ACUTE CORONARY SYNDROMEJarrod D. Frizzell, MD, MS

Fellow, Cardiovascular Medicine

July 10, 2014

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• iStat Tn: 0

Outline• Definitions

• ACS• MI

• STEMI• NSTEMI• UA• Pearls

Acute Coronary Syndrome

Acute Coronary Syndrome

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

Acute Coronary Syndrome

Goldacre, Acad Emer Med 2003

Acute Coronary Syndrome• ACS typically implies “type I event”• Divided into:

• STEMI• NSTEMI• UA

Braunwald, AJRCCM 2012

Types of MI

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

Features

Braunwald, 9th ed.

ECG

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”

STEMI

ECG.utah.edu

STE

Ecginterpretation.blogspot.com

ECG

ECG

ECG

ECG

ECG• STEMI vs everything else• Why?

• Very specific for transmural ischemia (diagnosis & location)• “Time is muscle”

THE Graph

Gersh, JAMA 2005

2013 STEMI Guidelines

2013 STEMI Guidelines

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)

Back to ACS

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

Braunwald, AJRCCM 2012

NSTEMI

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)

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

“Routine Medical Therapy”• Within 24h:

• Beta-blocker• ACEI• High-intensity statin

• Also get TTE

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

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)

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