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Chest pain of recent onset and ACS
few highlights
GP - meeting at NNUH13 September 2011
Toomas Särev Consultant Cardiologist
NNUH-JPUH
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Challenges - Chest pain + ECG & Lab
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Concept of Supply - Demand
O2 supply O2 demand
Coronary anatomyDiastolic BPHeart RateCharacteristics of bloodO2-extraction •Hb •PaO2
Heart RatePreloadAfterloadContractility
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Pathophysiology Clinical Diagnosis
UNST
ABLE
ANGIN
A
ASYM
PTOMAT
IC/
SYMPT
OMAT
IC
CHRO
NIC
ACUTE
STE
MI
Markers of myocardial injury (TnI, CK-Mb)
ECG
RISK
PLAQUE RUPTURE
INTRACORONARYTHROMBUS
DECREASED FLOW
MYOCARDIAL HYPOXIA
ISCHAEMIA IN MYOCYTES
→
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Rupture of a plaque
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The spectrum of ACS
Dia
gnos
tic C
halle
nges
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diagnostic challenges?• risk assessment
• individuals without clear symptoms or ECG features
• atypical presentations (dyspnea, syncope, abdominal pain)
• older patients (> 75 y)
• women
• diabetes, chronic renal failure, dementia
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How to identify high risk patients?
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ECG - when should you
be concerned?
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• collateral circulation• “double” supply• preconditioning
Grade of ischaemia in EGG depends on
• normal ECG does not rule out ACS
• negative T waves indicate open vessel
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This patient developed
cardiogenic shock shortly after
debut of his chest pain
LM
normal RCAThe patient died
despite initial success with PPCI
Occlusion in the LEFT MAIN STEM: deep ST-depressions and negative T waves in inferolateral
and antero-septal leads
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Culprit in the proximal LAD (before the take-off of a Diagonal branch) - no protection
LAD
Diagonal
Intermediate
ST elevations in I, aVL and V2-V5
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RCAa 100%
RCA POST-PTCA
Occlusion in the proximal RCA:
ST-elevaton in in II, III, aVF + V1 & V4R
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The spectrum of ACS
Dia
gnos
tic C
halle
nges
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Abnormal Troponinpossible causes
• chronic or acute renal dysfunction
• severe congestive heart failure - acute and chronic
• hypertensive crisis
• tachy- or bradyarrhythmias
• pulmonary embolism, PAH
• myocarditis
• acute neurological disease, stroke, SAH
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ACS in the elderly
• clinical presentation might be different (dyspnea)
• more extensive and severe CAD,
• more comorbidities, level of frailty very individual
• worse prognosis
• different benefit/risk ratio with usual therapies
• higher rate of secondary effects and complications
© Gary Larson 2002 17
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How to manage?
When to refer?
© Gary Larson 2002
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decision-making algorithm in ACS
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Targets for Management
O2 supply O2 demand
Revascularisation (PCI, CABG)Antithrombotic therapy•Antiplatelet therapy•AnticoagulationPreventive and plaque stabilising•Statins•ACEiOptimal hemodynamics (anti-ishcaemic therapy)•Beta blockers•NitratesOptimise PaO2Optimise Hb
Optimal hemodynamics•Beta blockers•Nitrates•IvabradineRespiratory support (CPAP)PainkillersSedation
GUIDELINES
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Revascularisation• medical therapy if no critical coronary
lesions if no options for revascularisation
• PCI with stenting of the cuprit lesion
• individualised decision in multivessel disease
• staged PCI or all at once
• PCI at first and then CABG
• CABG
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new guidelines summary
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Thank You!
this presentation can be downloaded from:
www.slideshare.net/kardiostar
comments: [email protected]
© Gary Larson 2002
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