1. 1 Case 6 Acute Coronary Syndromes © 2001 American Heart Association

2. 2 Learning Objectives At the end of Case 6 be able to uDefine acute coronary syndromes uUse the Ischemic Chest Pain Algorithm uConsider the Why? (actions), When? (indications), How? (dose), and Watch Out! (precautions) of medications for ischemic chest pain patients

3. 3 Learning Objectives (cont’d) At the end of Case 6 be able to uRecognize significant ST-segment changes uKnow how to measure ST-segment elevation and depression uKnow basic principles of anatomic localization of infarct, injury, and ischemia uKnow how to use the ECG to risk-stratify patients

4. 4 Case 1 A 55-year-old man presents with a chief complaint of severe (10 of 10) substernal chest pain. He has pain radiating down his left arm and up into his jaw, nausea, and a profound sense of impending doom. He is covered with small beads of sweat. Vital signs: TEMP = 37.2°C; HR = 110 bpm; BP = 150/100 mm Hg; RESP = 12 Describe your immediate assessment. Describe your immediate general treatment.

5. 5 Ischemic Chest Pain Algorithm Immediate assessment (<10 minutes) Measure vital signs (automatic/standard BP cuff) Measure oxygen saturation Obtain IV access Obtain 12-lead ECG (physician reviews) Perform brief, targeted history and physical exam; focus on eligibility for fibrinolytic therapy Obtain initial serum cardiac marker levels Evaluate initial electrolyte and coagulation studies Request, review portable chest x-ray (<30 minutes) Chest pain suggestive of ischemia Immediate general treatment Oxygen at 4 L/min Aspirin 160 to 325 mg Nitroglycerin SL or spray Morphine IV (if pain not relieved with nitroglycerin) Memory aid: “MONA” greets all patients (Morphine, Oxygen, Nitroglycerin, Aspirin) EMS personnel can perform immediate assessment and treat- ment (“MONA”), including initial 12-lead ECG and review for fibrinolytic therapy indications and contraindications. Assess initial 12-lead ECG

6. 6 Items of Immediate Assessment (<10 min) uCheck vital signs with automatic or standard BP cuff uDetermine oxygen saturation uObtain IV access uObtain 12-lead ECG uObtain a brief, targeted history and perform a physical examination; use checklist (yes-no); focus on eligibility for fibrinolytic therapy uObtain blood sample for initial cardiac marker levels uInitiate electrolyte and coagulation studies

7. 7 Immediate General Treatment uOxygen at 4 L/min uAspirin 160 to 325 mg uNitroglycerin SL or spray uMorphine IV (if pain not relieved with nitroglycerin) Review the Why? (actions), When? (indications), How? (dose), and Watch Out! (precautions) of these medications to consider in patients with ischemic chest pain.

8. 8 Medications Used in ACLS uWhy? (Actions) uWhen? (Indications) uHow? (Dose) uWatch Out! (Precautions)

9. 9 Oxygen Used in Acute Coronary Syndromes Why? uIncreases supply of oxygen to ischemic tissue When? uAlways when AMI is suspected How? uStart with nasal cannula at 4 L/min uRemember one word: oxygen-IV-monitor Watch Out! uRarely COPD patients with hypoxic ventilatory drive will hypoventilate

10. 10 Nitroglycerin: Actions uDecreases pain of ischemia uIncreases venous dilation uDecreases venous blood return to heart uDecreases preload and cardiac oxygen consumption uDilates coronary arteries uIncreases cardiac collateral flow

11. 11 Nitroglycerin: Indications uClass I: First 24 to 48 hours in patients with ST-segment elevation or depression including LV failure (acute pulmonary edema or CHF) Elevated BP (especially with signs of LV failure) Large anterior infarction Persistent ischemia uSuspected ischemic chest pain uUnstable angina (change in angina pattern) uAcute pulmonary edema (if BP >90 mm Hg systolic)

12. 12 Nitroglycerin: Dose uSublingual: 0.3 to 0.4 mg; repeat every 5 minutes uSpray inhaler: 2 metered doses at 5-minute intervals  IV infusion: 12.5 to 25  g bolus, 10 to 20  g/min infusion, titrated

13. 13 Nitroglycerin: Precautions uUse extreme caution if systolic BP <90 mm Hg uUse extreme caution in RV infarction –Suspect RV infarction with inferior ST changes uLimit BP drop to 10% if patient is normotensive uLimit BP drop to 30% if patient is hypertensive uWatch for headache, drop in BP, syncope, tachycardia uTell patient to sit or lie down during administration

14. 14 Morphine Sulfate: Actions, Indications uWhy? (Actions) To reduce pain of ischemia To reduce anxiety To reduce extension of ischemia by reducing oxygen demands uWhen? (Indications) Continuing pain Evidence of vascular congestion (acute pulmonary edema) Systolic blood pressure >90 mm Hg No hypovolemia

