Acute Coronary Syndrome

Objectives
The healthcare professional will have the ability to list the three classes of Acute Coronary Syndrome. The healthcare professional will have the ability to list the appropriate acute interventions needed for a patient symptomatic for Acute Coronary Syndrome. The healthcare professional will have the ability to list at least three differential diagnosis of chest pain. The healthcare professional will be able to list four diagnostic tests needed for a patient symptomatic for Acute Coronary Syndrome.

Acute Coronary Syndrome includes the following diagnoses:

ST elevation MI (STEMI) Non ST elevation MI (NSTEMI)

Unstable Angina (UA)

Stable Angina
Stable Angina is not included in ACS
It is predictable
Is associated with activities such as physical activity, cold and even eating Usually last for 1-5 minutes and is relieved by rest Transient ST depression may be visible but disappears with pain relief

Unstable Angina
Considered to be unstable if presented in any of the following three ways:
Angina at rest lasting for more than 20 minutes New onset angina that markedly limits physical activity

Increasing angina that is more frequent, lasts longer, or occurs with less exertion than previous angina

Symptoms of unstable angina

Substernal pain/pressure radiating to the jaws and down arms Nausea Dyspnea Diaphoresis Nitroglycerin may not give total relief of symptoms

NSTEMI vs. UA
NSTEMI and UA can at times only be discernible by the presence of positive serum biomarkers such as cpk-mb and Troponin. Consider data from 12 lead Diagnosis of NSTEMI versus UA until proven otherwise

Disposition of UA and NSTEMI may be determined by their TIMI score.

Time Course for cardiac enzymes

Test CPK-MB Troponin Onset Peak 3-12 hours 18-24 hours 3-12 hours 18-24 hours Duration 36-48 hours Up to 10 days

NSTEMI and UA
Ischemic ST-segment depression > 0.5mm Dynamic T-wave inversion with pain or discomfort Nonpersistent or transient ST-segment elevation > 0.5 mm for < 20 minutes

TIMI
Early risk stratification for UA and NSTEMI
TIMI 11B and ESSENCE trials

Seven variables predictive of outcomes

A TIMI score is determined by a list of 7 risk factors.

Age>65 Three or more cardiac risk factors Aspirin use in the last 7 days Two or more episodes of chest pain in the last 24 hr ST-segment deviation on presenting EKG Increased biomarkers Prior coronary artery stenosis > 50%

High risk patients have a TIMI score >5

Typically admitted to the ICU or telemetry depending on their hemodynamic state Patients with hemodynamic compromise or continued chest pain should undergo PCI.

Moderate Risk
TIMI score of 3-4 Can be admitted to the chest pain center or telemetry for further evaluation.

Low Risk TIMI

TIMI score of <2 and no other concerning features of their presentation can be considered for an abbreviated evaluation protocol Serial serum biomarkers Discharge with outpatient stress testing within 72 hours Serial EKGs

 The AHA classifies a STEMI as ST-segment elevation or presumed new Left Bundle Branch Block (LBBB)

ST segment elevation Myocardial Infarction (STEMI)

STEMI is characterized by ST-segment elevation >1mm in 2 or more contiguous precordial leads or 2 or more adjacent limb leads

Contiguous Leads
Area of infarction
Inferior

Leads Associated
II, III, & AVF; ST elevation

Vessels Involved
Right coronary artery, Left circumflex Proximal Right Coronary artery, Left circumflex

Posterior

V1, V2, V3 ST depression; Large R waves

Anterior Lateral

V1, V2, V3, V4;ST elevation V1, AVL, V5, V6;ST elevation

Left Anterior descending Left Circumflex

Right Ventricular

Elevation II < III, AVF,V1;Large R V4

Proximal right coronary artery

Physical signs of STEMI

Severe chest discomfort but may include discomfort in other areas of the upper body Shortness of breath Sweating Dizziness Usually intense lasting for more then 15 minutes

Treatment of Patients with Acute Coronary Syndrome

Should be rapid

STEMI should be the presumed diagnosis until proven other wise with serial EKGs and cardiac markers.

Initial treatment should include

ABCs Maintain a saturation above 90% Administer O2 to all patients with chest pain for the first 6 hours 12 lead EKG

12 Leads
First 10 minutes of the patients presentation and presented to an experienced physician
If the first ECG is not clearly diagnostic and patient is still symptomatic a 12-lead should be repeated

Inferior wall MI
Affecting the RV Sensitive to nitrates

Susceptible to hypotension
Elevations in leads II, III and AVF Consider a right sided EKG

Right Sided EKG

Move the V3, V4, V5 and V6 leads to the mirrored right sided position of the chest
Be certain to label this EKG as right sided.

