Dr. Ahmed M. Hussein

Spectrum of coronary artery disease -Silent ischemia -Chronic stable angina -Acute coronary syndromes (ACS) NSTE-ACS (Unstable angina , NSTEMI) STEMI -Heart failure -Arrhythmia -Sudden death

Chronic stable angina Angina pectoris is the clinical syndrome caused by transient myocardial ischaemia. It may occur whenever there is an imbalance between myocardial oxygen supply and demand. Coronary atheroma is by far the most common cause of angina.

Investigations Resting ECG often normal. Exercise ECG. Myocardial perfusion scanning. Stress echocardiography. Coronary arteriography

ST depression Note widespread ST depression and T waves inverted in several leads.

ST Segment Depression Upward sloping depression of ST segment is not indicative of IHD It is called J point depression or sagging ST seg Downward slopping or Horizontal depression of ST segment leading to T↓is significant of IHD

Exercise (stress) ECG For more presentations www.medicalppt.blogspot.com

Coronary Angiography For more presentations www.medicalppt.blogspot.com

Management Risk factors modification such as smoking, hypertension and hyperlipidaemia. Drugs Antiplatelet therapy Low-dose aspirin reduces the risk of adverse events such as MI and should be prescribed for all patients with coronary artery disease indefinitely .Clopidogrel (75 mg daily) is an equally effective. Anti-anginal drug treatment Nitrates Beta-blockers

Calcium channel antagonists Potassium channel activators Invasive treatment Percutaneous coronary intervention PCI. CABG

ACUTE CORONARY SYNDROMES Myocardial Infarction No ST Elevation ST Elevation NSTEMI Unstable Angina NSTEMI STEMI Myocardial Infarction

MI Pathogenesis of ACS Anti-platelet drugs Sequence of events Platelet rupture Platelet Adhesion Platelet Activation Sequence of events Plaque Rupture Platelet Adhesion Platelet Activation Platelet Aggregation Thrombotic Occlusion Platelet Aggregation Thrombotic Occlusion Anti-platelet drugs MI

Thrombus Formation and ACS UA NSTEMI Plaque Disruption/Fissure/Erosion Thrombus Formation Non-ST-Segment Elevation Acute Coronary Syndrome (ACS) ST-Segment Elevation Acute Coronary Syndrome (ACS) Terminology: It is now recognized that unstable angina (UA), non-Q-wave myocardial infarction (NQMI), and ST-segment elevation myocardial infarction (STE-MI) are all parts of the spectrum of clinical manifestations of acute coronary syndrome (ACS). The older terminology has now been replaced with terminology that divides ACS into non-ST-elevation ACS (NSTE-ACS) and ST-segment-elevation. All the slides in this teaching set deal with NSTE-ACS. High Serum Troponin

Differential diagnosis: Pericarditis Pulmonary embolism Pneumothorax Aortic dissection Esophageal spasm

Ischemia and Infarction TRANSMURAL Injury ST Elevation

T Wave Inversion Deep symmetric inverted T waves In more than 2 precardial leads 85% of the patients with such T wave↓had > 75% stenosis of the coronary artery T wave ↓are significantly associated with MI or death during follow up

Stages of STEMI

ST elevation Ask group to look for ST elevation. The ST elevation implied epicardia ischemia (injury pattern).

Arrangement of Leads on the EKG

Acute Anterior MI

Cardiac Enzymes

Cardiac imaging 2D echocardiography reveals regional wall motion abnormality also useful to identify mechanical complications of MI Radionuclide imaging used infrequently in the diagnosis of acute MI mainly used to risk stratify patients with CHD

Very Striking

Acute Antero-Lateral MI

Severe Chest Pain – Why ?

Acute Inferior wall MI

What is striking ? Acute Inf Post

Where are the ST ↑ ? Inf Lysed

Reciprocal ST segment depression Acute ST segment elevation

What changes we see ?

Why Acute changes disappeared ? r TPA

Guess How Old is this MI !

Acute True Posterior MI

Decipher V1, V2, V3

Identify the Double wall MI

Inferior STEMI + Hypotension = ?? Next ??

Look at the Right Chest Leads

Management Prehospital care: Major elements include Recognition of symptoms by the patient and prompt medical attention Rapid deployment of EMS capable of resuscitation and defibrillation

Goals of Initial management in ED Control of cardiac pain Rapid identification of patients suitable for reperfusion Triage of low risk patients for subsequent care Avoiding inappropriate discharge of patients with MI

Initial management Focused history and Focused examination Reassurance Ensure IV access + Basic investigations Aspirin: 160-325 mg chewable aspirin + Clopidogril Oxygen by nasal cannula if hypoxemia is present Sublingual nitroglycerine followed by IV infusion if needed Intravenous beta blockers (decrease myocardial oxygen demand, control chest pain and reduce mortality) Morphine for pain relief (given IV in small doses)+ Metelopromide Monitor 12 Leads ECG Consider Reperfusion

Reperfusion therapy Primary percutaneous coronary intervention (PCI). Thrombolysis.

Absolute Contraindications Any prior intracranial hemorrhage Known structural cerebral vascular lesion (e.g., AV malformation) Malignant intracranial neoplasm Ischemic stroke in last 3 months Suspected aortic dissection Active bleeding or bleeding diathesis Closed head or facial trauma in last 3 months

Relative Contraindications Recent (3 weeks) major surgery Recent (3 weeks) trauma Cardiopulmonary resuscitation of >10min BP > 180/110 Ischemic stroke more than 3 months old Internal bleeding in last month Noncompressible vascular punctures For streptokinase/Anistreplase: prior exposure or allergy Pregnancy Active peptic ulcer Currently on anticoagulants (sodium warfarin, Coumadin); the higher the INR, the higher the risk

Complications of acute coronary syndrome Arrhythmias VF,AF, BRADYCARDIA Ischemia Acute circulatory failure Pericarditis Mechanical complications Embolism Impaired ventricular function HF Ventricular aneurysm RADYCARDIA

Maintenance Therapy Life style changes Aspirin Clopidogril B blocker ACE inhibitors Calcium channel blocker Statins ( Antilipids)

Normal initial ECG exclude STEMI??

23 min. later

1 hr post revascularization