Acute Coronary Syndrome

Zohair Alaseri, MDFRCPc, Emergency MedicineFRCPc, Critical Care Medicine

Intensivist and Emergency Medicine Consultant

Director, Department of Emergency Medicine

King Khalid University HospitalRiyadh, KSA

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• Introduction• Chest Pain history• Physical Exam• Cardiac risk factors• Cardiac biomarkers• ECG in ACS• Risk Stratification• New imaging modality• CONCEPTS OF QUALITY AND QUALITY

IMPROVEMENT

Acute Coronary Syndrome

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1. Patient with DM,HTN and FH of heart disease

2. Patient with typical chest pain and ECG finding

3. 90 year old diabetic & hypertensive male Patient with typical chest pain

4. 50 year old female with typical chest pain & PMH of MI

Among the following patients who has theAmong the following patients who has the highest risk for ACShighest risk for ACS::

Chest Pain Evaluation

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The level of discomfort does not necessarily The level of discomfort does not necessarily correlate with the severity of illnesscorrelate with the severity of illness::

• TRUE• FALSE

Chest Pain Evaluation

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Lack of pain predicts increased hospital mortality?

• TRUE• FALSE

Chest Pain Evaluation

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The chest pain history itself has been proven to be a The chest pain history itself has been proven to be a powerful enough predictive tool to obviate the need for powerful enough predictive tool to obviate the need for at least some diagnostic testingat least some diagnostic testing??

• TRUE• FALSE

Chest Pain Evaluation

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1. Radiation to shoulder2. Radiation to both arms3. Burning/indigestion pain4. Nausea/vomiting5. Exertional pain6. Tender chest wall

Among the following features which one Among the following features which one has the highest predictive value for ACShas the highest predictive value for ACS??

Chest Pain Evaluation

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1.1. nausea nausea 2.2. diaphoresis diaphoresis 3.3. dyspnea dyspnea 4.4. syncope syncope 5.5. arms pain arms pain 6.6. pain epigastrium pain epigastrium

The most frequent NON CHEST PAIN The most frequent NON CHEST PAIN symptomsymptom in ACS isin ACS is

Chest Pain Evaluation

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CT Scan is available tool to exclude ACS in low to medium risk patient with chest pain in ED

• TRUE• FALSE

Chest Pain Evaluation

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• Patient less than 40 years and some cardiac risk factors has low probability of ACS

• TRUE• FALSE

Chest Pain Evaluation

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• Patient more than 65 years and no cardiac risk factors has low probability of ACS

• TRUE• FALSE

Chest Pain Evaluation

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• Begins before the physician sees the patient

• Depends on the actions of triage staff and other non-physician personnel.

Chest Pain Evaluation

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• Many patients will not admit having chest “pain,” but will acknowledge the presence of chest “discomfort”

Pain in ArabicWajaAlamThogolthaghett

Chest Pain Evaluation

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0

1

2

3

4

5

6

Radiation to shoulder

Radiation to both arms

Burning/indigestion pain

Nausea/vomiting

Exertional pain

Tender chest wall

O R

atio

0.0090.02

0.27

0.54

0.014P Value

Goodacre S, Locker T, Morris F, Campbell S. How useful are clinical features in the diagnosis of acute, undifferentiated chest pain? Acad Emerg Med. 2002;9:203-208

Multivariate Analysis of Predictors of Acute Myocardial Infarction

CHEST PAIN

0.18

Chest Pain Evaluation

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Lee TH, Cook EF, Weisberg M, Sargent RK, Wilson C, Goldman L. Acute chest pain in the emergency room. Identification and examination of low-risk patients. Arch Intern Med

1985;145:65–9

• Atypical symptoms do not necessarily rule out acute coronary syndrome.

• In 22 percent of 596 patients who presented to ED with sharp or stabbing pain had ACS

A combination of atypical symptoms A combination of atypical symptoms improves identification of low-risk improves identification of low-risk

patientspatients..

Chest Pain Evaluation

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•Goldman L., Cook E., Brand D.,  et al.   A computer protocol to predict myocardial infarction in emergency department patients with chest pain   N Engl J Med (1988) 318 : pp 707-803

•Goldman L., Cook E., Johnson P.,  et al.   Prediction of the need for intensive care in patients who come to the emergency department with acute chest pain.   N Engl J Med (1996) 334 : pp 1498-1504

Patients who describe their discomfort as Similar to previous episodes of

cardiac ischemia are more likely to have ACSs

Chest Pain Evaluation

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An easy-to-remember for possible precipitating factors is the 3 p’s, which are :

Pleuritic, Positional, or reProducible chest pain more more likely represents a non-ACS syndromelikely represents a non-ACS syndrome

Chest Pain Evaluation

Precipitating and Aggravating Factors

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28% ,

19% ,

31% ,

22% ,

patients had no change in pain

patients had minimal reduction

patients had moderate reduction

patients had significant or complete reduction in pain .

