What you need to know

Acute Coronary Syndrome

Identify who has ACS ( hx /PE/ ECG/labs) STEMI vs UAP/NSTEMI Risk stratify the rest General measures Specific tx modalities( PCI for STEMI) Mx complications( arrhythmias/pump failure)

ACS 1 May 2011

ACS 1 May 2011

Case Scenario
55/m/ hpt/DM/smoker 1 hr of anterior compressive chest pain + diaphoresis Radiating to jaw BP: 150/100 PR 85 sats 95% RR: 15 H/L- NAD How do you approach this patient?

Acute Coronary Syndrome

The spectrum of clinical conditions ranging from: unstable angina NSTEMI STEMI characterized by the common pathophysiology of a disrupted atheroslerotic plaque

ACS 1 May 2011

ACS 1 May 2011

Definition of Coronary Artery Disease

Clinical Presentation of ACS

-Classical features -Angina equivalent - dyspnea (LV failure) - arrhythmia, faint, tiredness -Autonomic features -Atypical chest pain - musculoskeletal, pleuritic features etc

CAD

IHD

Acute coronary syndrome

All patients with coronary artery atherosclerosis

Cardiac disease as a result of myocardial ischemia (imbalance between oxygen requirements and supply)

1. Unstable angina 2. Non-ST elevation MI 3. ST elevation MI

ACS 1 May 2011

ACS 1 May 2011

Unstable Angina
Rest Angina New-onset Angina Increasing Angina
Occurrence of angina Class I : Strenuous, rapid or prolonged exercise Class II : Slight limitation of ordinary activity Class III : Mark limitation of ordinary physical activity Class IV : At rest
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Unstable Angina - Definition

angina at rest (> 20 minutes) new-onset (< 2 months) exertional angina (at least CCSC III in severity) recent (< 2 months) acceleration of angina (increase in severity of at least one CCSC class to at least CCSC class III)
Canadian Cardiovascular Society Classification Agency for Health Care Policy Research - 1994

ACS 1 May 2011

Definition of AMI
Necrosis of a portion of heart muscle due to inadequate blood supply

Based on history Pain > 15 minutes Crushing, chocking, tight; substernal Unrelieved by rest or nitroglycerin Radiation to arms, neck, back, jaw, epigastrium Associated sighs: diaphoresis, shortness of breath, anxiety Feeling of impending doom, death

Diagnosis: Clinical Investigations

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ACS 1 May 2011

Complications of UA, AMI

Evolving AMI Congestive heart failure Malignant arrhythmia bradyarrhythmia, tachyarrhythmia
Pain > 15 mins crushing, tight Unrelieved by rest or GTN Radiation of pain Associated signs : diaphoresis, shortness of breath, anxiety, impending doom

Pulmonary edema Cardiogenic shock

ACS 1 May 2011

ACS 1 May 2011

Ischemic Chest Pain Algorithm

The first healthcare providers to encounter the ACS pt can have a big impact on pts outcome Reduce myocardial necrosis Prevent and treat major complications e.g. VF, VT, pulm edema, shock, unstable bradyarrhythmia or tachyarrhythmia Reduce subsequent heart failure, death
Chest pain suggestive of ischaemia

Immediate assessment (<10 minutes) Measure vital signs (automatic/standard BP cuff) Measure oxygen saturation Obtain IV access Obtain 12-lead ECG (physician reviews) Perform brief, targeted history and physical exam; focus on eligibility for fibrinolytic therapy Obtain initial serum cardiac marker levels Evaluate initial electrolyte and coagulation studies Request, review portable chest x-ray (<30 minutes)

Immediate general treatment Oxygen at 4 L/min Aspirin 160 to 325 mg Nitroglycerin SL or spray Morphine IV (if pain not relieved with nitroglycerin) Memory aid: MONA greets all patients (Morphine, Oxygen, Nitroglycerin, Aspirin)

EMS personnel can perform immediate assessment and treatment (MONA), including initial 12lead ECG and review for fibrinolytic therapy indications and contraindications.

Assess initial 12-lead ECG

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Items of Immediate Assessment (<10 min)

Based on ECG
Check vital signs with automatic or standard BP cuff Determine oxygen saturation Obtain IV access Obtain 12-lead ECG Obtain a brief, targeted history and perform a physical examination; use checklist (yes-no); focus on eligibility for fibrinolytic therapy Obtain blood sample for initial cardiac marker levels Initiate electrolyte and coagulation studies
ST depression > 0.5 mm or dynamic T inversion ( UA or NSTEMI )

Normal ECG does not rule out AMI When in doubt, repeat the ECG 15 min to 30 min later
2 adjacent leads with > 1mm ST segment elevation, or new LBBB ( STEMI )

ACS 1 May 2011

ACS 1 May 2011

Assess Initial 12-Lead ECG Findings

ST elevation or new or presumably new LBBB: strongly suspicious for injury ST-elevation AMI

ST depression or dynamic T-wave inversion: strongly suspicious for ischaemia High-risk unstable angina/ nonST-elevation AMI

