Acute coronary syndromes
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Acute Coronary Syndromes. Jason Ryan, M.D. UA + NSTEMI (life-threating but not medical emergency). STEMI (medical emergency). Acute Coronary Syndromes. Unstable Angina + Non-ST-Elevation MI + ST-Elevation MI Acute Coronary Syndromes (ACS). Acute Coronary Syndromes.

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Acute Coronary Syndromes

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Acute coronary syndromes

Acute Coronary Syndromes

Jason Ryan, M.D.


Acute coronary syndromes1

UA + NSTEMI

(life-threating but

not medical emergency)

STEMI

(medical emergency)

Acute Coronary Syndromes

Unstable Angina +

Non-ST-Elevation MI +

ST-Elevation MI

Acute Coronary Syndromes (ACS)


Acute coronary syndromes2

Acute Coronary Syndromes

  • Generally, same symptoms for all

    • Squeezing, pressure-like, substernal chest pain

    • Often associated with shortness of breath and diaphoresis

    • Pearl: If nausea and vomitting think inferior wall MI

    • With UA/NSTEMI, often preceding history of exertional symptoms


Remember the ddx for chest pain

Remember the DDx for Chest Pain

  • ACS

  • Aortic Dissection

  • Pulmonary Embolism

  • Acute choleycystitis

  • Pericarditis

  • Costocondritis

  • Esophogeal spasm

  • Many others

The

Can’t

Misses


St elevation mi

ST-Elevation MI


St elevation mi1

ST-Elevation MI


St elevation mi2

ST-Elevation MI


St elevation mi3

ST-Elevation MI

Coronary Stenosis: Progression to STEMI

Serial Angiogrpahy in 239 Patients

Stenosis

Pre-MI

0%

25%

50%

75%

90-99%

Culprit

For MI

8

10

5

6

10

39

29

Nobuyoshi M et al., JACC 1991;18:904-10


St elevation mi4

ST-Elevation MI

  • If you suspect STEMI:

    • OMI: Oxygen, monitor, IV access

    • ABC: Ensure patient is stable

    • Call cardiology

    • Pre-cath medication:

      • Aspirin 325mg PO

      • Lopressor 25mg PO (if BP and Pulse will tolerate)

        • Beware cardiogenic shock

      • Heprin 5000U bolus (if no active bleeding issues)

      • Discuss IIB/IIIA and Clopidogrel with cardiology


Unstable angina ua and non st elevation myocardial infarction nstemi

Unstable Angina (UA) and Non ST Elevation Myocardial Infarction (NSTEMI)

  • 5,315,000 annual ER presentations for chest pain

  • 1,433,000 annual U.S. hospital admissions for UA/NSTEMI

  • 50 patients per month at BIDMC coded as: AMI, SUBENDOCARDIAL ISCHEMIA


Placebo event rates in recent trials of ua and nstemi

Placebo Event Rates in Recent Trials of UA and NSTEMI

UA and NSTEMI

  • PRISM1 7.1%

  • PRISM-PLUS211.9%

  • PURSUIT315.7%

  • GUSTO-IV ACS4 8.0%

  • PARAGON A511.7%

Death/MI at 30 days

1. PRISM Study Investigators. N Engl J Med 1998;338:1498-1505. 2. PRISM-PLUS Study Investigators. N Engl J Med 1998;338:1488-1497.3. Harrington RA. Am J Cardiol 1997;80:34B-38B.4. The GUSTO IV-ACS Investigators. Lancet 2001;357:1915-1924.5. The PARGON Investigators. Circulation 1998;97:2386-2395.


