Unstable Angina - NSTEMI - Muhammad Aminuddin, MD, FIHA.pdf

8/18/2019 Unstable Angina - NSTEMI - Muhammad Aminuddin, MD, FIHA.pdf

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CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015

Unstable Angina &

Non-ST ElevationMyocardial Infarction

Muhammad Aminuddin

Rahmania


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Coronary Artery Disease

Stable Angina

Acute Coronary Syndrome

Unstable Angina

Non ST Elevation Myocardial Infarction

ST Elevation Myocardial Infarction


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Epidemiology

CAD is a leading cause of

mortality

17,1 million deaths worldwide

(WHO, 2008)

1,5 million pts hospitalized with ACS in

US, 80% with NSTEMI, 20% with STEMI

(AHA Statistic, 2008)

American and Europe statistic reveal

declining of STEMI insidence with increased

of NSTEMI case


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Definition An acute coronary syndrome manifestation

involve symptoms vary from myocardial

ischemia to infarction or necrosis caused by

sudden decreased coronary blood perfusion.

(Amsterdam et al, 2014)


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Clinical Spectrum of Acute Coronary Syndrome

Acute Coronary Syndrome

Non-ST SegmentElevation

ST SegmentElevation

Unstable

Angina Pector isNon-Q-wave Q-wave

Acute Myocardial Infarction

STEMI

NSTEMI


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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 cardiacenzymes

Complete thrombus

occlusion

ST elevations on

ECG or new LBBB

Elevated cardiac

enzymes

More severe

symptoms


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Cause of UA/NSTEMIReduced coronary perfusion due to coronary artery narrowing

Dynamic obstruction

•Coronary spasm

•Microvascular dysfunctionn

Severe narrowing without spasm or thrombus (progressive atherosclerosis, restenosis after PCI)

Thrombus or thromboembolism formation from disrupted atherosclerotic plaque,

•Distal microembolism from plaque associated thrombus

•Subtotal occlusive thrombus from preexisting plaque•Occlusive thrombus with extensive collateral supply

Other cause:

Coronary artery dissection in peripartum women

Secondary UA (tyrotoxicosis)


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Pathophysiology

Plaque

ruptured

Thrombus

formation

Vasoconstriction


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Clinical PresentationTypical chest pain characterized by a retrosternal sensation of

pressure or heaviness radiating to the left arm (less frequently to

both arms or to the right arm), neck or jaw, which may be

intermittent (usually lasting several minutes) or persistent.

Additional symptoms

sweating, nausea, abdominal pain, dyspnoea and syncope


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11

Pain Patterns with Myocardial Ischemia


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Physical Examination To know precipitating factor of myocardial ischemia and it’s

complication

Hemodynamic consequence

Eliminate other differential diagnosis

Findings include:

1. S3 gallop , Lung : Rh +/+

2. Murmur tricuspid regurgitation

3. Pericardial friction rub

4. Cardiogenig Shock signs 20% NSTEMI


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ECG Findings in UA/NSTEMI1. ST depression and/ or T inversion; unsignificant ST

elevation

2. Pathologic Q waves

3. Non diagnostik

4. Normal ECG (1-6% patients)


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EKG diagnosis of MI

ST segment

elevation

ST segmentdepression

T wave inversion

Q wave formation


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ECG findings in UA/ NSTEMI

Horizontal or downsloping ST depression ≥ 0.5 mm at the J-point in ≥

2 contiguous leads spesific for ischemia

ST depression ≥ 1 mm is more specific

T wave inversion at least 1 mm deep, in ≥ 2 continuous

leads that have dominant R waves (R/S ratio > 1)


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Cardiac Marker

Troponin I/T

CKMB (Creatinin

Kinase MB)

Myoglobin

(Kumar et al, 2008; Anderson et al 2012)


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Diagnostic

-- NSTEMI : - Ax :Typical Angina

ECG change

Cardiac Marker +

-- Unstable Angina : Cardiac Marker -


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Risk Stratification Choosing therapy : Conservatif or Intervention