Right Sided EKG

Posterior MI
If depression is noted in leads V1, V2, and V3 with large R waves a posterior EKG is recommended to diagnose a posterior MI

V4 is placed at the left posterior axillary line, V5 is on the border of the left scapula and V6 is near the spine
Re-label the EKG V7, V8 and V9 posterior view

Dont forget
Resuscitation equipment
Two large bore IVs Bedside monitor

Initial Testing
CBC Differential CPK-MB Troponin PT PTT Comprehensive metabolic profile CXR

Remember MONA
Oxygen Aspirin

Nitroglycerin
Morphine

Aspirin
Dose 4--81mg baby aspirin Contraindication could include allergy or suspect for AAA Clarify a documented allergy to aspirin as true allergy or sided effect and discuss with physician

Nitroglycerin
Effective treatment for the pain associated with ischemic chest pain Dilation of coronary arteries 0.4 mg every 5 minutes until pain free or a total of three

Use Nitrates with caution

Do not use if blood pressure is less than 90 systolic Systolic blood pressure is < 30 of baseline Caution with bradycardia and hypotension Inferior wall MI may have inadequate preload use with caution

Avoid nitrates in patients who take medicines for erectile dysfunction

Phosphodiesterase-5 inhibitors are:
Viagra (sildenafil) Levitra (vardenafil) Cialis (tadalafil)
May lead to severe hypotension
Patients may be reluctant to include with medication reconciliation

Morphine
For patients with ACS that are unresponsive to nitrates 2-4mg increments Analgesic for pain Reduce pulmonary congestion

Vasodilator that reduces oxygen requirements

Reduces preload

Clopidogrel (Plavix)
Reduces platelet aggregation through a different mechanism than aspirin Initial loading dose of 600mg for patients requiring primary PCI and stenting Ideally primary PCI should be done within 90 minutes of dosing

Heparin
Indirect inhibitor of thrombin Disadvantages: Frequent need for monitoring of PTT Unpredictable anticoagulation Need for IV administration Possibility of HIT (heparin induced thrombocytopenia)

LMW Heparins
Better outcomes than heparin in patient survival rates and frequency of ischemic complications

LMWH such as enoxaparin (Lovenox) is recommended for patients <75 years of age Creatinine levels should be monitored

Beta Blockers
Recommended for most patients with ST elevation MI Watch for signs of inadequate perfusion Beta blockers reduce the size of the infarct, reduce likelihood of cardiac rupture and reduce mortality They also reduce the incidence of VT and Vfib

Contraindications for Beta Blockers

Severe LV failure with pulmonary edema, HR <60bpm, SBP <100, Signs of poor peripheral perfusion 2nd degree heart block 3rd degree heart block Reactive airway disease Cocaine use

History and physical

Presenting symptoms Characteristic of pain associated with symptoms Past medical history Significant family history

Differential Diagnoses
AAA PE

Tension pneumothorax
Perforated peptic ulcer Esophageal rupture

Reperfusion Therapy
Percutaneous Coronary Intervention has been shown to be superior to fibrinolysis Considered if less than 12 hours has elapsed from the onset of symptoms The goal for PCI is less then 90 minutes from the time the patient seeks medical attention

Mortality rates for patients with AMI treated with PCI

Lower then those treated with fibrinolysis
Mortality rate at 6 months was significantly lower for patients with early PCI (50% vs. 63%) In the subgroup <75 years old early PCI had a 15% reduction in the 30 day mortality rate and improvement in the one year survival rate

Further Diagnostic Studies

Patients with persistent chest pain, a non-definitive 12 lead and negative cardiac enzymes may be a candidate for more definitive testing.

Resting Myocardium Perfusion Imaging

Injected thallium-201 and technetium-99m accumulates in myocardial tissue Ischemia will demonstrate a decreased radioactive count

Limitations of Resting Stress

Preexisting myocardial damage May be falsely negative if pain has resolved for more than three hours The acute rest imaging must be readily available.

References
Advanced Cardiovascular Life Support, American Heart Association, 2006

The Role of Invasive Therapy of Acute Myocardial Infarction after TIMI 11 B. Journal of Interventional Cardiology; Vol 2 Issue 1; pages 1-3; June 2007

Echocardiography
Exclude other potential diagnosis Aortic dissection

PE
Pericarditis with pericardial effusion

DC planning Per facility

Life style modifications Future risk education Aspirin prescribed at discharge Beta Blockers prescribed at discharge Dietary consult for education Smoking Cessation