Ua and nstemi

UA and NSTEMI

  • Definitions

    • Unstable angina

      • New onset angina

      • Angina that occurs at rest

      • Angina that occurs with accelerating frequency (crescendo angina)

      • May have EKG changes (ST depression)

      • Biomarkers will be negative


Ua and nstemi1

UA and NSTEMI

  • Definitions

    • NSTEMI

      • Typical rise and fall of cardiac biomarkers plus at least one of the following:

        • Anginal chest pain

        • Ischemic EKG changes (ST-depression)

        • Development of Q waves on EKG

        • Coronary intervention

  • Often can’t tell UA from NSTEMI at presentation

Joint European Society of Cardiology/American College of Cardiology committee


Nstemi

NSTEMI

  • The Biomarkers:

    • CK

      • Rises 4-6 hours after MI

      • Peaks and falls by 36-48 hours after MI

      • Total CK is non-specific

      • CK-MB is more specific for cardiac tissue

        • (but there is still some in skeletal muscle!!)

    • Remember this is one component in the diagnosis of NSTEMI

    • CK alone cannot be used to diagnose NSTEMI


Nstemi1

NSTEMI

  • The Biomarkers:

    • Troponin

      • Rises 4-6 hours after MI

      • Can remain elevated for up to two weeks!

      • Very specific for cardiac damage

      • Elevated in many other conditions than ACS

        • Hypotension of any cause (~80% patients)

        • Renal failure

        • Congestive heart failure

        • Many others

      • Always predicts worse outcomes


Nstemi2

NSTEMI

  • Four pieces to NSTEMI:

    • Symptoms

    • EKG changes

    • CK

    • Troponin


Acc guidelines for management of ua nstemi

Definite/Likely UA/NSTEMI with cath

or PCI planned

Definite/Likely UA/NSTEMI

Possible

UA/NSTEMI

MSO4

NTG

ASA

Beta Blockers

Heparin

Plavix

MSO4

NTG

ASA

Beta Blockers

MSO4

NTG

ASA

Beta Blockers

Heparin

Plavix

IIB/IIIA Inhibitor

ACC Guidelines for Management of UA/NSTEMI

Chest Pain

EKG

Follow ST

Protocols

ST

No ST


American college of cardiology acc 2002 guidelines for ua nstemi

American College of Cardiology (ACC)2002 Guidelines for UA/NSTEMI

Medications with Class I indication

  • First 24 hours

  • Morphine

  • Nitroglycerin

  • Aspirin

  • Beta Blocker

  • Plavix

  • Heparin

  • IIB/IIIA Inhibitors

  • Discharge

  • Aspirin

  • Beta Blocker

  • Plavix

  • ACE Inhibitor

  • Statin


Nrmi 4 nste mi acute care 3rd quarter 2001

ACC 2002 Guidelines for UA/NSTEMI

How well do we do?

NRMI-4 NSTEMI AcuteCare: 3rd Quarter 2001


Nrmi 4 nste mi discharge care 3rd quarter 2001

ACC 2002 Guidelines for UA/NSTEMI

How well do we do?

NRMI-4 NSTEMI Discharge Care: 3rd Quarter 2001

100%

84%

75%

80%

71%

56%

60%

40%

21%

20%

0%

ASA

Beta Blocker

ACE

Statins #

Cardiac

Inhibitor *

Rehab

* LVEF < 40%

# Known hyperlipidemia


Gap between leading and lagging us hospitals

ACC 2002 Guidelines for UA/NSTEMI

How well do we do?

Gap between ‘Leading and Lagging’ US Hospitals

Performance

Quality IndicatorBottom 10% Top 10%

ASA use < 24 h54%99%

 blocker use < 24 h33%98%

Heparin use <24 h50%92%

GP IIb-IIIa < 24 h0%51%

D/C ASA use 54%99%

D/C  blocker use44%96%

D/C ACE-I use21%83%

D/C lipid lowering33%99%


Benefits of using evidence based therapies non st acs patients from gusto iib

ACC 2002 Guidelines for UA/NSTEMI

Does doing well matter?

