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

2. 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

4. 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 ) .

5. 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 )

6. Diagnosis of ACS Cardiac biomarkers

7. 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

8. 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 )

9. 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 .

10. Hyperacute Anterior MI

11. 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

12. 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

13. 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

15. 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.

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

18. 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

19. NSTEMI

21. Initial general therapy
Aspirine: mg
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

22. 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 .

25. 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

26. 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

28. 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