart 2000; 83:361-366.
Anderson JL, et al. J Am Coll Cardiol. 2007;50:e1-e157, Figure 1. Reprinted with permission.
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Acute Coronary Syndromes
Similar pathophysiology
Similar presentationand early managementrules
STEMI requiresevaluation for acutereperfusion
intervention
Unstable Angina
Non-ST-SegmentElevation MI(NSTEMI)
ST-SegmentElevation MI(STEMI)
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Diagnosis of Angina
Typical angina²All three of thefollowing
Substernal chest discomfort
Onset with exertion or emotional stress Relief with rest or nitroglycerin
Atypical angina 2 of the above criteria
Noncardiac chest pain 1 of the above
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Diagnosis of Unstable Angina
Patients with typical angina - An episode of
angina
Increased in severity or duration
Has onset at rest or at a low level of exertion
Unrelieved by the amount of nitroglycerin or rest
that had previously relieved the pain
Patients not known to have typical angina
First episode with usual activity or at rest within the
previous two weeks
Prolonged pain at rest
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Diagnosis of Acute MI
STEMI / NSTEMI At least 2 of the
following
Ischemic symptoms
Diagnostic ECG
changes
Serum cardiacmarker elevations
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Unstable
Angina
STEMINSTEMI
Non occlusive
thrombus
Non specific
ECG
Normal cardiac
enzymes
Occluding thrombus
sufficient to cause
tissue damage & mild
myocardial necrosis
ST depression +/-
T wave inversion on
ECG
Elevated cardiac
enzymes
Complete thrombus
occlusion
ST elevations onECG or new LBBB
Elevated cardiac
enzymes
More severe
symptoms
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Evaluation
Efficient & direct history
Initiate stabilization interventions
Plan for moving rapidly to
indicated cardiac care
Directed Therapiesare
Time Sensitive!
Occurs
simultaneousl
y
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CHEST PAIN ASSESSMENT
History Vitally Important
Pain -Nature
Site
Severity
Radiation
Onset
Exac/relieving factors
Associated features
Duration
Previous similar pains
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Coronary Heart DiseaseCoronary Heart DiseaseRISK FACTORSRISK FACTORS
Advancing AgeAdvancing Age Family historyFamily history
Non ModifiableNon Modifiable
Sex: MaleSex: Male
MenopauseMenopause
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Coronary Heart DiseaseCoronary Heart DiseaseRISK RISK FACTORSFACTORS
SmokingSmoking
HypertensionHypertensionDiabetesDiabetesObesityObesity InactivityInactivity
AlcoholAlcohol
ModifiableModifiable
DyslipidemiaDyslipidemia OC PillsOC Pills
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Focused History
Aid in diagnosis andrule out other causes
± Palliative/Provocative
factors
± Quality of discomfort
± Radiation
± Symptoms associated
with discomfort
± Cardiac risk factors
± Past medical history -
especially cardiac
Reperfusionquestions
± Timing of
presentation ± ECG c/w STEMI
± Contraindication to
fibrinolysis
± Degree of STEMI risk
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Targeted Physical
Recognize factors that
increase risk Hypotension
Tachycardia
Pulmonary rales, JVD,
pulmonary edema,
New murmurs/heart
sounds Diminished peripheral
pulses
Signs of stroke
Examination
± Vitals
± Cardiovascular
system ± Respiratory
system
± Abdomen
± Neurologicalstatus
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ECG assessment
ST Elevation or new LBBBST Elevation or new LBBB
STEMISTEMI
NonNon--specific ECGspecific ECG
Unstable AnginaUnstable Angina
ST Depression or dynamicST Depression or dynamic
T wave inversions T wave inversions
NSTEMINSTEMI
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Acute MI: ECG Changes
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Acute MI: Initial ECG
Non-diagnostic ECG¶s Normal
Subtle ST-T changes
Isolated T-wave changes Negative U-waves
Normalization of previous abnormal ST-
segment and T-waves
Conduction defects
³Silent´ areas: right, posterior
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Acute Anterior MI
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Acute Inferior MI
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Acute Posterior MI
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New LBBB
QRS > 0.12 sec
L Axis deviation
Prominent R wave V1-V3
Prominent S wave 1, aVL, V5-V6
with t-wave inversion
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Cardiac markers
Troponin ( T, I)
± Very specific and moresensitive than CK
± Rises 4-8 hours after
injury ± May remain elevated
for up to two weeks
± Can provideprognostic information
± Troponin T may beelevated with renal dz,poly/dermatomyositis
CK-MB isoenzyme
± Rises 4-6 hours after injury and peaks at 24hours
± Remains elevated 36-48hours
± Elevation can bepredictive of mortality
± False positives with
exercise, trauma,muscle dz, DM, PE
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Acute Management
Initial evaluation &
stabilization
Efficient risk
stratification
Focused cardiac
care
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Chest pain suggestive of ischemia
± 12 lead ECG ± Obtain initial
cardiac
enzymes
± electrolytes,
cbc lipids,
bun/cr,
glucose,
coags
Immediate assessment within 10 Minutes
± Establishdiagnosis
± Read ECG
± Identify
complicatio
ns
± Assess for
reperfusion
Initial labsInitial labs
and testsand tests
EmergentEmergent
carecare
History &History &
PhysicalPhysical
± IV access ± Cardiac
monitoring
± Oxygen
± Aspirin
± Nitrates
± Morphine
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Acute coronary syndrome
ST elevation MI
Thrombolysis Primary PTCAMonitoring
Aspirin
Nitrates
Beta-blockers
Ace inhibitors
Statins
Fondaparinux/Enoxaparin
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ACUTE CORONARY SYNDROME
Non ST elevationTrop T+Trop T-
UA NSTEMImonitor ing
Aspir in
Beta blocker sNitrate
Hepar in/ClexaneIIB/IIIA inhibitor s
Invasivestrategy
Conservative
strategy
Recurrent
symptoms
Patient stabilizes
Stress test-
Medical Rx+
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