Acute Coronary Syndrome MINI LECTURE Kelvin Nguyen 2016 Update: Ryan Burris

OBJECTIVES Understand the definition of ACS Be able to explain the differences between UA, NSTEMI, and STEMI Know how to risk stratify UA/NSTEMI Be familiar with the basic management of ACS

Acute Coronary Syndrome Definition: a group of 3 different diagnoses: UA, NSTEMI, STEMI which share a common pathology: obstruction of coronary arteries.

Acute Coronary Syndrome Definition: a group of 3 different diagnoses: UA, NSTEMI, STEMI which share a common pathology: obstruction of coronary arteries. Chest pain is the most common symptom Anginal equivalents: shortness of breath (dyspnea), diaphoresis, extreme fatigue Can also include nausea

Acute Coronary Syndrome Definition: a group of 3 different diagnoses: UA, NSTEMI, STEMI which share a common pathology: obstruction of coronary arteries. Chest pain is the most common symptom Chest pain caused by coronary occlusion often feels like a sub-sternal pressure which can radiate to the left arm or angle of the jaw.

Chest Pain Suspicious Chest Pain can be put into 3 different categories Typical (3/3 criteria) 3 criteria are: 1. the presence of substernal chest pain or (2) discomfort that was provoked by exertion or emotional stress and (3) was relieved by rest and/or nitroglycerin.

Chest Pain Suspicious Chest Pain can be put into 3 different categories Typical (3/3 criteria) Atypical (2/3 criteria) 3 criteria are: 1. the presence of substernal chest pain or (2) discomfort that was provoked by exertion or emotional stress and (3) was relieved by rest and/or nitroglycerin.

Chest Pain Suspicious Chest Pain can be put into 3 different categories Typical (3/3 criteria) Atypical (2/3 criteria) Non-cardiac (1/3 criteria) 3 criteria are: 1. the presence of substernal chest pain or (2) discomfort that was provoked by exertion or emotional stress and (3) was relieved by rest and/or nitroglycerin.

Review Slide The 3 Criteria are: 3 criteria are: 1. the presence of substernal chest pain or (2) discomfort that was provoked by exertion or emotional stress and (3) was relieved by rest and/or nitroglycerin.

Review Slide The 3 Criteria are: 1. the presence of substernal chest pain 2. discomfort that was provoked by exertion or emotional stress 3. relieved by rest and/or nitroglycerin. 3 criteria are: 1. the presence of substernal chest pain or (2) discomfort that was provoked by exertion or emotional stress and (3) was relieved by rest and/or nitroglycerin.

Acute coronary syndrome Based on ECG and cardiac enzymes, ACS is classified into: STEMI: ST elevation, elevated cardiac enzymes

Acute coronary syndrome Based on ECG and cardiac enzymes, ACS is classified into: STEMI: ST elevation, elevated cardiac enzymes NSTEMI: ST depression, T-wave inversion, elevated cardiac enzymes

Acute coronary syndrome Based on ECG and cardiac enzymes, ACS is classified into: STEMI: ST elevation, elevated cardiac enzymes NSTEMI: ST depression, T-wave inversion, elevated cardiac enzymes Unstable Angina: Non specific or no EKG changes, normal cardiac enzymes

Acute coronary syndrome Now to review the different acute coronary syndromes in more detail

Unstable Anginal Chest Pain New onset angina Unstable angina is a symptom that the coronary artery has a unstable non-occlusive blockage (e.g. it is spasming) causing intermittent angina

Unstable Anginal Chest Pain New onset angina Occurs at rest and prolonged, usually lasting >20 minutes

Unstable Anginal Chest Pain New onset angina Occurs at rest and prolonged, usually lasting >20 minutes Increasing angina: Pain that occurs more frequently, lasts for longer periods or is increasingly limiting the patients activity

Unstable Angina EKG May present with nonspecific ST segment changes that do not meet criteria for NSTEMI or STEMI Each little box on the EKG is 1mm

Unstable Angina EKG Troponin May present with nonspecific ST segment changes that do not meet criteria for NSTEMI or STEMI Troponin normal Each little box on the EKG is 1mm

NSTEMI EKG: ST depressions (0.5 mm at least) or T wave inversions ( 1.0 mm at least) without Q waves in 2 contiguous leads with prominent R wave or R/S ratio >1. Each little box on the EKG is 1mm

NSTEMI EKG: ST depressions (0.5 mm at least) or T wave inversions ( 1.0 mm at least) without Q waves in 2 contiguous leads with prominent R wave or R/S ratio >1. Troponins: Elevated Each little box on the EKG is 1mm

STEMI EKG: Q waves , ST elevations, hyper acute T waves; followed by T wave inversions.

STEMI EKG: Q waves , ST elevations, hyper acute T waves; followed by T wave inversions. Troponins: Elevated

STEMI 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) The cutoff is higher for the precordial leads because they are physically placed closer to the heart

STEMI 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 Right sided or inferior infarctions on the EKG may reflect right ventricular dysfunction. Be careful to not decrease these patients’ preload! Modified sgarbossa criteria can be used to help diagnose StEMIs in patient’s with LBBB: Modified Sgarbossa Criteria: ≥ 1 lead with ≥1 mm of concordant ST elevation ≥ 1 lead of V1-V3 with ≥ 1 mm of concordant ST depression ≥ 1 lead anywhere with ≥ 1 mm STE and proportionally excessive discordant STE, as defined by ≥ 25% of the depth of the preceding S-wave. Medications that decrease preload and to be avoided in right sided Mis include nitroglycerin and possibly morphine

Cardiac Enzyme Details 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 CK-MB: "cwik”shorter half life. rises 2-8 hrs post MI, normal in 2-3 days

