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

2. 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

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

4. 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

5. 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.

6. 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.

7. 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.

8. 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.

9. 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.

10. 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.

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

12. 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

13. 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

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

15. 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

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

17. 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

18. 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

19. 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

20. 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

21. 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

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

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

24. 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

25. 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

26. 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

27. 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

28. 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

29. Now for a review of the different acute coronary syndromes

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

31. 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

32. 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

33. 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

34. 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 : Intermediate : High risk
If intermediate risk or high risk, consider earlier catheterization.

35. 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

36. 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

37. 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 hours to reach full efficiency. Loading with Plavix can also lead to delays in CABG if found to be necessary
2014 most recent guidelines

38. 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.

39. 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

40. 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.

41. 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.

42. 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!

43. 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

44. 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 :
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