Benefits of Using Evidence-Based Therapies (Non-ST  ACS Patients from GUSTO IIb)

Additional Lives

Discharge Saved per 1,000

TherapyCurrent Use(ideal use)

Aspirin86%9

Beta blockers59%11

ACE inhibitors52%23

Alexander K, JACC, 1998


Case 1

Case 1

  • A 54 year old man with DM, HTN, and high cholesterol presents to the ER complaining of substernal chest pain. The pain feels like his chest is being squeezed. He first noted it two months ago when carrying packages up a flight of stairs. Last week he noticed it when walking to work. The past two days, the pain has occurred whenever he climbs the stairs in his house. This morning it occurred while driving to work.

  • His initial EKG shows sinus tachycardia with anterior ST depressions.

  • His initial cardiac biomarkers are negative.

  • He becomes pain free during his first few minutes in the ER and his EKG changes resolve.


Case 11

Case 1

  • Is this an ACS?

    • YES!!!

  • How should this patient be managed?

    • Morphine and NTG to make him pain free

    • Aspirin, Beta blocker, Heparin, Integrillin

    • Plan for catheterization with 24-48 hours


Case 2

Case 2

  • A 75 yom with HTN presents to the ER complaining of squeezing, substernal chest pain. The pain began this morning while taking a shower and has waxed and waned all day (~10 hours time).

  • Initial EKG shows sinus tachycardia without ST changes

  • Initial biomarkers:

    • CK 300, MB 20, Trop T 0.5


Case 21

Case 2

  • Is this an ACS?

    • YES!!!

  • How should this patient be managed?

    • Morphine and NTG to make him pain free

    • Aspirin, Beta blocker, Heparin, Integrillin

    • Plan for catheterization within 24-48 hours


Case 3

Case 3

  • A 82 yof is transferred to the ED from her nursing home where she was noted to be lethargic. For the past two days, she has had decreased POs and one episode of vomiting. The patient is unable to give a history.

  • On initial ED eval, her blood pressure is 72/45 and her temp is 101.4

  • Initial EKG shows sinus tachycardia

  • Initial biomarkers show CK 110, MB 6, Trop 0.5


Case 31

Case 3

  • In this an ACS?

    • Unlikely

  • How should this patient be managed

    • ASA if no contraindication

    • No BB given hypotension

    • No heparin or IIB/IIIA as this is not likely ACS

    • Work up fever and hypotension

    • Cycle biomarkers

    • Repeat EKG in 6-12 hours


Case 4

Case 4

  • A 62 yom with a history of ESRD on HD, Ischemic CM with EF 20% presents with lethargy and altered mental status for two days

  • Initial vitals are remarkable for a room air O2 sat of 88%

  • EKG shows sinus rhythm with old anterior Q waves (see on EKG 1 year prior). No new ST changes.

  • Initial cardiac markers:

    • CK 200 MB 9 Trop 0.8


Case 41

Case 4

  • In this an ACS?

    • Unlikely

    • Troponin is his only marker of ACS and he has at least two reasons for false positive (CRF, CHF)

  • How should this patient be managed

    • ASA if no contraindication

    • BB if not in CHF

    • No heparin or IIB/IIIA unless further evidence of ACS develops

    • Work up lethargy and altered mental status

    • Cycle biomarkers

    • Repeat EKG in 6-12 hours


Case 5

Case 5

  • A 55 yom presents to the ED c/o episodic chest pain for one week. The pain is sharp, left sided, and lasts 10-15 minutes. The pain occurs when walking and never at rest, although sometimes he can walk without symptoms. He is pain free now.

  • EKG shows sinus rhythm without ST changes.

  • Initial biomarkers

    • CK 90, MB not done, Trop <0.01


Case 51

Case 5

  • In this an ACS?

    • Can’t tell

    • Some features consistent, some not

  • How should this patient be managed

    • ASA and BB

    • No heparin or IIB/IIIA unless biomarkers become elevated

    • Cycle biomarkers

    • Repeat EKG in 6-12 hours

    • If rules out, consider exercise stress test


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