664664 patientspatientsCardiac-related in 122 Cardiac-related in 122 patients (18%)patients (18%) . .

Response to Nitroglycerin

Diercks DB, Boghos E, Guzman H, et al. Changes in the numeric descriptive scale for pain after sublingual nitroglycerin do not predict cardiac etiology of chest

pain. Ann Emerg Med. 2005;45:581-585.

Chest Pain Evaluation

19Servi RJ, Skiendzielewski JJ. Relief of myocardial ischemia pain with a GI cocktail. Am J Emerg

Med. 1985;3:208-209

Doesn't help to differentiate

Chest Pain Evaluation

GI Cocktail

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(ACC/AHA )guidelines list the following as pain descriptions that are not characteristic of MI

Atypical Chest Pain

•Pleuritic pain )i.e., sharp or knife-like pain brought on by respiratory movements or cough( •Middle or lower abdominal region•Localized at the tip of one finger, particularly over the )LV( apex •Reproduced with movement or palpation of the chest wall or arms •Constant pain•Very brief•Radiates into the lower extremities

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Brieger, D. et al. Chest 2004;126:461-469

Dominant presenting symptoms in patients without chest pain (total exceeds 100% as patients may have presented with more than one dominant symptom)

ACS without Chest Pain

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Soft Clinical Features

So-called “soft clinical features,” such as • Fatigue• Weakness• Malaise• Dizziness• “clouding of the mind,”

occurring in 11% to 40% of patients who have AMI

23Pope J., Clinical features of emergency department patients presenting with symptoms of

acute cardiac ischemia: a multicenter studyJ Thromb Thrombolysis 6 )1998( : pp 63-74 .

Cardiac ischemia can present with abdominal pain 1%

Abdominal Pain

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If a patient already If a patient already

carries a known carries a known diagnosis of IHD, a risk diagnosis of IHD, a risk

factor analysis is factor analysis is unnecessary because unnecessary because

the risk is known to be the risk is known to be 100%100%..

Chest Pain Evaluation

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Conclusion

• Cardiac risk factor burden has limited clinical value in diagnosing ACS in the ED setting, especially in patients older than 40 years.

Jin H. Han, The Role of Cardiac Risk Factor Burden in Diagnosing Acute Coronary Syndromes in the Emergency Department Setting

Annals of Emergency Medicine Volume 49 • Number 2 • February 2007

Chest Pain Evaluation

Cardiac Risk Factor

Chest Pain Evaluation

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•The physical examination in patients with ACS frequently is normal .

•Ominous findings • new mitral regurgitation murmur

• hypotension• pulmonary rales

• S3 gallop • JV distention .

• tachycardia • bradycardia

portends a patient at high risk for ischemic complication .

Physical ExaminationACS Evaluation

InclusionInclusionExclusionExclusionComplicationComplication

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Chest Pain & Biomarkers

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Myocardial perfusion imaging and multidetector CT accuracy (n=85).

Imaging MethodSensitivitySpecificityPPV (n)NPV (n)

Stress nuclear imaging )95% CI(

71% )5/7()36%–92%(

90% 38%

97%

Multidetector CT (95% CI)

86% )6/7(92% 50%99%

Michael J. Gallagher The Diagnostic Accuracy of 64-Slice Computed Tomography Coronary Angiography Compared With Stress Nuclear Imaging in Emergency Department

Low-Risk Chest Pain Patients Annals of Emergency MedicineVolume 49 • Number 2 • February 2007

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• The initial presentation and early management of unstable angina, STEMI, and NSTEMI frequently are similar.

Why the term Why the term ““ACSACS”” is useful is useful????

Chest Pain Evaluation

31Unstable angina

Entry Chest pain or angina equivalent

Working diagnosis

ACS

ECG ST Elevation No ST elevation

Biomarkers CKMB Troponin positive

Troponin negativeFinal

DiagnosisAcute MI

In Triage

In Monitored bed

Chest Pain Evaluation

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Chest PainChest Pain

Esophageal perforationEsophageal perforation

PEPE

PrognosticPrognostic

InclusionInclusionExclusionExclusion

PneumothoraxPneumothorax

A DissectionA DissectionAnti ischemic

contraindications

Anti ischemic contraindications

ComplicationComplication

Life Threatening Conditions

CXR, Bil BP

Chest Pain Evaluation

Low Risk Pain that is pleuritic ,

positional, or reproducible with palpation

described as stabbing lasts only secondslasts only seconds

Probable Low Risk Pain not related to exertion or that

occurs in a small inframammary area of the chest wall

Risk Stratification & Chest Pain History

Probable High Risk Pain described as pressure ,

is similar to that of prior myocardial infarction or worse than prior anginal pain, or

is accompanied by nausea, vomiting, or diaphoresis

High Risk •Pain that radiates to one or both shoulders or arms or

•is related to exertion •similar to previous cardiac ischemia

•Radiated to arms•IHD DMIHD DM

Chest Pain Evaluation ED ACS Management

and Algorithms

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1. The diagnosis: door-to-ECG )preferably less than 10 minutes(

