Medically managed acs

patient
Case presentation

Case
54 year old male with history of DM2 for 20 years, HTN, who
presented to the ED with 4 hour onset of chest pain which
was described as in the anterior chest without radiation. The
pain seemed to improve when he sits down and worsening
when he walked upstairs
VS: T 36.9, HR: 105, BP: 135/86, RR 22, O2 sat. 99% RA
ECGs are shown as followed

 What will you do?

Whats your diagnosis?
What should be done now?

Acute Coronary Syndrome

Definition: a constellation of symptoms related to
obstruction of coronary arteries with chest pain being
the most common symptom in addition to nausea,
vomiting, diaphoresis etc.
Chest pain concerned for ACS is often radiating to the
left arm or angle of the jaw, pressure-like in character,
and associated with nausea and sweating. Chest pain is
often categorized into typical and atypical angina.

EKG
STEMI:
Q waves , ST elevations, hyper acute T waves; followed by T wave
inversions.
Clinically significant ST segment elevations:
> than 1 mm (0.1 mV) in at least two anatomical contiguous leads
or 2 mm (0.2 mV) in two contiguous precordial leads (V2 and V3)

Note: LBBB and pacemakers can interfere with diagnosis of MI on EKG

Cardiac Enzymes
Troponin is primarily used for diagnosing MI because it has
good sensitivity and specificity.
CK-MB is more useful in certain situations such as post
reperfusion MI or if troponin test is not available
Other conditions can cause elevation in troponin such as
renal failure or heart failure
The increasing troponin trend is the important thing to look
for in diagnosing MI. Order Troponin together with ECG
when doing serial testing to rule out ACS.

Recommendations For Initial Diagnosis

European Heart Journal (2012) 33, 25692619

Diagnosis

A summary of important delays and

treatment goals in the management of acute
ST-segment elevation myocardial infarction

Early response: treatment is time

critical
Time from symptom onset and likely outcome
< 1 hour
Aborted heart attack or only little heart muscle damage
12 hours
Minor heart muscle damage only
24 hours
Some heart muscle damage with moderate heart muscle salvage
46 hours
Significant heart muscle damage with only minor heart muscle salvage

612 hours
No heart muscle salvage (permanent loss) with potential infarct
healing benefit
> 12 hours
Reperfusion is not routinely recommended if the patient is
asymptomatic and haemodynamically stable

In cases of major delay to hospitalisation (> 30 minutes) ambulance crews should consider prehospital fibrinolysis.

Recommendations for reperfusion therapy

Choice of reperfusion therapy

In general, PCI is the treatment of choice, providing it can be performed

promptly by a qualified interventional cardiologist in an appropriate

facility.1
All PCI facilities should be able to perform primary angioplasty within

90 minutes of patient presentation.

Fibrinolysis should be considered early if PCI is not readily available.

Reference
1. Acute Coronary Syndrome Guidelines Working Group. Guidelines for the management of acute coronary syndromes 2006. Med J Aust 2006; 184(8 Suppl):S929.

STEMI Management
Initial management for STEMI:
Cardiac monitor
Supplemental O2
Good IV access
Nitrates*
Beta blocker
Morphine
Clopidogrel
Aspirin
Call expert

Bleeding Risk
The following risk factors should be considered when assessing bleeding risk and choosing
antithrombotic therapies in patients with ACS (Grade B):

age > 75 years

female
history of bleeding
history of stroke or transient ischaemic attack (TIA)
creatinine clearance rate < 60 mL/min
diabetes
heart failure
tachycardia
blood pressure < 120 mmHg or 180 mmHg
peripheral vascular disease (PVD)
anaemia
concomitant use of GP IIb/IIIa inhibitor
enoxaparin 48 hours prior
switching between unfractionated heparin and enoxaparin
procedural factors (femoral access, prolonged, intra-aortic balloon pump, right heart
catheterisation).

Fibrinolysis
Fibrinolysis is the administration of a pharmacologic agent to break down blood clots in the
coronary vessels to restore blood flow to the heart muscle. 1

Consider early routine revascularisation of patients receiving fibrinolysis, regardless of success

of pharmacologic reperfusion (Grade A).

Absolute contraindications

Active bleeding or bleeding diathesis (excluding menses).

Significant closed head or facial trauma within 3 months.

Suspected aortic dissection.

Any prior intracranial haemorrhage.

Ischaemic stroke within 3 months.

Known structural cerebral vascular lesion.

Known malignant intracranial neoplasm.

Reference
1. Dugdale DC , Chen Y-B, Zieve D, et al. Fibrinolysis primary or secondary fibrinolysis. Available from: http://www.nlm.nih.gov/medlineplus/ency/article/000577.htm. Accessed 7
August 2011.

FIBRINOLYSIS
Relative contraindications

Current use of anticoagulants.

Non-compressible vascular punctures.

Recent major surgery (< 3 weeks).

Traumatic or prolonged (> 10 mins) CPR.

Recent internal bleeding (within 4 weeks).

Active peptic ulcer.

History of chronic, severe, poorly controlled hypertension.

Severe uncontrolled hypertension on presentation (systolic 180 mmHg or

diastolic 110 mmHg).

Ischaemic stroke > 3 months ago, dementia or known intracranial abnormality.

Pregnancy.

Doses of fibrinolytic agents

Fibrinolitic therapy

Doses of antiplatelet & antithrombin

co-therapies

Management of hyperglycaemia in
ST-segment elevation myocardial infarction

Checklist of treatments when an ACS

diagnosis appears likely

Measures checked at discharge

Thank You