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SYN D R O M E
Inferior W allM I
Anterior Wall MI
(Left Ventricle) =
Left Anterior
Descending Artery
Blockage
LateralW allM I
Lateral Wall =
Circumflex Artery
Blockage
O bjectives
Define & delineate acute coronary
syndrome
Review Management Guidelines
Unstable Angina / NSTEMI
STEMI
initiatives
Scope ofProblem
(2004 stats)
CHD single leading
in 2004
recurrent coronary
attacks per year
Diabetes Mellitus
Dyslipidemia
Family History
Similar pathophysiology
Non-ST-Segment
Elevation MI
(NSTEMI)
ST-Segment
Elevation MI
(STEMI)
STEMI requires
evaluation for acute
reperfusion intervention
Distruption of coronary
D iagnosis ofAcute M I
STEM I/N STEM I
At least 2 of the
following
Ischemic
symptoms
Diagnostic ECG
changes
Serum cardiac
marker elevations
D iagnosis ofAngina
Typical anginaAll three of the
following
Atypical angina
2 of the above criteria
of angina
Increased in severity or duration
Has onset at rest or at a low level of exertion
Unrelieved by the amount of nitroglycerin or
rest that had previously relieved the pain
Unstable
Angina
Non
occlusive
thrombus
Non specific
ECG
Normal
cardiac
enzymes
Occluding
thrombus
sufficient to
cause
tissue damage &
mild
myocardial
necrosis
NSTEMI
ST depression
+/T wave inversion
on
ECG
Elevated cardiac
enzymes
STEMI
Complete thrombus
occlusion
ST elevations on
ECG or new LBBB
Elevated cardiac
enzymes
More severe
symptoms
Evaluation
Efficient & direct history
Initiate stabilization
interventions
Occurs
simultaneo
usly
labs
and tests
12 lead ECG
Obtain initial
cardiac
enzymes
electrolytes,
cbc lipids,
bun/cr,
glucose,
coags
care
IV access
Cardiac
monitorin
g
Oxygen
Aspirin
Nitrates
&
Physical
Establish
diagnosis
Read ECG
Identify
complicati
ons
Assess for
reperfusio
Focused H istory
Aid in diagnosis and
factors
Quality of discomfort
Radiation
Symptoms associated
with discomfort
Cardiac risk factors
Past medical history
-especially cardiac
Reperfusion
questions
Timing of
presentation
ECG c/w STEMI
Contraindication to
fibrinolysis
Degree of STEMI
risk
Targeted Physical
Examination
Vitals
Cardiovascular
system
Respiratory
system
Abdomen
Neurological
status
Recognize factors
NSTEMI
Non-specific ECG
Unstable Angina
ST D epression or D ynam ic T
w ave Inversions
N ew LBBB
Cardiac m arkers
Troponin ( T, I)
CK-MB isoenzyme
Rises 4-6 hours after
Mortality at 42 Days
%
%
%
%
%
831
174
148
134
50
67
Risk Stratifi
cation
YES
STEMI
Patient?
- Assess for
reperfusion
- Select &
implement
reperfusion
therapy
- Directed medical
therapy
Based on initial
Evaluation, ECG, and
Cardiac markers
NO
UA or NSTEMI
- Evaluate for
Invasive vs.
