Acute Coronary Syndrome

1. Acute Coronary Syndrome

2. Objectives • The healthcare professional will have the ability to list the three classes of Acute Coronary Syndrome. • The healthcare professional will have the ability to list the appropriate acute interventions needed for a patient symptomatic for Acute Coronary Syndrome. • The healthcare professional will have the ability to list at least three differential diagnosis’ of chest pain. • The healthcare professional will be able to list four diagnostic tests needed for a patient symptomatic for Acute Coronary Syndrome.

3. Acute Coronary Syndrome includes the following diagnoses: • ST elevation MI (STEMI) • Non ST elevation MI (NSTEMI) • Unstable Angina (UA)

4. Stable Angina Stable Angina is not included in ACS • It is predictable • Is associated with activities such as physical activity, cold and even eating • Usually last for 1-5 minutes and is relieved by rest • Transient ST depression may be visible but disappears with pain relief

5. Unstable Angina Considered to be unstable if presented in any of the following three ways: • Angina at rest lasting for more than 20 minutes • New onset angina that markedly limits physical activity • Increasing angina that is more frequent, lasts longer, or occurs with less exertion than previous angina

6. Symptoms of unstable angina • Substernal pain/pressure radiating to the jaws and down arms • Nausea • Dyspnea • Diaphoresis • Nitroglycerin may not give total relief of symptoms

7. NSTEMI vs. UA • NSTEMI and UA can at times only be discernible by the presence of positive serum biomarkers such as cpk-mb and Troponin. • Consider data from 12 lead • Diagnosis of NSTEMI versus UA until proven otherwise • Disposition of UA and NSTEMI may be determined by their TIMI score.

8. Time Course for cardiac enzymes

9. NSTEMI and UA • Ischemic ST-segment depression > 0.5mm • Dynamic T-wave inversion with pain or discomfort • Nonpersistent or transient ST-segment elevation > 0.5 mm for < 20 minutes

10. TIMI • Early risk stratification for UA and NSTEMI • TIMI 11B and ESSENCE trials • Seven variables predictive of outcomes

11. A TIMI score is determined by a list of 7 risk factors. • Age>65 • Three or more cardiac risk factors • Aspirin use in the last 7 days • Two or more episodes of chest pain in the last 24 hr • ST-segment deviation on presenting EKG • Increased biomarkers • Prior coronary artery stenosis > 50%

12. High risk patients have a TIMI score >5 • Typically admitted to the ICU or telemetry depending on their hemodynamic state • Patients with hemodynamic compromise or continued chest pain should undergo PCI.

13. Moderate Risk • TIMI score of 3-4 • Can be admitted to the chest pain center or telemetry for further evaluation.

14. Low Risk TIMI • TIMI score of <2 and no other concerning features of their presentation can be considered for an abbreviated evaluation protocol • Serial serum biomarkers • Discharge with outpatient stress testing within 72 hours • Serial EKGs

15. ST segment elevation Myocardial Infarction (STEMI) • The AHA classifies a STEMI as ST-segment elevation or presumed new Left Bundle Branch Block (LBBB) • STEMI is characterized by ST-segment elevation >1mm in 2 or more contiguous precordial leads or 2 or more adjacent limb leads

16. Contiguous Leads

17. Physical signs of STEMI • Severe chest discomfort but may include discomfort in other areas of the upper body • Shortness of breath • Sweating • Dizziness • Usually intense lasting for more then 15 minutes

18. Treatment of Patients with Acute Coronary Syndrome • Should be rapid • STEMI should be the presumed diagnosis until proven other wise with serial EKG’s and cardiac markers.

19. Initial treatment should include • ABCs • Maintain a saturation above 90% • Administer O2 to all patients with chest pain for the first 6 hours • 12 lead EKG

20. 12 Leads • First 10 minutes of the patients’ presentation and presented to an experienced physician • If the first ECG is not clearly diagnostic and patient is still symptomatic a 12-lead should be repeated

21. Inferior wall MI • Affecting the RV • Sensitive to nitrates • Susceptible to hypotension • Elevations in leads II, III and AVF • Consider a right sided EKG

22. Right Sided EKG • Move the V3, V4, V5 and V6 leads to the mirrored right sided position of the chest • Be certain to label this EKG as right sided.

