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Acute Coronary Syndrome

Acute Coronary Syndrome. Zohair Alaseri, MD FRCPc, Emergency Medicine FRCPc, Critical Care Medicine Intensivist and Emergency Medicine Consultant Director, Department of Emergency Medicine King Khalid University Hospital Riyadh, KSA. Acute Coronary Syndrome. Introduction

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Acute Coronary Syndrome

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  1. Acute Coronary Syndrome Zohair Alaseri, MD FRCPc, Emergency Medicine FRCPc, Critical Care Medicine Intensivist and Emergency Medicine Consultant Director, Department of Emergency Medicine King Khalid University Hospital Riyadh, KSA

  2. Acute Coronary Syndrome • Introduction • Chest Pain history • Physical Exam • Cardiac risk factors • Cardiac biomarkers • ECG in ACS • Risk Stratification • New imaging modality • CONCEPTS OF QUALITY AND QUALITY IMPROVEMENT

  3. Chest Pain Evaluation Among the following patients who has the highest risk for ACS: • Patient with DM,HTN and FH of heart disease • Patient with typical chest pain and ECG finding • 90 year old diabetic & hypertensive male Patient with typical chest pain • 50 year old female with typical chest pain & PMH of MI

  4. Chest Pain Evaluation The level of discomfort does not necessarily correlate with the severity of illness: • TRUE • FALSE

  5. Chest Pain Evaluation Lack of pain predicts increased hospital mortality? • TRUE • FALSE

  6. Chest Pain Evaluation The chest pain history itself has been proven to be a powerful enough predictive tool to obviate the need for at least some diagnostic testing? • TRUE • FALSE

  7. Chest Pain Evaluation Among the following features which one has the highest predictive value for ACS? • Radiation to shoulder • Radiation to both arms • Burning/indigestion pain • Nausea/vomiting • Exertional pain • Tender chest wall

  8. Chest Pain Evaluation The most frequent NON CHEST PAIN symptom in ACS is • nausea • diaphoresis • dyspnea • syncope • arms pain • pain epigastrium

  9. Chest Pain Evaluation CT Scan is available tool to exclude ACS in low to medium risk patient with chest pain in ED • TRUE • FALSE

  10. Chest Pain Evaluation • Patient less than 40 years and some cardiac risk factors has low probability of ACS • TRUE • FALSE

  11. Chest Pain Evaluation • Patient more than 65 years and no cardiac risk factors has low probability of ACS • TRUE • FALSE

  12. Chest Pain Evaluation • Begins before the physician sees the patient • Depends on the actions of triage staff and other non-physician personnel.

  13. Chest Pain Evaluation • Many patients will not admit having chest “pain,” but will acknowledge the presence of chest “discomfort” Pain in Arabic Waja Alam Thogol thaghett

  14. Chest Pain Evaluation 0.009 CHEST PAIN 0.02 0.27 0.014 P Value 0.54 0.18 Multivariate Analysis of Predictors of Acute Myocardial Infarction Goodacre S, Locker T, Morris F, Campbell S. How useful are clinical features in the diagnosis of acute, undifferentiated chest pain? Acad Emerg Med. 2002;9:203-208

  15. Chest Pain Evaluation • Atypical symptoms do not necessarily rule out acute coronary syndrome. • In 22 percent of 596 patients who presented to ED with sharp or stabbing pain had ACS But • A combination of atypical symptoms improves identification of low-risk patients. Lee TH, Cook EF, Weisberg M, Sargent RK, Wilson C, Goldman L. Acute chest pain in the emergency room. Identification and examination of low-risk patients. Arch Intern Med 1985;145:65–9

  16. Chest Pain Evaluation Patients who describe their discomfort as Similar to previous episodes of cardiac ischemia are more likely to have ACSs • GoldmanL.,CookE.,BrandD.,et al. A computer protocol to predict myocardial infarction in emergency department patients with chest pain • N Engl J Med (1988) 318 : pp 707-803 • GoldmanL.,CookE.,JohnsonP.,et al. Prediction of the need for intensive care in patients who come to the emergency department with acute chest pain. N Engl J Med (1996) 334 : pp 1498-1504

  17. Chest Pain Evaluation Precipitating and Aggravating Factors • An easy-to-remember for possible precipitating factors is the 3 p’s, which are: • Pleuritic, Positional, or reProducible chest pain more likely represents a non-ACS syndrome

  18. Chest Pain Evaluation Response to Nitroglycerin Cardiac-related in 122 patients (18%). 664 patients patients had moderate reduction patients had minimal reduction patients had no change in pain patients had significant or complete reduction in pain. Diercks DB, Boghos E, Guzman H, et al. Changes in the numeric descriptive scale for pain after sublingual nitroglycerin do not predict cardiac etiology of chest pain. Ann Emerg Med. 2005;45:581-585.

