1 / 37

Acute coronary syndrome - Diagnosis and management

diagnosis & management of ACS

lifeline143
Download Presentation

Acute coronary syndrome - Diagnosis and management

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Acute Coronary Syndrome - Diagnosis and Management

  2. Acute Coronary Syndrome • Acute coronary syndrome (ACS) describes the range of myocardial ischemic states that includes unstable angina (UA), non-ST elevated myocardial infarction (NSTEMI), or ST-elevated myocardial infarction (STEMI) • The diagnosis and classification of ACS is based on a thorough review of clinical features, including electrocardiogram (ECG) findings and biochemical markers of myocardial necrosis Smith JN et al. J Am Board Fam Med. 2015; 28(2):283-93.

  3. Universal Definition of Myocardial Infarction Eur Heart J. 2012; 33(20):2569-619.

  4. Scope of the Problem • Coronary heart disease (CHD) is responsible for more than half of all cardiovascular events in individuals less than 75 years of age • During the past several years, the rates of hospitalization for MI and mortality associated with CHD have decreased • The decline in CHD mortality is partially reflective of the change in the pattern of clinical presentations of ACS • There has been a substantial reduction in the incidence of STEMI and a subsequent increase in the incidence of NSTEMI Smith JN et al. J Am Board Fam Med. 2015; 28(2):283-93.

  5. Mechanisms of Coronary Thrombosis Lilly. Pathophysiology of Heart Disease, 4th Ed. Lippincott Williams, 2007. Page 171

  6. Consequences of Coronary Thrombosis Lilly. Pathophysiology of Heart Disease, 4th Ed. Lippincott Williams, 2007. Page 173

  7. Symptoms • Pressure • Burning (hot) • Chest/arms/jaw/back Pain Sympathetic response Parasympathetic response Inflammatory response Other • Sweats • Tachycardia • Cool, clammy skin • Nausea • Vomiting • Weak • Mild fever • Dyspnea • Asymptomatic

  8. INITIAL ASSESSMENT European Heart Journal (2016) 37, 267–315

  9. ECG Changes • ST-segment elevation found on an ECG is the hallmark sign of a STEMI • ECG changes such as ST deviation may be present in other conditions, such as left ventricular hypertrophy, left bundle branch block, or acute pericarditis Smith JN et al. J Am Board Fam Med. 2015; 28(2):283-93.

  10. Location, ECG Findings and Suspected Artery

  11. Location, ECG Findings and Suspected Artery

  12. Cardiac Biomarkers • Troponin levels should be measured on first assessment, within 6 hours of the onset of pain, and in the 6–12 hour time frame after onset of pain, due to the delayed increase in circulating levels of cardiac biomarkers (strength of recommendation A) • If troponin concentrations are unavailable, then CKMB should be measured Smith JN et al. J Am Board Fam Med. 2015; 28(2):283-93.

  13. Clinical implications of high-sensitivitycardiac troponin assays European Heart Journal (2016) 37, 267–315

  14. 0 h/3 h rule-out algorithm of non-ST-elevation acute coronary syndromes using high-sensitivity cardiac troponin assays European Heart Journal (2016) 37, 267–315

  15. Am Fam Physician. 2017;95(4):232-240

  16. Initial ACS Management Early Management: • Thrombosis in Myocardial Infarction (TIMI) risk score, a scoring system for UA and NSTEMI that incorporates seven variables on hospital admission, has been validated as a reliable predictor of subsequent ischemic events . Smith JN et al. J Am Board Fam Med. 2015; 28(2):283-93.

  17. TIMI Risk Score for UA/NSTEMI Smith JN et al. J Am Board Fam Med. 2015; 28(2):283-93.

  18. Recommendations for relief of pain,breathlessness and anxiety Eur Heart J. 2012; 33(20):2569-619.

  19. Coronary Revascularization • STEMI- Reperfusion therapy to all eligible patients with symptom onset within the prior 12 hours • PCI - goal of time from first medical contact to device time of less than or equal to 90 minutes (strength of recommendation A) Smith JN et al. J Am Board Fam Med. 2015; 28(2):283-93.

  20. Am Fam Physician. 2017;95(4):232-240 .

  21. Medical Management of Patients with UA/NSTEMI (1) Smith JN et al. J Am Board Fam Med. 2015; 28(2):283-93.

  22. Medical Management of Patients with UA/NSTEMI (2) Smith JN et al. J Am Board Fam Med. 2015; 28(2):283-93.

  23. Medical Management of Patients with STEMI (1) Smith JN et al. J Am Board Fam Med. 2015; 28(2):283-93.

  24. Medical Management of Patients with STEMI (2) Smith JN et al. J Am Board Fam Med. 2015; 28(2):283-93.

  25. Am Fam Physician. 2017;95(4):232-240

  26. Am Fam Physician. 2017;95(4):232-240

  27. Am Fam Physician. 2017;95(4):232-240

  28. Fibrinolytics Am Fam Physician. 2017;95(4):232-240

  29. Other Adjuvants aPTT = activated partial thromboplastin time; GP = glycoprotein; IV = intravenous; NSTE-ACS = non–ST elevation acute coronary syndrome; PCI = percutaneous coronary intervention; STEMI = ST elevation myocardial infarction. Am Fam Physician. 2017;95(4):232-240.

  30. Complications of MI Myocardial Infarction Ventricular thrombus Electrical instability Tissue necrosis Pericardial inflammation Contractility Embolism Arrhythmias Pericarditis Cardiogenic shock Ischemia Hypotension Papillary muscle infarction/ ischemia Ventricular septal defect Ventricular rupture Coronary perfusion pressure Cardiac tamponade Mitral regurgitation Congestive heart failure

  31. PrimaryAngioplastyExplained • Coronaryarteries: balloonangioplasty • The European Society of Cardiology (ESC) guidelines recommend primary PCI as the preferred treatment whenever it is available within 90-120 minutes of the first medical contact Arrival After balloon Balloon Open artery Closed

  32. Contraindications and Cautions for Fibrinolytic Therapy in Patients with STEMI* Am Fam Physician. 2017;95(4):232-240

  33. Angioplasty Reduces Mortality and Morbidity Primary PCI vs. Thrombolysis in STEMI Meta-analysis (23 Randomised controlled trials, N=7,739) Short-term Outcomes (4-6 weeks) P<.0001 P<.0001 PPCI Frequency (%) Thrombolytictherapy P=.0002 P<.0001 Death Nonfatal MI Recurrent Ischemia Death, Nonfatal, Reinfarction, or Stroke Based on Keeley EC, et al. Lancet. 2003;361:13-20.

  34. Coronary artery ectasia (CAE) often presents in the form of an acute coronary syndrome (ACS) due to slow flow leading to thrombus formation in ectatic coronary arteries 2019 Waqas et al. Cureus 11(1): e3928 Ectactic left coronary system (large arrow) with thrombotic occlusion of the first obtuse marginal (OM-1) artery (small arrow) Plump and ectactic right coronary system

  35. Conclusion of coronary artery ectasia • To remove the maximum clot burden with mechanical thrombectomyalone and provide secondary prophylaxis with oral anticoagulation in addition to GDMT* for CAD. *guideline directed medical therapy (GDMT) 2019 Waqas et al. Cureus 11(1): e3928

  36. Differential diagnosis of acute coronary syndromes in the setting of acute chest pain • European Heart Journal (2016) 37, 267–315 European Heart Journal (2016) 37, 267–315

  37. Thank You!

More Related