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ACS and the 12 Lead ECG. The 12 Lead ECG is at the center of the decision pathway in the management of patients with ischemic chest pain. AHA Guidelines 2000. Scenario #1.

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Presentation Transcript
slide2
The 12 Lead ECG is at the center of the decision pathway in the management of patients with ischemic chest pain.

AHA Guidelines 2000

scenario 1
Scenario #1
  • 55 y/o male c/o sub-sternal chest pressure that started while exerting himself. Pain radiates to his neck/jaw. Pain unrelieved with rest or patients own NTG.
  • Patient is cool, and pale.
  • DX?
scenario 2
Scenario #2
  • 60 y/o female c/o dull, aching, pain in her chest that radiates to her left breast. Sts pain has been constant for past hour, getting increasingly worse. Hx of HTN, NIDDM, Angina. Sts pain is like previous angina attack, just worse.
  • Patient is cool, pale, diaphoretic.
  • DX?
slide5
What similarities do these two scenarios share?
  • How can their treatment both be different.
  • How will the 12 lead guide our treatment of these patients?
introduction
Introduction
  • Acute Coronary Syndrome is a group of disease process’s that signs and symptoms mimic each other.
  • Although similar, they are not the same.
  • The treatment for ACS is based on the patient’s current “stage” in the disease process
slide7

A

C

S

S

T

A

G

E

S

stable angina
Stable Angina
  • A flow/demand imbalance between reduced blood flow through a narrowed artery, and increased demand.
unstable angina non q wave infarction
Unstable Angina/Non-Q Wave Infarction
  • Symptoms of angina that are new or increasing or that occur at rest. Seldom relieved with rest, O2, or NTG.
  • Symptoms are usually due to platelet aggregation in narrowed arteries with chronic atherosclerotic occlusions.
unstable angina non q wave infarction1
Unstable Angina/Non-Q Wave Infarction

Unstable Angina can be complicated by the release of micro-emboli that occlude distal micro-vasculature.

q wave infarction
Q-Wave Infarction
  • Complete formation of thrombus in an artery.
  • Spontaneous lysis of the clot can occur, but often too late to salvage the heart muscle.
indicative changes
Indicative Changes
  • Ischemia: Symmetrically inverted T waves or down sloping ST segment depression greater then 1mm
  • Injury: ST segment elevation greater then 1mm
  • Infarct: Pathological Q wave formation
indicative changes1
Indicative Changes
  • Based on the patients 12 lead ECG, they will be placed into 1 of 3 treatment categories that are aimed at correcting the specific Acute Coronary Syndrome present.
why do we care
Why Do We Care?
  • The only ACS disease process that benefits from Thrombolytic therapy are those that are caused by complete occlusion of an artery.
  • Recognition of ST SegmentElevation ACS is the first step in a race against the clock.
scenario 11
Scenario #1
  • 55 y/o male c/o sub-sternal chest pressure that started while exerting himself. Pain radiates to his neck/jaw. Pain unrelieved with rest or patients own NTG.
  • Patient is cool, and pale.
scenario 12
Scenario #1
  • Does this patient meet ECG requirements for thrombolysis?
  • What stage of ACS can you predict from the presenting 12 lead?
  • What complications can you expect to see if the patient’s condition worsens?
scenario 21
Scenario #2
  • 60 y/o female c/o dull, aching, pain in her chest that radiates to her left breast. Sts pain has been constant for past hour, getting increasingly worse. Hx of HTN, NIDDM, Angina. Sts pain is like previous angina attack, just worse.
  • Patient is cool, pale, diaphoretic.
scenario 22
Scenario #2
  • Does this patient meet ECG requirements for thrombolysis?
  • What significance do the tall T waves suggest?
  • What complications can you expect to see if the patient’s condition worsens?
exceptions to the rules
Exceptions to the Rules
  • Some subsets of patients may be eligible for Fibrinolytic therapy even though they do not present with ST segment elevation.
    • Posterior current of injury
    • Tall, hyperacute t waves