2. The decision to treat: door-to-catheterization team activation )preferably within 15–25 minutes (

3. The transition in care: door-to-ED departure )preferably within 45–60 minutes(

Chest Pain & Time management

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Chest Pain & normal ECG & CE in ED

Observe for 6 hours with continuous 12 lead ECG monitoring

Rpeate CK, troponin & ECG in 6 to 8 hours

Any one of the following•Recurent pain•ECG changes ST depression or elevation or t inversionor •arrythmia•Positive Enzymes

All of the following•No further pain•No ECG changes ST depression or elevation or t inversionor •No arrythmia•Negative Enzymes

Stress Test

-ve

+veHigh Risk

CCU Admission

No Yes

Discharge

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• Triage to a telemetry bed for immediate assessment and delivering ACLS if needed.

• Placement on a monitor

• IV

• )ASA(

• ECG5 minutes

of patient arrival

Chest Pain Evaluation

Immediate actions

Administer oxygen to all patients with overt pulmonary congestion or arterial oxygen saturation <90% )Class I(.

It is also reasonable to administer supplementary oxygen to all patients with ACS for the first 6 hours of therapy

Oxygen

Eight RCT showed decreased mortality rates when ASA was given to hospitalized patients with ACS.

Aspirin

The International Study of Infarct Survival )ISIS(-2 trial )odds reduction=0.23; 95% CI, 0.15–0.30

Limited evidence from several very small studies suggests that the bioavailability and pharmacologic action of other formulations of ASA )soluble, IV( may be as effective as chewed tablets.

7 RCT indicated decreased mortality rates when ASA was given as early as possible.

Aspirin

Freimark D, Matetzky S, Leor J, Boyko V, Barbash IM, Behar S, Hod H. Timing of aspirin administration as a determinant of survival of patients with acute myocardial infarction treated with thrombolysis. Am J Cardiol. 2002; 89: 381–385

• Early users experienced lower mortality at 7 days )2.5% vs 6.0%, p = 0.01(, 30 days )3.3% vs 7.3%, p = 0.008(, and 1 year )5.0% vs 10.6%, p = 0.002( than late users.

Aspirin

Give a 300-mg oral loading dose of clopidogrel in addition to standard care )ASA, heparin( to patients with ACS

within 4 to 6 hours

Clopidogrel

• Clopidogrel in combination with aspirin is more effective than ASA alone in reducing cardiovascular death, MI,

and stroke for 9 months after the index visit.

The Clopidogrel in Unstable Angina to Prevent Recurrent Events Trial Investigators : Effects of clopidogrel in addition to aspirin in patients with

acute coronary syndromes without ST-segment elevation. N Engl J Med2001;345:494.[errata, N Engl J Med 345:1506, 1716, 2001].

Clopidogrel

• Although the recent CLARITY TIMI 28 trial did not document increased bleeding in patients undergoing CABG within 5 to 7 days of receiving clopidogrel.

----Current ACC/AHA recommendations advise withholding clopidogrel for 5 to 7 days before planned CABG.

• It is reasonable to give clopidogrel 300 mg orally to patients with suspected ACS )without ECG or cardiac marker changes( who have hypersensitivity to or gastrointestinal intolerance of ASA.

Clopidogrel

In the ED giving LMWH instead of UFH in addition to aspirin

to patients with UA/NSTEMI is helpful.

There is insufficient evidence to identify the optimal time for administration after onset of symptoms.

Changing from one form of heparin to another )crossover of antithrombin therapy( during an acute event is not recommended.

LMWH is an acceptable alternative to UFH as ancillary therapy for patients with STEMI who are <75 years of age and receiving fibrinolytic therapy.

Heparins

In patients with STEMI proceeding to PCI, there is no evidence in favor of LMWH over UFH

LMWH )specifically enoxaparin( improved overall TIMI flow )coronary reperfusion( and ischemic outcomes better than UFH when given to patients with STEMI within 6 hours of onset of symptoms

Van de Werf FJ. Efficacy and safety of tenecteplase in combination with enoxaparin, abciximab, or unfractionated heparin: the ASSENT-3 randomised trial in acute myocardial infarction. Lancet. 2001; 358: 605–613.

Wallentin L, Low molecular weight heparin )dalteparin( compared to unfractionated heparin as an adjunct to rt-PA )alteplase( for improvement of coronary artery patency in acute myocardial infarction—the ASSENT Plus study. Eur Heart J. 2003; 24: 897–908.