23. Right Sided EKG

24. Posterior MI • If depression is noted in leads V1, V2, and V3 with large R waves a posterior EKG is recommended to diagnose a posterior MI • V4 is placed at the left posterior axillary line, V5 is on the border of the left scapula and V6 is near the spine • Re-label the EKG V7, V8 and V9 posterior view

25. Don’t forget • Resuscitation equipment • Two large bore IVs • Bedside monitor

26. Initial Testing • CBC • Differential • CPK-MB • Troponin • PT • PTT • Comprehensive metabolic profile • CXR

27. Remember MONA • Oxygen • Aspirin • Nitroglycerin • Morphine

28. Aspirin • Dose 4--81mg baby aspirin • Contraindication could include allergy or suspect for AAA • Clarify a documented allergy to aspirin as true allergy or sided effect and discuss with physician

29. Nitroglycerin • Effective treatment for the pain associated with ischemic chest pain • Dilation of coronary arteries • 0.4 mg every 5 minutes until pain free or a total of three

30. Use Nitrates with caution • Do not use if blood pressure is less than 90 systolic • Systolic blood pressure is < 30 of baseline • Caution with bradycardia and hypotension • Inferior wall MI –may have inadequate preload use with caution

31. Avoid nitrates in patients who take medicines for erectile dysfunction Phosphodiesterase-5 inhibitors are: • Viagra (sildenafil) • Levitra (vardenafil) • Cialis (tadalafil) • May lead to severe hypotension • Patients may be reluctant to include with medication reconciliation

32. Morphine • For patients with ACS that are unresponsive to nitrates • 2-4mg increments • Analgesic for pain • Reduce pulmonary congestion • Vasodilator that reduces oxygen requirements • Reduces preload

33. Clopidogrel (Plavix) • Reduces platelet aggregation through a different mechanism than aspirin • Initial loading dose of 600mg for patients requiring primary PCI and stenting • Ideally primary PCI should be done within 90 minutes of dosing

34. Heparin • Indirect inhibitor of thrombin Disadvantages: • Frequent need for monitoring of PTT • Unpredictable anticoagulation • Need for IV administration • Possibility of HIT (heparin induced thrombocytopenia)

35. LMW Heparins • Better outcomes than heparin in patient survival rates and frequency of ischemic complications • LMWH such as enoxaparin (Lovenox) is recommended for patients <75 years of age • Creatinine levels should be monitored

36. Beta Blockers • Recommended for most patients with ST elevation MI • Watch for signs of inadequate perfusion • Beta blockers reduce the size of the infarct, reduce likelihood of cardiac rupture and reduce mortality • They also reduce the incidence of VT and Vfib

37. Contraindications for Beta Blockers • Severe LV failure with pulmonary edema, • HR <60bpm, SBP <100, • Signs of poor peripheral perfusion • 2nd degree heart block • 3rd degree heart block • Reactive airway disease • Cocaine use

38. History and physical • Presenting symptoms • Characteristic of pain associated with symptoms • Past medical history • Significant family history

39. Differential Diagnoses • AAA • PE • Tension pneumothorax • Perforated peptic ulcer • Esophageal rupture

40. Reperfusion Therapy • Percutaneous Coronary Intervention has been shown to be superior to fibrinolysis • Considered if less than 12 hours has elapsed from the onset of symptoms • The goal for PCI is less then 90 minutes from the time the patient seeks medical attention

41. Mortality rates for patients with AMI treated with PCI • Lower then those treated with fibrinolysis • Mortality rate at 6 months was significantly lower for patients with early PCI (50% vs. 63%) • In the subgroup <75 years old early PCI had a 15% reduction in the 30 day mortality rate and improvement in the one year survival rate

42. Further Diagnostic Studies Patients with persistent chest pain, a non-definitive 12 lead and negative cardiac enzymes may be a candidate for more definitive testing.

43. Resting Myocardium Perfusion Imaging • Injected thallium-201 and technetium-99m accumulates in myocardial tissue • Ischemia will demonstrate a decreased radioactive count

44. Limitations of Resting Stress • Preexisting myocardial damage • May be falsely negative if pain has resolved for more than three hours • The acute rest imaging must be readily available.

45. References • Advanced Cardiovascular Life Support, American Heart Association, 2006 • “The Role of Invasive Therapy of Acute Myocardial Infarction after TIMI 11 B.” Journal of Interventional Cardiology; Vol 2 Issue 1; pages 1-3; June 2007

46. Echocardiography • Exclude other potential diagnosis • Aortic dissection • PE • Pericarditis with pericardial effusion

47. DC planning Per facility • Life style modifications • Future risk education • Aspirin prescribed at discharge • Beta Blockers prescribed at discharge • Dietary consult for education • Smoking Cessation