Predicting early prognosis

TIMI (Thrombolysis in Myocardial

Infarction) Risk Score

Predicting Mortality in 30days and

1 year patient with NSTEMI

GRACE (Global Registry Of Acute

Coronary Events) Score

Predicting mortality during

hospitalization and six months

after discharge mortality and

myocardial infarction risk


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Risk Stratification (TIMI)


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Risk Stratification (GRACE)

Grace 140

High Risk


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Early Hospital Care

The standard of care for patients who present with

NSTE-ACS, including those with recurrent symptoms,

ischemic electrocardiographic changes, or positive

cardiac troponins, is admission for inpatientmanagement

Goals of Treatment

Immediate relief of ischemia and the

prevention of MI and death.


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Algorythm for Evaluation and Management of

Patient Suspected ACS

ACC/AHA Guideline 2012 for the Management of Patient with UA/NSTEMI


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Invasive Strategy

Immediate invasive Strategy (


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Guide Line ESC 2015(Amsterdam et al, 2015)


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Initial Therapy

Suplemental oxygen if needed (Saturation below 90%,respiratory distress, or other high risk feature of hipoxemia)

Loading Aspirin 160-320mg

12 lead ECG within 10 minutes from first medical contact

Establish iv access and obtain initial cardiac marker level

Supportive drugs for chest pain include nitrat iv or morphin ivif needed

Haemodynamic monitoring

Perform brief targeted history, risk factor, physicalexamination, and early risk stratification


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Pharmacological Therapy Anti Ischemic and Anti Angina Therapy

Nitrat

Patients with UA/NSTEMI with ongoing ischemic discomfort should receive sublingual NTG (0.4 mg) every 5 min for a total of 3 doses, afterwhich assessment should be made about the need for intravenous NTG, if not contraindicated.

Morphin

In patients with symptoms despite antiajnginal treatment, morphine (1 mg to 5 mg IV) may be administered during intravenousnitroglycerin therapy with BP monitoring.

Beta Blocker

Oral beta blocker in first 24 hour for patient without sign of congestive heart failure, low output state, increased risk of cardiogenic

shock, or with contraindication of beta blocker.

Ca Channel Blocker

Can be used in patient with contraindication of beta blocker without sign of LV disfunction


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ACE Inhibitor

ACE Inhibitor within 24 hours with congestive

pulmonum or LV ejection fraction


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A P2Y12 inhibitor (either clopidogrel or ticagrelor) in addition toaspirin should be administered for up to 12 months to all patientswith NSTE-ACS without contraindications who are treated witheither an early invasive or ischemia-guided strategy.

Options include:

Clopidogrel: 300-mg or 600-mg loading dose, then 75mg daily(Level of Evidence: B)

Ticagrelor: 180-mg loading dose, then 90 mg twice daily (Level of Evidence: B)

Ticagrelor in preference to clopidogrel in NSTEMI patient treatedwith early invasive or ischemia guided strategy (Level of Evidence:B)


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Anticoagulant

Low Molecule Weight Heparin

Fondaparinux

Unfractionated Heparin

Bivalirudin

Cholesterol Therapy


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(Ezra et al,AHA ACC 2014)


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Case 60 year old male with history of DM2 for 20 years, HTN,

Smoking and 3 days ago he has Chest pain which was

described as in the anterior chest and radiation to the left

arm. 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


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Case


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What will you do?

What’s your diagnosis?

What should be done now?


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Conclusion - Unstable Angina and NSTEMI

- Caused of UA and NSTEMI

- Diagnosis : Anamnesa, Physical Examination,ECG,

Cardiac Marker .

- Stratification risk

- UA and NSTEMI with hight Risk Revascularisation

and Medical therapy


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THANK

YOU

Unstable Angina - NSTEMI - Muhammad Aminuddin, MD, FIHA.pdf

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