ACUTE CORONARY SYNDROMEJarrod D. Frizzell, MD, MS

Fellow, Cardiovascular Medicine

July 9, 2015

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

Outline• Definitions

• ACS• MI

• STEMI• NSTEACS• Pearls

Acute Coronary Syndrome

Acute Coronary Syndrome

Acute Coronary Syndrome• 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

Acute Coronary Syndrome

Goldacre, Acad Emer Med 2003

Acute Coronary Syndrome• ACS typically implies “type I event”• Divided into:

• STEMI• NSTEACS

Braunwald, AJRCCM 2012

Types of MI

Universal Definition of MI• Detection of rise and/or fall of cardiac biomarkers with at

least 1 value above the 99th %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

Features

Braunwald, 9th ed.

ECG

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”

STEMI

ECG.utah.edu

Clev Clin J Med 2015

Clev Clin J Med 2015

STE

Ecginterpretation.blogspot.com

ECG

ECG

ECG

ECG

ECG

ECG

ECG• STEMI vs everything else• Why?

• Very specific for transmural ischemia (diagnosis & location)• “Time is muscle”

THE Graph

Gersh, JAMA 2005

2013 STEMI Guidelines

2013 STEMI Guidelines

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)

Back to ACS

NSTEACS• Still presentation of ACS, but not STE

• NSTEMI• UA

• Elevated Tn• TIMI Score

Unstable Angina• Definition

• CP that occurs at rest or with minimal exertion, lasts >20min• Onset within past month• Crescendo pattern

• A dying breed?

NSTEACS 2014 Guidelines

Braunwald, AJRCCM 2012

NSTEACS 2014 Guidelines

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

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

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)

Miscellany

Emsworld.com

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)

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