Professional Documents
Culture Documents
Syndrome Syndrome
Rich Derby, Lt Col, USAl Rich Derby, Lt Col, USAl
MGMC lamily Practice Program MGMC lamily Practice Program
-ectives -ectives
Deine & delineate acute coronary syndrome Deine & delineate acute coronary syndrome
Reiew Management Guidelines Reiew Management Guidelines
Unstable Angina , NS1LMI Unstable Angina , NS1LMI
S1LMI S1LMI
Reiew secondary preention initiaties Reiew secondary preention initiaties
Scope of Pro-em Scope of Pro-em
(2004 stats) (2004 stats)
ClD single leading cause o ClD single leading cause o
death in United States death in United States
452,32 deaths in the U.S. in 2004 452,32 deaths in the U.S. in 2004
1,200,000 new & recurrent 1,200,000 new & recurrent
coronary attacks per year coronary attacks per year
38 o those who with 38 o those who with
coronary attack die within a year coronary attack die within a year
o haing it o haing it
Annual cost >300 billion Annual cost >300 billion
panding Risk Iactors panding Risk Iactors
Smoking Smoking
lypertension lypertension
Diabetes Mellitus Diabetes Mellitus
Dyslipidemia Dyslipidemia
Low lDL 40 Low lDL 40
Lleated LDL , 1G Lleated LDL , 1G
lamily listory lamily listory- -eent in eent in
irst degree relatie irst degree relatie 55 55
male,65 emale male,65 emale
Age Age-- -- 45 or male,55 45 or male,55
or emale or emale
Chronic Kidney Disease Chronic Kidney Disease
Lack o regular physical Lack o regular physical
actiity actiity
Obesity Obesity
Lack o Ltoh intake Lack o Ltoh intake
Lack o diet rich in ruit, Lack o diet rich in ruit,
eggies, iber eggies, iber
Acute Coronary Syndromes Acute Coronary Syndromes
Similar pathophysiology Similar pathophysiology
Similar presentation and Similar presentation and
early management rules early management rules
S1LMI requires ealuation S1LMI requires ealuation
or acute reperusion or acute reperusion
interention interention
Unstable Angina Unstable Angina
Non Non--S1 S1--Segment Segment
Lleation MI Lleation MI
,NS1LMI, ,NS1LMI,
S1 S1--Segment Segment
Lleation MI Lleation MI
,S1LMI, ,S1LMI,
iagnosis of Acute MI iagnosis of Acute MI
S1MI / NS1MI S1MI / NS1MI
At least 2 o the ollowing At least 2 o the ollowing
Ischemic symptoms Ischemic symptoms
Diagnostic LCG Diagnostic LCG
changes changes
Serum cardiac marker Serum cardiac marker
eleations eleations
iagnosis of Angina iagnosis of Angina
1ypical angina 1ypical angina--All three o the ollowing All three o the ollowing
Substernal chest discomort Substernal chest discomort
Onset with exertion or emotional stress Onset with exertion or emotional stress
Relie with rest or nitroglycerin Relie with rest or nitroglycerin
Atypical angina Atypical angina
2 o the aboe criteria 2 o the aboe criteria
Noncardiac chest pain Noncardiac chest pain
1 o the aboe 1 o the aboe
iagnosis of Unsta-e Angina iagnosis of Unsta-e Angina
Patients with typical angina Patients with typical angina -- An episode o angina An episode o angina
Increased in seerity or duration Increased in seerity or duration
las onset at rest or at a low leel o exertion las onset at rest or at a low leel o exertion
Unrelieed by the amount o nitroglycerin or rest that had Unrelieed by the amount o nitroglycerin or rest that had
preiously relieed the pain preiously relieed the pain
Patients not known to hae typical angina Patients not known to hae typical angina
lirst episode with usual actiity or at rest within the lirst episode with usual actiity or at rest within the
preious two weeks preious two weeks
Prolonged pain at rest Prolonged pain at rest
Unstable Unstable
Angina Angina
S1LMI S1LMI
NS1LMI NS1LMI
Non occusive
throm-us
Non specific
CG
Norma cardiac
enzymes
ccuding throm-us
sufficient to cause
tissue damage & mid
myocardia necrosis
S1 depression +/-
1 wave inversion on
CG
evated cardiac
enzymes
Compete throm-us
occusion
S1 eevations on
CG or new LBBB
evated cardiac
enzymes
More severe
symptoms
Acute Management Acute Management
Initial ealuation & Initial ealuation &
stabilization stabilization
Licient risk Licient risk
stratiication stratiication
locused cardiac care locused cardiac care
vauation vauation
Licient & direct history Licient & direct history
Initiate stabilization interentions Initiate stabilization interentions
Plan or moing rapidly to Plan or moing rapidly to
indicated cardiac care indicated cardiac care
irected 1herapies
are
1ime Sensitive!
