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Spencer Toombes FRACP. Acute Coronary Syndrome: GP Essentials. Learning Plan. Challenges of assessing patients with chest pain... Terminology & Pathophysiology ECG interpretation Use of Troponin Risk Assessment Inpatient management - how and when to transfer Post-discharge management.

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learning plan
Learning Plan...
  • Challenges of assessing patients with chest pain...
  • Terminology & Pathophysiology
  • ECG interpretation
  • Use of Troponin
  • Risk Assessment
  • Inpatient management

- how and when to transfer

  • Post-discharge management
5 min task in pairs
5 min task in pairs:
  • For each of the following scenarios...

What is the most likely diagnosis?

What is this patient’s risk of having an

Acute Coronary Syndrome?

68 yo man
68 yo man:
  • Complaining of intermittent central chest pain.
  • Previous ischaemic heart disease:

Coronary angiogram 2 years ago showed 40% LAD and 30% RCA stenosis.

  • Managed medically.
  • Has noticed over the past 2 months that he needs to use his GTN spray whenever he exerts himself.
the same 68 yo man
The same 68 yo man:
  • What if he had received a stent 5 months ago?
68 yo woman
68 yo woman:
  • Recent sharp, stabbing pain adjacent to her left sternum.
  • There doesn’t seem to be a clear precipitant.
  • She feels a bit washed out, but otherwise reasonably well.

…but she is a Type II diabetic.

46 yo man
46 yo man:
  • 10 minutes of central chest heaviness after he finished mowing the lawn
  • Associated with pallor and breathlessness
  • His wife thought he looked ill and talked him into coming up to your practice.
  • Positive family history, heavy smoker.
cardiac vs oesophageal chest pain is not distinguished by site of radiation

Cardiac

Oesophageal

28%

14%

60%

37%

10%

23%

100%

100%

49%

35%

5%

18%

33%

12%

Back 12%

Back 33%

Cardiac vs Oesophageal Chest Pain:is not distinguished by Site of Radiation

Bennett et al. Lancet. 1966

more difficulties in evaluating the patient with chest pain
More difficulties in evaluating the Patient with Chest Pain:
  • Intensity of Pain - no indication of severity.
  • Nature of Pain - no indication of diagnosis:
    • 5-19% acute coronary syndromes ‘sharp’ or pleuritic.
  • Physical Signs - no indication of diagnosis:
    • 15% AMI patients have chest wall tenderness.
  • ‘Atypical’ Presentations:
    • Up to 25% patients with ACS do not present with “classical” chest pain.
terminology define in pairs
Terminology: define in pairs...
  • Acute Coronary Syndrome (ACS)
  • Stable angina
  • Unstable angina
  • Myocardial ischaemia
  • Q wave infarction
  • Non-Q wave infarction
  • STEMI... STEACS
  • Non-STEMI... Non-STEACS
pathophysiology safe or stable plaque
Pathophysiology:Safe or Stable plaque:
  • little cholesterol content
  • thick fibrous cap
  • low risk of rupture

The proportion of the lumen occluded determines the degree of exercise related ischaemia, and the severity of symptoms.

pathophysiology unsafe unstable plaque
Pathophysiology:Unsafe / Unstable Plaque
  • Lotsof Low Density Lipoprotein Cholesterol
  • Thin fibrous cap
  • Lots of inflammation:
    • Activated T cells, Macrophages, Foam Cells
    • Mediators: Cytokines and C reactive protein

HIGH RISK OF RUPTURE

acs dynamic clot formation spectrum of possible outcomes
ACS / Dynamic Clot formation:Spectrum of Possible Outcomes -
  • Dynamic Partial Occlusion: No damage
    • Worsened Angina pain, possible ECG change
    • No cardiac enzyme rise
  • Dynamic Partial Occlusion: Some damage
    • Worsened Angina pain, probable ECG change
    • Rise in cardiac troponin, +/- creatinine kinase
  • Complete Occlusion:
    • Full thickness myocardial infarction
    • ST segment elevation, Q wave formation if not treated
chest pain getting the basics right
Chest Pain: Getting the basics right...
  • Rapid assessment.
  • Observed environment.
  • Aspirin 300mg.
  • ECG within 10 minutes of presentation.
12 lead ecg interpretation
12 Lead ECG interpretation:
  • STEMI: requires immediate reperfusion
  • Everything else: still requires risk assessment.
cardiac troponin complex
Cardiac Troponin Complex:

Tnl

TnC

TnT

Ca++

Tropomyosin

Actin

cardiac troponin
Cardiac Troponin:
  • Exquisitely sensitive marker of myocardial distress... not necessarily muscle necrosis
  • Onset 4-6, peak 24-36 hours, offset 7 days
  • Normal initial troponin is NOT reassuring
  • Normal 12 hour troponin is quite reassuring
troponin t and probability of death
Troponin T and probability of death

Lindahl NEJM 2000 343:16;1139-47

practice points troponin
Practice Points: Troponin
  • Don’t necessarily mean ACS...
    • Pulmonary embolus
    • Left ventricular failure
    • Renal failure
    • Sepsis
  • True false positives related to assay
    • Immune cross reactivity
practice points troponin1
Practice Points: Troponin

GENERALLY DO NOT ORDER

IN GENERAL PRACTICE

diagnosis of acs evolves over time
Diagnosis of ACS evolves over time…

Presentation of ACS

(clinical presentation, initial ECG)

Working diagnosis

STEMI

NSTEACS

Time

Evolution of ECG and biomarkers

Myonecrosis confirmed

Myonecrosis not confirmed

Final diagnosis

STEMI

NSTEMI

Unstable angina

ACS = acute coronary syndromes; ECG = electrocardiogram; STEMI = ST-segment-elevation myocardial infarction; NSTEACS = non-ST-segment elevation acute coronary syndromes; NSTEMI = non-ST-segment elevation myocardial infarction

Acute Coronary Syndrome Guidelines Working Group. Med J Aust 2006;184(8 Suppl):S9-29.

