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Acute Coronary Syndrome

Acute Coronary Syndrome. MINI LECTURE Kelvin Nguyen. OBJECTIVES. Definition of ACS UA, NSTEMI, and STEMI Risk stratification in NSTEMI Management. Acute Coronary Syndrome.

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Acute Coronary Syndrome

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  1. Acute Coronary Syndrome MINI LECTURE Kelvin Nguyen

  2. OBJECTIVES • Definition of ACS • UA, NSTEMI, and STEMI • Risk stratification in NSTEMI • Management

  3. Acute Coronary Syndrome Definition: a constellation of symptoms related to obstruction of coronary arteries with chest pain being the most common symptom in addition to nausea, vomiting, diaphoresis etc. Chest pain concerned for ACS is often radiating to the left arm or angle of the jaw, pressure-like in character, and associated with nausea and sweating. Chest pain is often categorized into typical and atypical angina.

  4. Acute coronary syndrome • Based on ECG and cardiac enzymes, ACS is classified into: • STEMI: ST elevation, elevated cardiac enzymes • NSTEMI: ST depression, T-wave inversion, elevated cardiac enzymes • Unstable Angina: Non specific EKG changes, normal cardiac enzymes

  5. Unstable Angina • Occurs at rest and prolonged, usually lasting >20 minutes • New onset angina that limits activity • Increasing angina: Pain that occurs more frequently, lasts longer periods or is increasingly limiting the patients activity

  6. EKG • STEMI: • Q waves , ST elevations, hyper acute T waves; followed by T wave inversions. • Clinically significant ST segment elevations: • > than 1 mm (0.1 mV) in at least two anatomical contiguous leads • or 2 mm (0.2 mV) in two contiguous precordial leads(V2 and V3) • Note: LBBB and pacemakers can interfere with diagnosis of MI on EKG

  7. EKG • NSTEMI: • ST depressions (0.5 mm at least) or T wave inversions ( 1.0 mm at least) without Q waves in 2 contiguous leads with prominent R wave or R/S ratio >1. • Isolated T wave inversions: • can correlate with increased risk for MI • may represent Wellen’s syndrome: • critical LAD stenosis • >2mm inversions in anterior precordial leads • Unstable Angina: • May present with nonspecific or transient ST segment depressions or elevations

  8. Cardiac Enzymes • Troponin is primarily used for diagnosing MI because it has good sensitivity and specificity. • CK-MB is more useful in certain situations such as post reperfusion MI or if troponin test is not available • Other conditions can cause elevation in troponin such as renal failure or heart failure • The increasing troponin trend is the important thing to look for in diagnosing MI. Order Troponin together with ECG when doing serial testing to rule out ACS.

  9. Risk Stratification: TIMI score • NSTEMI or unstable angina are risk stratified: • Age>=65 • >= 3 CAD risk factors: • HTN, hyperlipidemia, diabetes, smoker, family hx of early MI • Documented CAD with >=50% stenosis • ST segment deviation • ≥ 2 aginal episodes in past 24 hours • Aspirin use in the past week (marker for more severe case) • Elevation of cardiac enzymes • Stratify risk based on number of variables • Risk: • 0-2: Low 3-4: Intermediate 5-7: High risk

  10. NSTEMI & Unstable Angina Management • NSTEMI or EKG changes suggest ischemia with high risk: • Telemetry • Aspirin • Beta blocker • Nitrates • Heparin (UFH or LMWH) • ACE-I/ARB • Statin • Consider GP IIb/IIIa inhibitor and clopidogrel • EKG normal or non-specific changes with intermediate or low risk: • Telemetry • Rule out ACS with 3 sets of troponin, EKG • Consider pre-discharge stress test

  11. STEMI Management • STEMI patients usually go straight to the cath lab from the ED. Goal: door to balloon 90 minutes. • Initial management for STEMI: • Cardiac monitor • Supplemental O2 • Nitrates* • Beta blocker • Morphine • Clopidogrel • Aspirin • Good IV access • Call cardiology fellow!

  12. Case • 60 year old male with history of DM2 for 20 years, HTN, HLD who presented to the ED with 4 hour onset of chest pain which was described as in the anterior chest without radiation. The pain seemed to improve when he sits down and worsening when he walked upstairs. • VS: T 36.9, HR: 95, BP: 84/56, RR 22, O2 sat. 99% RA. • ECGs are shown as followed

  13. What will you do? • What’s your diagnosis? • What should be done now?

  14. References • 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2005;112:IV-89-IV-110 • 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction : A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2013, epublished April 29th 2013 and print published june 4th 2013. • Herman LK, et al. Comparison of frequency of inducible myocardial ischemia in patients presenting to emergency department with typical versus atypical or nonanginal chest pain. Am J Cardiol. 2010 105:1561-4. • www.uptodate.com: • Overview of the acute management of unstable angina and acute non-ST elevation myocardial infarction • Initial evaluation and management of suspected acute coronary syndrome in the emergency department • Criteria for the diagnosis of acute myocardial infarction

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