1. ACUTE CORONARY SYNDROME Jarrod D. Frizzell, MD, MS Fellow, Cardiovascular Medicine July 9, 2015

2. A Case 37yoM awoke with chest pressure Radiating to left shoulder Still present after 1h. Tachy, “JVD to ears”, lungs clear Just diagnosed with DM last night iStat Tn: 0

6. Outline Definitions ACS MI STEMI NSTEACS Pearls

7. Acute Coronary Syndrome

9. Syndrome Chest pain (angina?) Most common: upper body discomfort & SOB Diaphoresis Nausea/vomiting Dizziness Angina: Substernal pressure/tightness/discomfort Onset: exertion/emotional stress Relief: rest/NTG Isolated atypical sx are uncommon (women, elderly, DM) Entire picture must be set in clinical context ECG or isolated Tn alone does not make it

10. Acute Coronary Syndrome Goldacre, Acad Emer Med 2003

11. Acute Coronary Syndrome ACS typically implies “type I event” Divided into: STEMI NSTEACS

12. Braunwald, AJRCCM 2012

13. Types of MI

14. Universal Definition of MI Detection of rise and/or fall of cardiac biomarkers with at least 1 value above the 99 th %ile reference limit and with at least 1 of the following Sx of ischemia New or presumed new significant ST-T changes or LBBB Development of pathologic Q waves Imaging evidence of new loss of viable myocardium or new WMA Identification of an intracoronary thrombus (cath or autopsy) Circulation 2012

15. Features Braunwald, 9 th ed.

16. ECG

17. STEMI ST elevations—measured at the J point V2-V3—age/gender dependent Women: 1.5mm Men ≥40: 2mm Men <40: 2.5mm 1mm in all other leads “Injury pattern”

18. STEMI ECG.utah.edu

19. Clev Clin J Med 2015

24. STE Ecginterpretation.blogspot.com

25. ECG

34. STEMI vs everything else Why? Very specific for transmural ischemia (diagnosis & location) “Time is muscle”

35. THE Graph Gersh, JAMA 2005

36. 2013 STEMI Guidelines

38. STEMI Meds—Before Cath Anti-platelet load ASA Thienopyridine (clopidogrel or ticagrelor) Anticoagulation Heparin/LMWH Bivalirudin (if PCI—started in cath lab) Not fonda IIb/IIIa fallen out of favor except special circumstances Pain relief NTG Morphine? If need beyond, call fellow (for boards: CCB, BB)

39. Back to ACS

40. NSTEACS Still presentation of ACS, but not STE NSTEMI UA Elevated Tn TIMI Score

41. Unstable Angina Definition CP that occurs at rest or with minimal exertion, lasts >20min Onset within past month Crescendo pattern A dying breed?

42. NSTEACS 2014 Guidelines

43. Braunwald, AJRCCM 2012

44. NSTEACS 2014 Guidelines

46. Low Risk with Ischemia-Guided Risk stratification before discharge: noninvasive imaging ETT (if normal ST at rest) Stress imaging (if abnl ST at rest) Pharm stress with imaging if can’t exercise Noninvasive eval of LV function

47. When to call? Whenever you feel uncomfortable Not the resident’s job to “rule out STEMI” on ECG You will only regret not calling If cannot get CP-free

48. Miscellany Elevated Tn—when to heparinize? DAPT—duration DES: 1y BMS: at least 1mo, up to 1y ACS but no intervention—1 year “No breakfast on 7S” (NPO for tests) “No coffee at the VA” (NPO for nuc, caffeine interferes)

49. Miscellany Emsworld.com

50. Brief Notes on Complications LAD Supplies most of myocardium  pump failure Supplies septum: VSD LCX Can be “electrically silent” Supplies lateral wall by itself  free wall rupture (late complication) RCA Supplies AVN: heart block RV infarct Posteromedial papillary muscle: Ischemic MR Pap muscle rupture (late)

51. Boards Odds & Ends RV Infarct Inferior STE (get right-sided ECG) +JVD but clear lungs (Borderline) Hypotensive  fluids Avoid NTG STEMI is not only cause of STE If STEMI at non-PCI OSH: Transfer if PCI within 120min Lytics if transfer outside window Idioventricular rhythm post reperfusion Looks like VT, but slower No additional therapy