conservative
treatment
- Directed medical
therapy
Fibrinolysis indications
ST segment elevation >1mm in two
contiguous leads
New LBBB
Symptoms consistent with ischemia
Symptom onset less than 12 hrs prior
to presentation
(primary or metastatic)
Ischemic stroke within 3 months EXCEPT acute
ischemic stroke within 3 hours
Suspected aortic dissection
Active bleeding or bleeding diathesis (excluding
menses)
Significant closed-head or facial trauma within 3
months
strategy
Fibrinolysis
preferred if:
PCI available
Door to balloon <
90min
Door to balloon
minus door to
needle < 1hr
Fibrinolysis
contraindications
Late Presentation >
3 hr
High risk STEMI
Killup 3 or higher
M edicalTherapy
M O N A + BAH
Morphine (class I, level C)
Analgesia
Reduce pain/anxietydecrease sympathetic
tone, systemic vascular resistance and oxygen
demand
Careful with hypotension, hypovolemia,
respiratory depression
(class I, level A)
Irreversible inhibition of platelet aggregation
Stabilize plaque and arrest thrombus
Reduce mortality in patients with STEMI
Careful with active PUD, hypersensitivity,
bleeding disorders
hospital discharge
and/or
High
Intermediate
INTERMEDIATE
likelihood of ACS in
absence of highlikelihood findings
Findings indicating
LOW likelihood of ACS
in absence of high- or
intermediate-likelihood
findings
History
Probable ischemic
symptoms
Recent cocaine use
Physical
examination
Extracardiac vascular
disease
Chest discomfort
reproduced by palpation
ECG
Fixed Q waves
Abnormal ST segments or
T waves not documented
to be new
T-wave flattening or
inversion of T waves in
leads with dominant R
waves
Normal ECG
Serum cardiac
markers
Normal
Normal
Intermediate Risk
ACS
Moderate to high likelihood
of CAD
>10 minutes rest pain,
now resolved
T-wave inversion > 2mm
Slightly elevated cardiac
markers
Low
risk
Intermediate
risk
High
risk
Chest Pain
center
Conserva
tive
therapy
Invasive
therapy
revascularization within 12 to 48
hours after presentation to ED
For high risk ACS (class I, level A)
MONA + BAH (UFH)
Clopidogrel
20% reduction death/MI/Stroke CURE trial
1 month minimum duration and possibly up
to 9 months
planned
MONA + BAH (LMW or UFH)
Clopidogrel
Glycoprotein IIb/IIIa inhibitors
Only in certain circumstances (planning PCI,
elevated TnI/T)
Surveillence in hospital
Serial ECGs
Serial Markers
Secondary Prevention
Disease
HTN, DM, HLP
Behavioral
smoking, diet, physical activity, weight
Cognitive
Education, cardiac rehab program
Secondary Prevention
disease m anagem ent
Blood Pressure
Goals < 140/90 or <130/80 in DM /CKD
Maximize use of beta-blockers & ACE-I
Lipids
LDL < 100 (70) ; TG < 200
Maximize use of statins; consider
Diabetes
A1c < 7%
Secondary prevention
behavioralintervention
Smoking cessation
Cessation-class, meds, counseling
Physical Activity
Goal 30 - 60 minutes daily
Risk assessment prior to initiation
Diet
DASH diet, fiber, omega-3 fatty acids
<7% total calories from saturated fats
M edication Checklist
after ACS
Antiplatelet agent
Statin*
Fibrate / Niacin / Omega-3
Antihypertensive agent
Beta blocker*
ACE-I*/ARB
Aldactone (as appropriate)
REPERFUSIO N STRATEGY
FIBRIN O LYTICS
AVAILABLE FIBRINOLYTICS:
STREPTOKINASE 1.5mu infusion over 30min (1hour ACLS)
rtPA accelerated infusion over 1.5hrs
- 15mg IV bolus, 0.75mg/kg over 30 min, 0.5mg/kg over
1hr
ANISTREPLASE 30 U IV over 5 min
TENECTEPLASE 30 TO 50 MG
RETEPLASE 10 U IV bolus, ffd. 10U IV after 30 min
WHICH FIBRINOLYTIC TO USE???
GISSI 2 trial tPA vs Streptokinase , no difference in
mortality, marginally higher stroke rate with tPA (1.3% vs 1%)
GUSTO 1 trial early vessel patency post infract assoc. with
better survival.
Accl. tPA/heparin cf comb. Streptokinase/tPA/heprain cf strep
with IV vs S/C heparin
Outcome better flow rates with accl. tPA -> lower mortality
rates
Prevention new s
From 1994 to 2004 the death
rate from coronary heart disease
declined33%...
But the actual number of deaths
declined only18%
Getting better with
treatment
But more patients developing
disease need for primary
prevention focus
Sum m ary
ACS includes UA, NSTEMI, and STEMI
Management guideline focus
Immediate assessment/intervention
(MONA+BAH)
Risk stratification (UA/NSTEMI vs. STEMI)
RAPID reperfusion for STEMI (PCI vs.
Thrombolytics)
Conservative vs Invasive therapy for
UA/NSTEMI
Question
&
Answer