Acute coronary syndrome Management Dr Pham Duc Tuan A&E dept. FVHospital 22/12/09

Introduction The spectrum clinical conditions ranging from : ST elevation MI ( 1/3 cases ) Non ST elevation MI ( 2/3 cases ) Characterized by the common physiopathology of disrupted atherosclerotic plaque

Diagnosis of ACS History of cardiac chest pain: accompanied by SOB , diaphoresis , palpitation , nausea , lightheadedness- radiates to arm , neck , jaw – is worse with exertion- may improve with NG administration Cardiac risk factor : Age ( men >55 , women >65 )-DM-Smoking-HTN- Hypercholesterolemia – Family history early of CAD .Approximately one half of all pts with ACS have no established risk factors other than age & gender . Physical examination : vital signs – heart failure . Atypical presentation : absence of chest pain “ silent MI ” , SOB , cardiogenic shock , altered mental stastus , epigastric pain , fatigue , nausea , palpitation ( especially in DM , elderly patients , post operations ) .

Diagnosis of ACS Differential diagnosis : Non cardiac life threatening causes : Aortic dissection , PE , Tension pneumothorax Cardiac causes : pericarditis , tamponade , myocarditis . Common non cardiac causes: GI ( GERD , cholecystitis , pancreatitis )- Musculoskeletal ( costeochondritis) – Pulmonary ( Pleurisy , pneumonia )- Psychiatric ( Panic attacks )

Diagnosis of ACS Cardiac biomarkers

ST elevation MI Cardiac biomarkers: An elevated level of Troponine correlates with increased risk of death , greater elevation predict greater risk of adverse outcome . They are insensitive during the first 4-6 hrs of presentation . Serial marker testing over time improves sensitivity but remains insensitive in the first 4-6 hrs

Conditions that cause an increased level of Troponine I ,T outside ACS Renal insufficiency PE Myopericarditis Decompensated HF Coronary spasm Critical illness ( including burns & sepsis ) Cardiac contusion , trauma, surgery Electrocardioversion/ defibrillation Electrophysiological procedures ( including arrhythmia ablation procedures )

STEMI ECG : The 12 lead ECG is central to the triage of pts with chest discomfort . A 12 lead ECG should be performed & shown to an experienced EP within 10 mins of ED arrival of all pts with chest discomfort . A normal ECG doesn’t preclude the diagnosis of ACS . Serial assessments improve sensitivity & specificity for detecting ACS .

Hyperacute Anterior MI

Difficult ECG interpretations ST elevation in absence of AMI : early repolarization , LVH , pericarditis , myocarditis , LV aneurysm , hypertrophic CM , ventricular paced rhythms , LBBB , hypothermia ST depression in absence of ischemia : hypokalemia , digoxin effect , cor pulmonale , LVH , LBBB T waves inversion without ischemia : CNS hemorrhage , mitral valve prolapse , pericarditis , PE , LVH , RBBB , LBB

STEMI ECG criteria for diagnosis of MI in the presence of LBBB. ST elevation of ≥ 1mm in leads with positive QRS ST depression ≥ 1mm in leads V1 to V3 ST elevation > 5mm in leads with a negative QRS

NSTEMI Presentation : Rest angina : prolonged (>20 min ) discomfort during lack of physical activity New onset angina: newly diagnosed severe discomfort causing marked limitation of physical activity Worsening angina : intense prolonged with less strenous activity

High risk patients with NSTEMI Refractory ischemic chest pain Recurrent/ Persistent ST deviation Ventricular tachycardia Hemodynamic instability Signs of pump failure Positive cardiac biomarkers TIMI ≥ 5  Early invasive strategies.

NSTEMI TIMI Risk Score : Risk Status 0 or 1 Low 2 3 Intermediate 4 5 High 6 or 7

NSTEMI ECG : ST depression consistent with high risk UA/NSTEMI Non diagnostic or Normal ECG 10% of ACS pts may present with normal ECG Repeating the ECG at 5-10 mins

NSTEMI

Initial general therapy Aspirine: 160-325mg Nitroglycerine: No apparent impact on mortality in pts with ACS. Indication : ongoing chest discomfort , HTN , pulmonary congestion . CI: hypotension , severe bradycardia < 50bpm, tachycardia > 100 bpm , RV infarction . Morphine Sulphate

Reperfusion therapies Fibrinolytics Percutaneous Coronary Intervention : Superior to fibrinolytics in combined end points of deah , stroke & reinfarction in many studies ( with skilled providers at a skilled PCI facility ) Preferred in patient with STEMI , symptoms duration ≤ 12hs , door to balloon time ≤90 mins. Preferred in patients with CI of fibrinolytics , cardiogenic shock , HF .

Adjunctive therapies Clopidogrel : oral loading dose 300 mg B Adrenergic Receptor Blokers Low Molecular Weight Heparin : Enoxaparin ( Lovenox ) NSTEMI 1mg/kg SC bid CrCl <30ml/min 1mg/kg qd STEMI: <75ys 30mg single bolus plus 1mg/kg SC then 1mg/kg SC q12h <75ys CrCl <30ml/min 30mg single bolus then 1mg/kg then 1mg qd ≥ 75ys 0.75mg/kg SC q12h ( no initial bolus ) ≥75ys CrCl <30ml/min 1mg SC qd Glycoprotein IIB/IIIA Inhibitors ACE Inhibitor Statins

Complications Cardiogenic shock , LV failure , CHF RV infarction : should be suspected in inferior and or/ posterior MI. Mechanical complications: rupture of free wall , IV septum , papillary muscle . Arrythmias : VF&VT : majority of early death , highest in the first 4 hrs , lidocaine plays no role in prophylaxis . AF Bradyarrythmias : sinus bradycardia, AV block

Conclusions Once the pts with ACS contacts with the health care system. Health care providers must focus on support of cardiopulmonary function , rapid transport , early classification based on ECG characteristics . Patients with STEMI require prompt reperfusion , the shorter the interval from onset to reperfusion , the greater the benefit . Patients with NSEMI require risk stratification , appropriate monitoring & therapy . Health care providers can improve survival rates, myocardial function of ACS patients by providing skilled , efficient , coordinated out of hospital & in hospital care