1. Dr. Ahmed M. Hussein

2. 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

3. 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.

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

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

6. 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

7. Exercise (stress) ECG
For more presentations

8. Coronary Angiography
For more presentations

10. 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

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

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

15. 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

16. Thrombus Formation and ACSUA
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

17. Differential diagnosis:
Pericarditis
Pulmonary embolism
Pneumothorax
Aortic dissection
Esophageal spasm

18. Ischemia and Infarction
TRANSMURAL Injury ST Elevation

19. 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

20. Stages of STEMI

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

22. Arrangement of Leads on the EKG

23. Acute Anterior MI

24. Cardiac Enzymes

25. 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

26. Very Striking

27. Acute Antero-Lateral MI

28. Severe Chest Pain – Why ?

29. Acute Inferior wall MI

30. What is striking ?
Acute Inf Post

31. Where are the ST ↑ ?
Inf Lysed

32. Reciprocal ST segment depression Acute ST segment elevation

33. What changes we see ?

34. Why Acute changes disappeared ?
r TPA

35. Guess How Old is this MI !

36. Acute True Posterior MI

37. Decipher V1, V2, V3

38. Identify the Double wall MI

39. Inferior STEMI + Hypotension = ??
Next ??

40. Look at the Right Chest Leads

41. 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

42. 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

43. Initial management
Focused history and Focused examination
Reassurance
Ensure IV access + Basic investigations
Aspirin: 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

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

45. 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

46. 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

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

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

50. Normal initial ECG exclude STEMI??

51. 23 min. later

52. 1 hr post revascularization