Acute Coronary syndrome

1. Acute Coronary syndrome Jarrod D. Frizzell, MD, MS Fellow, Cardiovascular Medicine July 10, 2014

2. A Case • 37yoM awoke with chest pressure • Radiating to left shoulder • Still present after 1h. • Tachy, “JVD to ears”, lungs clear • Just diagnosed with DM last night • iStatTn: 0

6. Outline • Definitions • ACS • MI • STEMI • NSTEMI • UA • Pearls

7. Acute Coronary Syndrome

8. Acute Coronary Syndrome

9. Acute Coronary Syndrome • Syndrome • Chest pain (angina?) • Most common: upper body discomfort & SOB • Diaphoresis • Nausea/vomiting • Dizziness • Isolated atypical sx are uncommon (women, elderly, DM) • Entire picture must be set in clinical context • ECG or isolated Tn alone does not make it

10. Acute Coronary Syndrome Goldacre, AcadEmer Med 2003

11. Acute Coronary Syndrome • ACS typically implies “type I event” • Divided into: • STEMI • NSTEMI • UA

12. Braunwald, AJRCCM 2012

13. Types of MI

14. Universal Definition of MI • Detection of rise and/or fall of cardiac biomarkers with at least 1 value above the 99th %ile reference limit and with at least 1 of the following • Sx of ischemia • New or presumed new significant ST-T changes or LBBB • Development of pathologic Q waves • Imaging evidence of new loss of viable myocardium or new WMA • Identification of an intracoronary thrombus (cath or autopsy) Circulation 2012

15. Features Braunwald, 9th ed.

16. ECG

17. STEMI • ST elevations—measured at the J point • V2-V3—age/gender dependent • Women: 1.5mm • Men ≥40: 2mm • Men <40: 2.5mm • 1mm in all other leads • “Injury pattern”

18. STEMI ECG.utah.edu

19. STE Ecginterpretation.blogspot.com

20. ECG

21. ECG

22. ECG

23. ECG

24. ECG • STEMI vs everything else • Why? • Very specific for transmural ischemia (diagnosis & location) • “Time is muscle”

25. THE Graph Gersh, JAMA 2005

26. 2013 STEMI Guidelines

27. 2013 STEMI Guidelines

28. STEMI • Meds—Before Cath • Anti-platelet load • ASA • Thienopyridine (clopidogrel) • Anticoagulation • Heparin/LMWH • Bivalirudin (if PCI—started in cath lab) • Not fonda • IIb/IIIa fallen out of favor except special circumstances • Pain relief • NTG • Morphine? • If need beyond, call fellow (for boards: CCB, BB)

29. Back to ACS

30. NSTEMI • Still presentation of ACS, but not STE • Elevated Tn • TIMI Score

31. Braunwald, AJRCCM 2012

32. NSTEMI

33. NSTEMI • If low risk, probably go with noninvasive imaging • Dob echo • Dipy/cardiolite • Initial meds overall similar to STEMI • ASA/clopidogrel • Heparin/LMWH • Time is less pressing • Urgent (<120min) • Early invasive (<72h) • Conservative (not cath)

34. Unstable Angina • Definition • CP that occurs at rest or with minimal exertion, lasts >20min • Onset within past month • Crescendo pattern • A dying breed? • Broadly speaking, treat like NSTEMI

35. “Routine Medical Therapy” • Within 24h: • Beta-blocker • ACEI • High-intensity statin • Also get TTE

36. When to call? • Whenever you feel uncomfortable • Not the resident’s job to “rule out STEMI” on ECG • You will only regret not calling • If cannot get CP-free

37. Miscellany • Elevated Tn—when to heparinize? • DAPT—duration • DES: 1y • BMS: at least 1mo, up to 1y • ACS but no intervention—1 year • “No breakfast on 7S” (NPO for tests) • “No coffee at the VA” (NPO for nuc, caffeine interferes)

38. Boards Odds & Ends • RV Infarct • Inferior STE (get right-sided ECG) • +JVD but clear lungs • (Borderline) Hypotensive  fluids • Avoid NTG • STEMI is not only cause of STE • If STEMI at non-PCI OSH: • Transfer if PCI within 120min • Lytics if transfer outside window • Idioventricular rhythm post reperfusion • Looks like VT, but slower • No additional therapy