  19. Chest Pain Evaluation GI Cocktail • Doesn't help to differentiate Servi RJ, Skiendzielewski JJ. Relief of myocardial ischemia pain with a GI cocktail. Am J Emerg Med. 1985;3:208-209

  20. Atypical Chest Pain (ACC/AHA) guidelines list the following as pain descriptions that are not characteristic of MI • Pleuritic pain (i.e., sharp or knife-like pain brought on by respiratory movements or cough) • Middle or lower abdominal region • Localized at the tip of one finger, particularly over the (LV) apex • Reproduced with movement or palpation of the chest wall or arms • Constant pain • Very brief • Radiates into the lower extremities

  21. ACS without Chest Pain Dominant presenting symptoms in patients without chest pain (total exceeds 100% as patients may have presented with more than one dominant symptom) Brieger, D. et al. Chest 2004;126:461-469

  22. Soft Clinical Features • So-called “soft clinical features,” such as • Fatigue • Weakness • Malaise • Dizziness • “clouding of the mind,” • occurring in 11% to 40% of patients who have AMI

  23. Abdominal Pain • Cardiac ischemia can present with abdominal pain • 1% Pope J., Clinical features of emergency department patients presenting with symptoms of acute cardiac ischemia: a multicenter studyJ Thromb Thrombolysis6 (1998) : pp 63-74.

  24. Chest Pain Evaluation If a patient already carries a known diagnosis of IHD, a risk factor analysis is unnecessary because the risk is known to be 100%.

  25. Chest Pain Evaluation Chest Pain Evaluation Cardiac Risk Factor Conclusion • Cardiac risk factor burden has limited clinical value in diagnosing ACS in the ED setting, especially in patients older than 40 years. Jin H. Han, The Role of Cardiac Risk Factor Burden in Diagnosing Acute Coronary Syndromes in the Emergency Department Setting Annals of Emergency MedicineVolume 49 • Number 2 • February 2007

  26. ACS Evaluation Physical Examination Exclusion Inclusion Complication • The physical examination in patients with ACS frequently is normal. • Ominous findings • new mitral regurgitation murmur • hypotension • pulmonary rales • S3 gallop • JV distention. • tachycardia • bradycardia portends a patient at high risk for ischemic complication.

  27. Chest Pain & Biomarkers

  28. Myocardial perfusion imaging and multidetector CT accuracy (n=85). Michael J. Gallagher The Diagnostic Accuracy of 64-Slice Computed Tomography Coronary Angiography Compared With Stress Nuclear Imaging in Emergency Department Low-Risk Chest Pain Patients Annals of Emergency MedicineVolume 49 • Number 2 • February 2007

  29. Chest Pain Evaluation Why the term “ACS” is useful?? • The initial presentation and early management of unstable angina, STEMI, and NSTEMI frequently are similar.

  30. Chest Pain Evaluation In Triage Chest pain or angina equivalent Entry Working diagnosis ACS In Monitored bed ECG ST Elevation No ST elevation Troponin positive Troponin negative Biomarkers CKMB Final Diagnosis Acute MI Unstable angina

  31. Chest Pain Evaluation Chest Pain Inclusion Exclusion Life Threatening Conditions Prognostic Complication Esophageal perforation Pneumothorax Anti ischemic contraindications CXR, Bil BP A Dissection PE

  32. Chest Pain Evaluation ED ACS Management and Algorithms Risk Stratification & Chest Pain History Low Risk Pain that is pleuritic, positional, or reproducible with palpation described as stabbing lasts only seconds Probable Low Risk Pain not related to exertion or that occurs in a small inframammary area of the chest wall Probable High Risk Pain described as pressure, is similar to that of prior myocardial infarction or worse than prior anginal pain, or is accompanied by nausea, vomiting, or diaphoresis • High Risk • Pain that radiates to one or both shoulders or arms or • is related to exertion • similar to previous cardiac ischemia • Radiated to arms • IHD DM

  33. Chest Pain & Time management 1. The diagnosis: door-to-ECG (preferably less than 10 minutes)2. The decision to treat: door-to-catheterization team activation (preferably within 15–25 minutes ) 3. The transition in care: door-to-ED departure (preferably within 45–60 minutes)

  34. Chest Pain & normal ECG & CE in ED Observe for 6 hours with continuous 12 lead ECG monitoring Rpeate CK, troponin & ECG in 6 to 8 hours • Any one of the following • Recurent pain • ECG changes ST depression or • elevation or t inversionor • arrythmia • Positive Enzymes • All of the following • No further pain • No ECG changes ST depression or • elevation or t inversionor • No arrythmia • Negative Enzymes No Yes +ve Stress Test High Risk - ve CCU Admission Discharge

  35. Chest Pain Evaluation Immediate actions • Triage to a telemetry bed for immediate assessment and delivering ACLS if needed. • Placement on a monitor • IV • (ASA) • ECG 5 minutes of patient arrival