15. 15 Morphine Sulfate: Dose, Precautions uHow? (Dose) 2 to 4 mg titrated to effect Goal: Eliminate pain uWatch out for (Precautions) Drop in blood pressure, especially in patients with –Volume depletion –Increased systemic resistance –RV infarction Depression of ventilation Nausea and vomiting (common) Bradycardia Itching and bronchospasm (uncommon)

16. 16 Aspirin: Actions uWhy? (Actions) Blocks formation of thromboxane A 2 (thromboxane A 2 causes platelets to aggregate and arteries to constrict) uThese actions will reduce Overall mortality from AMI Nonfatal reinfarction Nonfatal stroke

17. 17 Aspirin: Indications, Dose, Precautions uWhen? (Indications) As soon as possible! Standard therapy for all patients with new pain suggestive of AMI Give within minutes of arrival uHow? (Dose) 160- to 325-mg tablet taken as soon as possible uWatch Out! (Precautions) Relatively contraindicated in patients with active peptic ulcer disease or asthma Contraindicated in patients with known aspirin hypersensitivity Bleeding disorders Severe hepatic disease

18. 18 Assess Initial 12-Lead ECG Findings Classify patients with acute ischemic chest pain into 1 of the 3 groups above within 10 minutes of arrival. ST elevation or new or presumably new LBBB: strongly suspicious for injury ST-elevation AMI ST depression or dynamic T-wave inversion: strongly suspicious for ischemia High-risk unstable angina/ non–ST-elevation AMI Nondiagnostic ECG: absence of changes in ST segment or T waves Intermediate/low-risk unstable angina

19. 19 Recognition of AMI uKnow what to look for— ST elevation > 1 mm 3 contiguous leads uKnow where to look Refer to 2000 ECC Handbook PR baseline ST-segment deviation = 4.5 mm J point plus 0.04 second

20. 20 How to Measure ST-Segment Deviation PR baseline J point plus 0.04 second ST-segment deviation

21. 21 12-Lead ECG Variations in AMI and Angina Baseline Ischemia—tall or inverted T wave (infarct), ST segment may be depressed (angina) Injury—elevated ST segment, T wave may invert Infarction (Acute)—abnormal Q wave, ST segment may be elevated and T wave may be inverted Infarction (Age Unknown)—abnormal Q wave, ST segment and T wave returned to normal

22. 22 AMI Localization aVF inferiorIII inferiorV 3 anterior V 6 lateral aVL lateral II inferiorV 2 septalV 5 lateral aVRI lateralV 1 septalV 4 anterior

23. 23 Anterior Septal AMI

24. 24 ß -Blockers uMechanism of action Blocks catecholamines from binding to ß-adrenergic receptors Reduces HR, BP, myocardial contractility Decreases AV nodal conduction Decreases incidence of primary VF

25. 25 ß -Blockers uSevere CHF/PE uSBP <100 mm Hg uAcute asthma (bronchospasm) u2nd- or 3rd-degree AV block uMild/moderate CHF uHR <60 bpm uHistory of asthma uIDDM uSevere peripheral vascular disease Absolute Contraindications Cautions

26. 26 Heparin uMechanism of action Indirect thrombin inhibitor (with AT III) uIndications PTCA or CABG With fibrin-specific lytics High risk for systemic emboli –Conditions with high risk for systemic emboli, such as large anterior MI, atrial fibrillation, or LV thrombus

27. 27 ACE Inhibitors uMechanism of action Reduces BP by inhibiting angiotensin-converting enzyme (ACE) Alters post-AMI LV remodeling by inhibiting tissue ACE Lowers peripheral vascular resistance by vasodilatation Reduces mortality and CHF from AMI

28. 28 Fibrinolytic Therapy uBreaks up the fibrin network that binds clots together uIndications: ST elevation >1 mm in 2 or more contiguous leads or new LBBB or new BBB that obscures ST Time of symptom onset must be <12 hours Caution: fibrinolytics can cause death from brain hemorrhage uAgents differ in their mechanism of action, ease of preparation and administration; cost; need for heparin u5 agents currently available: alteplase (tPA, Activase), anistreplase (Eminase), reteplase (Retavase), streptokinase (Streptase), tenecteplase (TNKase)

29. 29 Antiplatelet Agents uBlocks glycoprotein IIb/IIIa receptors on platelets uBlocked receptors cannot attach to fibrinogen uFibrinogen cannot aggregate platelets to platelets uIndications: ACS with NO ST-segment elevation: Non–Q-wave MI Unstable angina managed medically UA undergoing PCI uExamples: abciximab (ReoPro), eptifibitide (Integrilin), tirofiban (Aggrastat)

30. 30 Percutaneous Transluminal Coronary Angioplasty uDirect treatment uMechanical reperfusion of infarct-related coronary artery uBest outcome achieved for patients with AMI plus cardiogenic shock

31. 31 What Does This 12-Lead ECG Show?

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