Nondiagnostic ECG: absence of changes in ST segment or T waves Intermediate/low-risk unstable angina

Classify patients with acute ischaemic chest pain into 1 of the 3 groups above within 10 minutes of arrival.
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AMI Localization
Based on biomarkers Cardiac enzymes e.g. CK-MB, troponin T or I Insensitive during the first 4-6 hrs of presentation. Hence may need serial testing
I lateral II inferior III inferior
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aVR aVL lateral aVF inferior

V1 septal V2 septal V3 anterior

V4 anterior V5 lateral V6 lateral

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Troponin elevation correlates with increased risk of adverse outcome, increased thrombus burden & microvascular embilization, increased risk of death

As it takes time for biomarkers to appear, an early, normal level does not exclude AMI

Pts with normal or non-diagnostic ECG with symptoms of ACS usually are at low risk or intermediate risk Aims: to risk stratify with diagnostic tests and to provide appropriate Rx e.g. cardiac biomarkers, TMX, stress echo, sestaMIBI scan

ACS 1 May 2011

ACS 1 May 2011

Immediate General Treatment

Oxygen at 4 L/min Aspirin 300mg Nitroglycerin SL Morphine IV (if pain not relieved with nitroglycerin)

Pts with STEMI usually have complete occlusion of an epicardial coronary artery Mainstay of treatment is reperfusion Rx fibrinolytics, or primary PCI Aims:rapidly identify pts with STEMI quickly screen them for indications or contraindications for reperfusion therapy

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ACS 1 May 2011

Thrombolytic Agents Currently available

- Streptokinase - Recombinant tissue plasminogen activator (r-TPA) - APSAC (anisoylated plasminogen-streptokinase activator complex)

Eligibility Criteria for Thrombolytic Therapy

C ntraindications

Active internal bleeding Suspected aortic dissection Significant head injury within 3 months Intracranial neoplasm or hemorrhage or AVM Stroke < 3 months History bleeding diathesis

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ACS 1 May 2011

Eligibility Criteria for Thrombolytic Therapy

Relative Contraindications
Recent trauma or major surgery < 3 months Traumatic or prolonged (>10 mins) CPR Pregnancy Severe HT (BP >180/110 mmHg) Recent internal bleeding > 1 month Active peptic ulcer disease Stroke > 3 months Current use of warfarin Significant liver or renal dysfunction
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Pts with UA or NSTEMI usually have critical but incomplete occlusion of an epicardial coronary artery

Mainstay of treatment is not fibrinolysis, But optimized medical therapy, or early invasive strategies

Symptoms & signs of ACS & suggestive ECG Symptoms & signs of ACS Pain Rx: Rx: nitrate, morphine Antiplatelets Rx Other or normal ECG STEMI NSTEMI / UAP

12 lead ECG ST elevation > 0.1 mV in > 2 adjacent limb leads > 0.2 mV in > 2 adjacent chest limbs

Thrombolysis Raised cardiac enzymes + ve Normal cardiac - ve enzymes UAP

Sx < 3 hrs & PCI delay > 60 mins No contraindication & PCI delay > 90 mins

PC I
Sx < 3 hrs & PCI delay < 60 mins Sx > 3 hrs & PCI delay < 90 mins Cardiogenic shock within 36 hrs

Early invasive

Delayed invasive, or conservative

STEMI
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NSTEMI

heparin

heparin Gp IIb/IIIa

heparin Gp IIb/IIIa

heparin Gp Iib/IIIa

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Initial general therapy (1)

M O N A Morphine Oxygen Nitrates ( S/L, aerosol spray, I.V.) Aspirin

Initial general therapy (2)

Clopidogrel b-blockers Heparin (unfractionated, low-molecular-weight) Glycoprotein IIb / IIIa

ACE inhibitors Statins

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Initial general therapy (3)

Management of rhythm disturbances
VT, VF Asystole, heart blocks Bradyarrhythmia Tachyarrhythmia narrow complex broad complex Management of pump complications/valve rupture

Case scenario:
55/m/ hpt/DM/smoker 1 hr of anterior compressive chest pain + diaphoresis Radiating to jaw BP: 150/100 PR 85 sats 95% RR: 15 H/L- NAD How do you approach this patient?

ACS 1 May 2011

ACS 1 May 2011

What Does This 12-Lead ECG Show?

I II III aVR aVL aVF V1 V2 V3 V4 V5 V6

What Does This 12-Lead ECG Show?

I II III aVR aVL aVF V1 V2 V3 V4 V5 V6

II

II

ACS 1 May 2011

ACS 1 May 2011

What Does This 12-Lead ECG Show?

I II III aVR aVL aVF V1 V2 V3 V4 V5

What Does This 12-Lead ECG Show?

I II aVR aVL aVF V1 V2 V3 V4 V5 V6

V6

III

II II

ACS 1 May 2011

ACS 1 May 2011

What Does This 12-Lead ECG Show?

I II III aVR aVL aVF V1 V2 V3 V4 V5 V6

II

ACS 1 May 2011