ccurs ccurs
simutaneousy simutaneousy
Chest pain suggestive of ischemia Chest pain suggestive of ischemia
12 lead LCG 12 lead LCG
Obtain initial Obtain initial
cardiac enzymes cardiac enzymes
electrolytes, cbc electrolytes, cbc
lipids, bun,cr, lipids, bun,cr,
glucose, coags glucose, coags
CXR CXR
Immediate assessment within 10 Minutes
Lstablish Lstablish
diagnosis diagnosis
Read LCG Read LCG
Identiy Identiy
complications complications
Assess or Assess or
reperusion reperusion
Initial labs Initial labs
and tests and tests
Lmergent Lmergent
care care
listory & listory &
Physical Physical
IV access IV access
Cardiac Cardiac
monitoring monitoring
Oxygen Oxygen
Aspirin Aspirin
Nitrates Nitrates
Iocused History Iocused History
Aid in diagnosis and rule Aid in diagnosis and rule
out other causes out other causes
Palliatie,Proocatie Palliatie,Proocatie
actors actors
Quality o discomort Quality o discomort
Radiation Radiation
Symptoms associated Symptoms associated
with discomort with discomort
Cardiac risk actors Cardiac risk actors
Past medical history Past medical history --
especially cardiac especially cardiac
Reperusion questions Reperusion questions
1iming o presentation 1iming o presentation
LCG c,w S1LMI LCG c,w S1LMI
Contraindication to Contraindication to
ibrinolysis ibrinolysis
Degree o S1LMI risk Degree o S1LMI risk
1argeted Physica 1argeted Physica
Recognize actors that Recognize actors that
increase risk increase risk
lypotension lypotension
1achycardia 1achycardia
Pulmonary rales, JVD, Pulmonary rales, JVD,
pulmonary edema, pulmonary edema,
New murmurs,heart sounds New murmurs,heart sounds
Diminished peripheral Diminished peripheral
pulses pulses
Signs o stroke Signs o stroke
Lxamination Lxamination
Vitals Vitals
Cardioascular Cardioascular
system system
Respiratory system Respiratory system
Abdomen Abdomen
Neurological status Neurological status
CG assessment CG assessment
S1 Lleation or new LBBB S1 Lleation or new LBBB
S1LMI S1LMI
Non Non--speciic LCG speciic LCG
Unstable Angina Unstable Angina
S1 Depression or dynamic S1 Depression or dynamic
1 wae inersions 1 wae inersions
NS1LMI NS1LMI
Norma or non Norma or non- -diagnostic G diagnostic G
S1 epression or ynamic 1 wave S1 epression or ynamic 1 wave
Inversions Inversions
S1 S1- -Segment evation MI Segment evation MI
New LBBB New LBBB
QRS > 0.12 sec
L Axis deviation
Prominent R wave V1-V3
Prominent S wave 1, aVL, V5-V6
with t-wave inversion
Cardiac markers Cardiac markers
1roponin , 1, I, 1roponin , 1, I,
Very speciic and more Very speciic and more
sensitie than CK sensitie than CK
Rises 4 Rises 4--8 hours ater 8 hours ater
injury injury
May remain eleated or May remain eleated or
up to two weeks up to two weeks
Can proide prognostic Can proide prognostic
inormation inormation
1roponin 1 may be 1roponin 1 may be
eleated with renal dz, eleated with renal dz,
poly,dermatomyositis poly,dermatomyositis
CK CK--MB isoenzyme MB isoenzyme
Rises 4 Rises 4--6 hours ater injury 6 hours ater injury
and peaks at 24 hours and peaks at 24 hours
Remains eleated 36 Remains eleated 36--48 48
hours hours
Positie i CK,MB 5 Positie i CK,MB 5
o total CK and 2 times o total CK and 2 times
normal normal
Lleation can be predictie Lleation can be predictie
o mortality o mortality
lalse posities with lalse posities with
exercise, trauma, muscle dz, exercise, trauma, muscle dz,
DM, PL DM, PL
Prognosis with 1roponin Prognosis with 1roponin
1.0
1.7
3.4
3.7
6.0
7.5
0
1
2
3
4
5
6
7
8
0 to <0.4 0.4 to <1.0 1.0 to <2.0 2.0 to <5.0 5.0 to <9.0 9.0
Cardiac troponin I (ng/mI)
M
o
r
t
a
I
i
t
y
a
t
4
2
D
a
y
s
831 174 148 134 50 67
K