68 yo man1
68 yo man:
  • Complaining of intermittent central chest pain.
  • Previous ischaemic heart disease:

Coronary angiogram 2 years ago showed 40% LAD and 30% RCA stenosis.

  • Managed medically.
  • Has noticed over the past 2 months that he needs to use his GTN spray whenever he exerts himself.
68 yo woman1
68 yo woman:
  • Recent sharp, stabbing pain adjacent to her left sternum.
  • There doesn’t seem to be a clear precipitant.
  • She feels a bit washed out, but otherwise reasonably well.

…but she is a Type II diabetic.

46 yo man1
46 yo man:
  • 10 minutes of central chest heaviness after he finished mowing the lawn
  • Associated with pallor and breathlessness
  • His wife thought he looked ill and talked him into coming up to your practice.
  • Positive family history, heavy smoker.
for each of these patients
For each of these patients:

What is their risk of having an

Acute Coronary Syndrome?

slide49

These patients can be managed with upgrade to their anti-anginal medications and outpatient referral for cardiac investigation.

slide50

These patients generally require emergency admission to a monitored environment, and aggressive drug therapy including parenteral anticoagulants.

slide51

These patients generally require a period of observation with serial ECG and biomarker assessment, enabling them to be re-classified as high or low risk...

transfer to hospital
Transfer to hospital:
  • Ambulance
  • Monitoring
  • Oxygen ?
  • Nitrates ?
  • Aspirin ?
  • Pain relief ?
what happens in hospital
What happens in hospital?
  • Intermediate risk: reclassify after 6-12 hours
  • Low risk:

Upgrade therapy?

Provocative investigation: EST or MPS

  • High risk...
high risk non steacs management anti platelet agents
High Risk - Non-STEACS management: Anti- Platelet agents…
  • Aspirin 300mg. stat. then 75 -100mg. daily.
  • Clopidogrel: 300mg. load then 75mg. daily
  • Gp IIbIIIa receptor antagonists:
    • Tirofiban (Aggrastat)
    • Abciximab (Reopro)
    • Eptifibatide (Integrilin)
where the anti platelet agents fit in

CLOPIDOGREL

C

ADP

ADP

GPllb/llla

(Fibrinogen receptor)

Collagen thrombin

TXA

Activation

2

COX

ASA

TXA

2

Where the anti-platelet agents fit in...

COX, cyclooxygenase; ADP, adenosine diphosphate; TxA2, thromboxane A2

Schafer AI Am J Med 1996;101:199–209

slide57

Pathways of Blood Coagulation during Hemostasis and Thrombosis

Furie B and Furie B. N Engl J Med 2008;359:938-949

non steacs management anticoagulants
Non-STEACS management:Anticoagulants...
  • IV unfractionated heparin infusion
  • s/c low molecular weight heparin

(eg. Clexane 1mg./kg. bd.)

  • s/c Fondaparinux (Erixtra)
high risk non steacs management additional proven therapeutics
High risk Non STEACS Management - additional proven therapeutics:
  • Beta blockers, IV and/or oral.
  • Insulin + dextrose infusion for high BSL.
  • High dose Statins: eg. 80mg. Atorvastatin
  • ACE inhibitors
  • Oxygen
  • Morphine & Nitrates for symptom control
non stemi management routine early angiography
Non-STEMI management: Routine Early Angiography…

Evidence supports prompt routine angiography with a view to angioplasty of the culprit lesion.

  • TACTICS TIMI18, FRISC II, RITA 3
  • ICTUS ???
stemi managment thrombolytics time is muscle ftt collaboration group lancet 343 311 22 1994
STEMI Managment:Thrombolytics: - time is muscleFTT collaboration group, LANCET 343:311-22 (1994)
lancet meta analysis primary pci vs thromblysis
Lancet Meta-analysis:Primary PCI vs. Thromblysis
  • Short term death 7% vs. 9%
  • STD excld. SHOCK 5% vs. 7%
  • Reinfarct rates 3% vs. 7%
  • CVA 1% vs. 2%
  • Combined endpoint 8% vs. 14%
ischaemic heart disease what patients should go home on
Ischaemic Heart Disease? What patients should go home on…

Cardiologists drive SAABs:

S tatin (high dose atorvastatin)

A nti platelet agents: Aspirin + Clopidogrel

A ce inhibitor

B eta-blocker

return to function
Return to Function:
  • Sexual Relations:
    • 6-7 METS: Stage II Bruce, 2 flights stairs
  • Driving: (private license)
    • Angioplasty: 2 days, assuming no MI, no symptoms and normal ecg.
    • Myocardial Infarct: 2 weeks, assuming uncomplicated
    • Cardiac Arrest: 6 months, unless assoc. MI
summary
Summary:
  • Assessing chest pain is notoriously difficult
  • Early aspirin, Early ECG
  • If in doubt, manage as an inpatient
  • Risk stratification, with serial data
  • Aggressive drug combinations for high risk patients... Anticoagulants, and Antiplatelets.