Heparins

Fondaparinux

If revascularization therapy )PCI or surgery( is planned, it is safe to give GP IIb/IIIa inhibitors in addition to standard therapy )including ASA and heparin( to patients with high-risk UA/NSTEMI in the ED.

This therapy reduce the risk of death or recurrent ischemia.

If revascularization therapy is not planned, the recommendation for use of GP IIb/IIIa varies by drug. Tirofiban and eptifibatide may be used in patients with high-risk UA/NSTEMI in conjunction with ASA and LMWH if PCI is not planned. But abciximab can be harmful in patients with high-risk UA/NSTEMI if early )eg, 24 hours( PCI is not planned.

Glycoprotein IIb/IIIa Inhibitors

• Abciximab is not currently recommended in patients receiving fibrinolytics for STEMI.

• In patients treated with PCI without fibrinolysis, abciximab is helpful in reducing mortality rates and short-term reinfarction.

STEMI

Glycoprotein IIb/IIIa Inhibitors

Glycoprotein IIb/IIIa Receptor Inhibitors

Three agents: • Abciximab• Eptifibatide• Tirofiban.

Fibrinolytics

In the ED fibrinolytics should be given to patients with symptoms of ACS and ECG evidence of on of the following:

•STEMI•New LBBB•True posterior infarction

The AHA recommends

• Fibrinolytics within 30 to 60 minutes of arrival in the emergency department.

It is encouraged that AMI patients who undergo primary PTCA have therapy initiated no later than 90 minutes after arrival.

Fibrinolytics

The four Ds of emergency department )ED(–based diagnosis and management of the patient with acute myocardial infarction )AMI( .

Fibrinolytics

Fibrinolytics

Fibrinolytics

Fibrinolytics

Fibrinolytics

)1( its longer half-life allows it to be administered as a single

bolus

)2( 14 times more fibrin specific than t-PA and even more so than r-PA

)3( 80 times more resistant to plasminogen activator inhibitor

type 1 than t-PA.

TNK was equally or minimally more effective, particularly in late presenters.

TNK

Fibrinolytics

TNK has several interesting characteristics and associated potential benefits:

• Most studies of intravenous NTG in the setting of AMI are from the prefibrinolytic era.

• A meta-analysis of multiple small trials noted a 35% mortality reduction with intravenous NTG.

Yusuf S: Effect of intravenous nitrates on mortality in acute myocardial infarction: An overview of the randomized trials. Lancet1988;1:1088.

Nitroglycerin

CIs

• Bradycardia• Hypotension• Inferior wall AMI• Right ventricular infarction

Nitroglycerin

Magnesium

ISIS-4 enrolled >58 000 patients and showed a trend toward increased mortality when magnesium was given in-hospital for primary arrhythmia prophylaxis to patients within the first 4 hours of known or suspected AMI.

ß-Blockers In the ED treat ACS patients promptly with IV ß-blockers followed by oral ß-blockers.

13% reduction in the risk of subsequent AMI.ß-Blockers are given irrespective of the need for revascularization therapies.

Contraindications to ß-blockers include hypotension bradycardia heart block moderate to severe CHF reactive airway disease

ACE Inhibitors

oStart an oral ACE inhibitor within 24 hours after onset of symptoms.

oCI Hypotension )systolic blood pressure <100 mm Hg or more than 30 mm Hg below baseline(.

• ACE inhibitors are most effective in patients with • anterior infarction• pulmonary congestion• left ventricular ejection fraction <40%.

• Avoid giving IV ACE inhibitors within the first 24 hours

ACE Inhibitors

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1.Timeliness

2.Effectiveness

3.Safety

4. Equity

5. Efficiency

6. Patient centeredness

Kelly L. Miller, Moving from Evidence to Practice in the Care of Patients Who Have Acute Coronary Syndrome Cardiology Clinics Volume 24 Num 1 Feb2006

CONCEPTS OF QUALITY AND QUALITY IMPROVEMENT

six aims for improvement

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• lack of awareness• lack of familiarity• lack of agreement• lack of self-efficacy• lack of outcome expectancy• inertia of previous practice• external barriers.

IMPROVING PRACTICE PATTERNS :BARRIERS TO EVIDENCE-BASED CARE

continuous feedback on guideline adherence & patient outcomes

educational initiatives

67The cycle of clinical therapeutics. )Adapted from Califf RM, Peterson ED, Gibbons RJ, et al. Integrating quality into the cycle of therapeutic development .

CYCLE OF CONTINUOUS QUALITY IMPROVEMENT

Comprehensive management plan can be assembled through

ABCDE Approach

Antiplatlet, anticoagulant, ACEI & ARB

B. blocker and blood pressure control

Cholesterol and cigarette control and cessation

Diet and Dm control

Exercise

A

B

C

D

E

ED ACS Management and Algorithms