  36. Oxygen • Administer oxygen to all patients with overt pulmonary congestionor arterial oxygen saturation <90% (Class I). • It is alsoreasonable to administer supplementary oxygen to all patientswith ACS for the first 6 hours of therapy

  37. Aspirin • Eight RCT showed decreased mortality rates when ASAwas given to hospitalized patients with ACS. The International Study of Infarct Survival (ISIS)-2 trial (odds reduction=0.23; 95% CI, 0.15–0.30

  38. Aspirin Limited evidence from several very small studies suggests thatthe bioavailability and pharmacologic action of other formulationsof ASA (soluble, IV) may be as effective as chewed tablets. 7 RCT indicated decreased mortality rates when ASAwas given as early as possible.

  39. Aspirin Freimark D, Matetzky S, Leor J, Boyko V, Barbash IM, Behar S, Hod H. Timing of aspirin administration as a determinant of survival of patients with acute myocardial infarction treated with thrombolysis. Am J Cardiol. 2002; 89: 381–385 • Early users experienced lower mortality at 7 days (2.5% vs 6.0%, p = 0.01), 30 days (3.3% vs 7.3%, p = 0.008), and 1 year (5.0% vs 10.6%, p = 0.002) than late users.

  40. Clopidogrel Give a 300-mg oral loading dose of clopidogrel in addition tostandard care (ASA, heparin) to patients with ACS within 4 to 6hours

  41. Clopidogrel • Clopidogrel in combination with aspirin is more effective than ASA alone in reducing cardiovascular death, MI, and stroke for 9 months after the index visit. • The Clopidogrel in Unstable Angina to Prevent Recurrent Events Trial Investigators : Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST-segment elevation. N Engl J Med2001;345:494.[errata, N Engl J Med 345:1506, 1716, 2001].

  42. Clopidogrel • Although the recent CLARITY TIMI 28 trialdid not documentincreased bleeding in patients undergoing CABG within 5 to 7days of receiving clopidogrel. ----Current ACC/AHA recommendationsadvise withholding clopidogrel for 5 to 7 days before plannedCABG. • It is reasonable to give clopidogrel 300 mg orally to patientswith suspected ACS (without ECG or cardiac marker changes) whohave hypersensitivity to or gastrointestinal intolerance ofASA.

  43. Heparins • In the ED giving LMWH instead of UFH in addition to aspirinto patients with UA/NSTEMI is helpful. • There is insufficientevidence to identify the optimal time for administration afteronset of symptoms. • Changing from one form of heparin to another (crossoverof antithrombin therapy) during an acute event is not recommended. • LMWH is an acceptable alternative to UFH as ancillary therapyfor patients with STEMI who are <75 years of age and receivingfibrinolytic therapy.

  44. Heparins • In patients with STEMI proceeding to PCI, there is no evidence in favor of LMWH over UFH • LMWH (specifically enoxaparin) improved overall TIMI flow (coronary reperfusion) and ischemicoutcomes better than UFH when given to patients with STEMI within 6hours of onset of symptoms Van de Werf FJ. Efficacy and safety of tenecteplase in combination with enoxaparin, abciximab, or unfractionated heparin: the ASSENT-3 randomised trial in acute myocardial infarction. Lancet. 2001; 358: 605–613. Wallentin L, Low molecular weight heparin (dalteparin) compared to unfractionated heparin as an adjunct to rt-PA (alteplase) for improvement of coronary artery patency in acute myocardial infarction—the ASSENT Plus study. Eur Heart J. 2003; 24: 897–908.

  45. Fondaparinux

  46. Glycoprotein IIb/IIIa Inhibitors • If revascularization therapy (PCI or surgery) is planned, itis safe to give GP IIb/IIIa inhibitors in addition to standardtherapy (including ASA and heparin) to patients with high-riskUA/NSTEMI in the ED. • This therapy reduce the risk of deathor recurrent ischemia. • If revascularization therapy is not planned, the recommendationfor use of GP IIb/IIIa varies by drug. Tirofiban and eptifibatidemay be used in patients with high-risk UA/NSTEMI in conjunctionwith ASA and LMWH if PCI is not planned. But abciximab can beharmful in patients with high-risk UA/NSTEMI if early (eg, 24hours) PCI is not planned.

  47. Glycoprotein IIb/IIIa Inhibitors STEMI • Abciximab is not currently recommended in patients receivingfibrinolytics for STEMI. • In patients treated with PCI withoutfibrinolysis, abciximab is helpful in reducing mortalityrates and short-term reinfarction.

  48. Glycoprotein IIb/IIIa Receptor Inhibitors • Three agents: • Abciximab • Eptifibatide • Tirofiban.

  49. Fibrinolytics • In the ED fibrinolytics should be given to patients with symptoms of ACS and ECG evidence ofon of the following: • STEMI • New LBBB • True posterior infarction

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