Cardiac Enzyme Details 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

Cardiac Enzyme Details 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 Troponins are trended every 6-8 hours until they peak

Now for a review of the different acute coronary syndromes

Acute coronary syndrome Based on ECG and cardiac enzymes, ACS is classified into: Repeat slide to review what’s been taught so far

Acute coronary syndrome Based on ECG and cardiac enzymes, ACS is classified into: STEMI: ST elevation, elevated cardiac enzymes Repeat slide to review what’s been taught so far

Acute coronary syndrome Based on ECG and cardiac enzymes, ACS is classified into: STEMI: ST elevation, elevated cardiac enzymes NSTEMI: ST depression, T-wave inversion, elevated cardiac enzymes Repeat slide to review what’s been taught so far

Acute coronary syndrome Based on ECG and cardiac enzymes, ACS is classified into: STEMI: ST elevation, elevated cardiac enzymes NSTEMI: ST depression, T-wave inversion, elevated cardiac enzymes Unstable Angina: Non specific or no EKG changes, normal cardiac enzymes Repeat slide to review what’s been taught so far

Risk Stratification: TIMI score NSTEMI or unstable angina are risk stratified: Age>=65 >= 3 CAD risk factors: HTN, hyperlipidemia, diabetes, smoker, family hx of early MI Documented CAD with >=50% stenosis ST segment deviation ≥ 2 aginal episodes in past 24 hours Aspirin use in the past week (marker for more severe case) Elevation of cardiac enzymes Stratify risk based on number of variables Risk: 0-2: Low 3-4: Intermediate 5-7: High risk If intermediate risk or high risk, consider earlier catheterization.

Risk Stratification: GRACE risk model Superior predictive power Risk factors include: Age Systolic blood pressure Presence of ST segment deviation Cardiac arrest during presentation Serum creatinine concentration Presence of elevated serum cardiac biomarkers Heart rate

Management of low risk Chest Pain EKG normal or non-specific changes with intermediate or low risk: Telemetry Rule out ACS with 3 sets of troponins and EKG Consider pre-discharge stress test 2014 most recent guidelines Heparin’s effect wears off in 3-4 hours allowing the patient to go to procedures faster

NSTEMI & Unstable Angina Management Telemetry Aspirin Beta blocker Nitrates Heparin (UFH or LMWH) ACE-I/ARB Statin Antiplatelet agent: Consider ticagrelor over clopidogrel. When Cangrelor becomes available at UCI, this will be preferable in many situations Heparin’s effect wears off in 3-4 hours allowing the patient to go to procedures faster Cangrelor is an IV anti-platelet agent which allows for faster onset of action and quicker offset. Oral agents like Plavix can take 10-12 hours to reach full efficiency. Loading with Plavix can also lead to delays in CABG if found to be necessary 2014 most recent guidelines

STEMI Management STEMI patients usually go straight to the cath lab from the ED. Goal: door to balloon 90 minutes. Initial management for STEMI: Otherwise similar to NSTEMI What will be contraindicated if the patient shows ST elevation in II, III, avF? Answer: not to give nitrate as there is a concern for right ventricular infarction and this situation is pre-load dependent.

Case 60 year old male with history of DM2 for 20 years, HTN, HLD who presented to the ED with 4 hour onset of chest pain which was described as in the substernal chest without radiation. The pain seemed to improve when he sits down and worsening when he walked upstairs. VS: T 36.9, HR: 95, BP: 84/56, RR 22, O2 sat. 99% RA. ECGs are shown as followed

Leads II, III and aVF reflect electrocardiogram changes associated with acute infarction of the inferior aspect of the heart. ST elevation, developing Q waves and T wave inversion may all be present depending on the timing of the ECG relative to the onset of myocardial infarction. Most frequently, inferior MI results from occlusion of the right coronary artery. Conduction abnormalities which may alert the physician to patients at risk include second degree AV block and complete heart block together with junctional escape beats. Note that the patient is also suffering from a concurrent posterior wall infarction as eveidenced by ST depression in leads V1 and V2.

What is this ECG. Answer: right sided ECG What is this ECG? Answer: right sided ECG. Electrocardiogram shows Q waves and prominent doming ST segment elevation in II, III, and aVF, findings which are characteristic of an acute inferior myocardial infarction. ST elevation in the right precordial leads - V4R, V5R, and V6R - indicates right ventricular involvement as well (arrows). The ST depressions in leads I and aVL represent reciprocal changes.

What will you do? What’s your diagnosis? What should be done now? ACITVATE STEMI code, call cardiology for emergent cath and ask which medications given to the patient before cath, draw troponin, IV fluid, O2, morphine, Aspirin 325 mg x1, and plavix 1 dose of 300 mg PO but NO nitrate!

Summary ACS is comprised of UA, NSTEMI, and STEMIs Chest pain is categorized based on location and relation to exertion ACS is categorized based on troponin levels and EKG Risk stratification for UA/NSTEMI can be done by the GRACE or TIMI score ACS management medications include: Aspirin, Beta Blocker, Nitrates, Heparin, Ace-I, Statin, an anti-platelet agent Door to balloon time for STEMI should be less than 90 minutes

References www.uptodate.com: 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2005;112:IV-89-IV-110 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction : A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2013, epublished April 29th 2013 and print published june 4th 2013. Herman LK, et al. Comparison of frequency of inducible myocardial ischemia in patients presenting to emergency department with typical versus atypical or nonanginal chest pain. Am J Cardiol. 2010 105:1561-4. www.uptodate.com: Overview of the acute management of unstable angina and acute non-ST elevation myocardial infarction Initial evaluation and management of suspected acute coronary syndrome in the emergency department Criteria for the diagnosis of acute myocardial infarction