Acute Coronary Syndrome

PI PROJECT 2011

LEARNING POINTS
Chest Pain Definition of ACS EKG

Cardiac Enzymes
Risk stratify Management

Chest Pain
Typical (~25%): Usually presents with a gradual onset,

provoked by activity but relieved by rest or nitroglycerin. It can be hard to localize and is retrosternal in nature; often radiating to the shoulders or arms, with associated diaphoresis, nausea, vomiting or shortness of breath. shortness of breath in the absence of pain; may present as heart failure, confusion, heartburn type pain, sharp or stabbing pain, reproducible pain, or pain in the jaw, neck, back, or left arm.

Atypical (~75%): Can present as silent ischemia, or as

Note: Atypical pain is more common in women, elderly, those with diabetes

Unstable Angina
Occurs at rest, usually lasting >20 minutes New angina that limits activity Pain that occurs more frequently, lasts longer

periods or is increasingly limiting the patients activity

Acute Coronary Syndrome

Patients who present with presumed ischemic chest

pain can be categorized based on their EKG and cardiac enzymes:

STEMI: ST elevation, elevated cardiac enzymes NSTEMI: ST depression, T-wave inversion, elevated cardiac enzymes Unstable Angina: Non specific EKG changes, normal cardiac enzymes

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.

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

EKG
NSTEMI: ST depressions or T wave inversions without Q waves. Isolated T wave inversions:
can correlate with increased risk for MI may represent Wellens syndrome: critical LAD stenosis >2mm inversions in anterior precordial leads

Angina: May present with nonspecific or transient ST segment depressions or elevations

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

Risk Stratify: TIMI

NSTEMI or unstable angina are risk stratified:

Age>=65 >= 3 CAD risk factors:

HTN, hyperlipidemia, diabetes, smoker, family hx of CAD

Documented CAD with >=50% stenosis ST segment deviation >=2 aginal episodes in past 24 hours Aspirin use in the past week Elevation of cardiac enzymes

Stratify risk based on number of variables Risk:

0-2: Low

3-4: Intermediate

5-7: High risk

NSTEMI & Unstable Angina Management

NSTEMI or EKG changes suggest ischemia with high risk: Telemetry Aspirin Beta blocker Nitrates Heparin (UFH or LMWH) ACE-I/ARB Statin Consider GP IIb/IIIa inhibitor and clopidogrel EKG normal or non-specific changes with intermediate or low

risk:

Telemetry Rule out ACS with 3 sets of troponin, EKG Consider pre-discharge stress test

STEMI Management
STEMI patients usually go straight to the cath lab from

the ED. However if your patient develops a STEMI, the initial management includes:

Place on cardiac monitor Supplemental O2 Nitrates Beta blocker Morphine Clopidogrel Aspirin Good IV access Call the cardiology fellow!

Circulation 2005;112:IV-89-IV-110
Copyright 2005 American Heart Association

References

2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2005;112:IV-89-IV-110 2011 ACCF/AHA Focused Update of the Guidelines for the Management of Patients with Unstable Angina/Non-ST Elevation MI; J. Am. Coll. Cardiol. 2011;57;1920-1959:
http://content.onlinejacc.org/cgi/content/full/57/19/1920

www.uptodate.com:

Overview of the acute management of unstable angina and acute non-ST elevation myocardial infarction Management of suspected acute coronary syndrome in the emergency department Criteria for the diagnosis of acute myocardial infarction