coronary syndrome

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Acute Coronary SyndromeAcute Coronary Syndrome



Life-threatening Causes of

Chest Pain Myocardial infarct

Unstable angina

Thoracic aortic dissection Pulmonary embolus

Tension pneumothorax

Oesophageal rupture



Differential Diagnosis?



NSTEMI

Presentation

Working Dx

ECG

Cardiac

Biomarker

Final DxNQMI Qw MI

UA

Unstable

Angina

Ischemic Discomfort

Acute Coronary Syndrome

Myocardial Infarction

ST ElevationNo ST Elevation

Non-ST ACS

Libby P. Circulation 2001;104:365, Hamm CW, Bertrand M, Braunwald E, Lancet 2001; 358:1533-1538; Davies MJ. Heart 2000; 83:361-366.

Anderson JL, et al. J Am Coll Cardiol. 2007;50:e1-e157, Figure 1. Reprinted with permission.



Acute Coronary Syndromes

Similar pathophysiology

Similar presentationand early managementrules

STEMI requiresevaluation for acutereperfusion

intervention

Unstable Angina

Non-ST-SegmentElevation MI(NSTEMI)

ST-SegmentElevation MI(STEMI)



Diagnosis of Angina

Typical angina²All three of thefollowing

Substernal chest discomfort

Onset with exertion or emotional stress Relief with rest or nitroglycerin

Atypical angina 2 of the above criteria

Noncardiac chest pain 1 of the above



Diagnosis of Unstable Angina

Patients with typical angina - An episode of

angina

Increased in severity or duration

Has onset at rest or at a low level of exertion

Unrelieved by the amount of nitroglycerin or rest

that had previously relieved the pain

Patients not known to have typical angina

First episode with usual activity or at rest within the

previous two weeks

Prolonged pain at rest



Diagnosis of Acute MI

STEMI / NSTEMI At least 2 of the

following

Ischemic symptoms

Diagnostic ECG

changes

Serum cardiacmarker elevations



Unstable

Angina

STEMINSTEMI

Non occlusive

thrombus

Non specific

ECG

Normal cardiac

enzymes

Occluding thrombus

sufficient to cause

tissue damage & mild

myocardial necrosis

ST depression +/-

T wave inversion on

ECG

Elevated cardiac

enzymes

Complete thrombus

occlusion

ST elevations onECG or new LBBB

Elevated cardiac

enzymes

More severe

symptoms



Evaluation

Efficient & direct history

Initiate stabilization interventions

Plan for moving rapidly to

indicated cardiac care

Directed Therapiesare

Time Sensitive!

Occurs

simultaneousl

y



CHEST PAIN ASSESSMENT

History Vitally Important

Pain -Nature

Site

Severity

Radiation

Onset

Exac/relieving factors

Associated features

Duration

Previous similar pains



Coronary Heart DiseaseCoronary Heart DiseaseRISK FACTORSRISK FACTORS

Advancing AgeAdvancing Age Family historyFamily history

Non ModifiableNon Modifiable

Sex: MaleSex: Male

MenopauseMenopause



Coronary Heart DiseaseCoronary Heart DiseaseRISK RISK FACTORSFACTORS

SmokingSmoking

HypertensionHypertensionDiabetesDiabetesObesityObesity InactivityInactivity

AlcoholAlcohol

ModifiableModifiable

DyslipidemiaDyslipidemia OC PillsOC Pills



Focused History

Aid in diagnosis andrule out other causes

± Palliative/Provocative

factors

± Quality of discomfort

± Radiation

± Symptoms associated

with discomfort

± Cardiac risk factors

± Past medical history -

especially cardiac

Reperfusionquestions

± Timing of

presentation ± ECG c/w STEMI

± Contraindication to

fibrinolysis

± Degree of STEMI risk



Targeted Physical

Recognize factors that

increase risk Hypotension

Tachycardia

Pulmonary rales, JVD,

pulmonary edema,

New murmurs/heart

sounds Diminished peripheral

pulses

Signs of stroke

Examination

± Vitals

± Cardiovascular

system ± Respiratory

system

± Abdomen

± Neurologicalstatus



ECG assessment

ST Elevation or new LBBBST Elevation or new LBBB

STEMISTEMI

NonNon--specific ECGspecific ECG

Unstable AnginaUnstable Angina

ST Depression or dynamicST Depression or dynamic

T wave inversions T wave inversions

NSTEMINSTEMI



Acute MI: ECG Changes



Acute MI: Initial ECG

Non-diagnostic ECG¶s Normal

Subtle ST-T changes

Isolated T-wave changes Negative U-waves

Normalization of previous abnormal ST-

segment and T-waves

Conduction defects

³Silent´ areas: right, posterior



Acute Anterior MI



Acute Inferior MI



Acute Posterior MI



New LBBB

QRS > 0.12 sec

L Axis deviation

Prominent R wave V1-V3

Prominent S wave 1, aVL, V5-V6

with t-wave inversion



Cardiac markers

Troponin ( T, I)

± Very specific and moresensitive than CK

± Rises 4-8 hours after

injury ± May remain elevated

for up to two weeks

± Can provideprognostic information

± Troponin T may beelevated with renal dz,poly/dermatomyositis

CK-MB isoenzyme

± Rises 4-6 hours after injury and peaks at 24hours

± Remains elevated 36-48hours

± Elevation can bepredictive of mortality

± False positives with

exercise, trauma,muscle dz, DM, PE



Acute Management

Initial evaluation &

stabilization

Efficient risk

stratification

Focused cardiac

care



Chest pain suggestive of ischemia

± 12 lead ECG ± Obtain initial

cardiac

enzymes

± electrolytes,

cbc lipids,

bun/cr,

glucose,

coags

Immediate assessment within 10 Minutes

± Establishdiagnosis

± Read ECG

± Identify

complicatio

ns

± Assess for

reperfusion

Initial labsInitial labs

and testsand tests

EmergentEmergent

carecare

History &History &

PhysicalPhysical

± IV access ± Cardiac

monitoring

± Oxygen

± Aspirin

± Nitrates

± Morphine



Acute coronary syndrome

ST elevation MI

Thrombolysis Primary PTCAMonitoring

Aspirin

Nitrates

Beta-blockers

Ace inhibitors

Statins

Fondaparinux/Enoxaparin



ACUTE CORONARY SYNDROME

Non ST elevationTrop T+Trop T-

UA NSTEMImonitor ing

Aspir in

Beta blocker sNitrate

Hepar in/ClexaneIIB/IIIA inhibitor s

Invasivestrategy

Conservative

strategy

Recurrent

symptoms

Patient stabilizes

Stress test-

Medical Rx+



THANK YOUTHANK YOU

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