Acute Coronary Syndromes

Front 1

epidemiology of CHD

Back 1

-Coronary heart disease (CHD) caused ~ 1/5 US deaths in 2005
~ 1/2 of men and 2/3 of women who die suddenly of CHD have no previous symptoms (FHS/NHLBI)!!

Front 2

risk factors

Back 2

1. age
2. gender
3. FH
4. genetics
5. hx of DM
6. hx of vascular dz
7. HTN
8. glucose control
9. lipid profile
10. smoking
11. obesity
12. sedentary lifestyle

Front 3

etiology

Back 3

1. coronary atherosclerosis (over 90%)
-Underlying cause in > 90% of patients
-Acute surge in arterial pressure or sudden vasoconstriction causes plaque to fissure, rupture, or ulcerate=>
2. thrombosis
3. coronary vasospasm- more commonly with stimulants (cocaine)
4. Other: vasculities, coronary ostial occlusion, congenital, trauma, metabolic

Front 4

vulnerable plaque

Back 4

-large lipid pool
-younger, less stenotic
-located at branch point
-infiltrated with macrophages
-more likely to rupture!

Front 5

2 distinct types of clots

Back 5

1. platelet rich- unstable angina/ NSTEMI
2. fibrin rich- completely occlude the vessel; STEMI

Front 6

pathophysiology

Back 6

-affected by distribution of coronary artery anatomy/ collaterals
-oxygen demand exceeds supply
-progression over time
ischemi --> injury --> infarct

Front 7

pathophysiologic gender differences

Back 7

-CAD is manifested earlier in men
-women have smaller hearts
-coronary vessels are smaller in women
-Women commonly have microvascular ischemia than cannot be detected by angiography

Front 8

goals in pts with ACS

Back 8

- identify early
-Treat to save muscle based on pathophysiology
-prevent early death from: arrhythmias, LV failure
-prevent recurrence

Front 9

Factors That Affect Prehospital Delay

Back 9

Sociodemographic characteristics
-Increase: Older age, Female, Lower educational level, Black or Latino, Low socioeconomic status
Clinical characteristics:
-Increase: History of angina, Prior MI ( no difference in some studies), Diabetes, Hypertension, Heart failure, Hyperlipidemia
Social:
-decrease: Consultation with a nonrelative
Cognitive and emotional:
-decrease:Correct attribution of symptom origin

Front 10

history: chest pain

Back 10

Location: usually substernal
Quality: pressure, crushing, squeezing, can resemble indigestion
Radiation: shoulders, arms, neck, jaw, epigastrium, scapulae, back
Duration: 15 minutes to several hours

Front 11

features not characteristic of MI

Back 11

1. pleuritic pain
2. Primary or sole location of discomfort in the middle or lower abdominal region
3. Pain that may be localized at the tip of 1 finger, particularly over the LV apex
4. Pain reproduced with movement or palpation
5. Episodes of pain that last a few seconds or less
6. pain that radiates into the lower extremities

Front 12

history: associated sx

Back 12

1. dyspnea
2. diaphoresis
3. weakness
4. nausea/vomiting
5 dizziness/syncope
6. angor animi (profound sense of impending doom)

Front 13

how presentations vary

Back 13

-Women present with more co-morbidities at a later age, with different types of complaints
-The elderly (esp. > 75 yo) and diabetics often present without “chest pain”

Front 14

circadian pattern of onset of ischemic events

Back 14

-in the morning more common

Front 15

physical exam

Back 15

-appearance: anxious, restless, pallor, diaphoresis
-vital signs: pulse, BP variable; fever within 24-48 hrs
-pulmonary: inc rate, cough, rales, wheeze
-JVD/edema
-Cardiac exam: ? muffled sounds, SEM (systolic ejection murmur), rub, paradoxical split S2 (LBBB), S3, S4

Front 16

diagnostic tests

Back 16

1. CBC, plts, ESR, coag profile
2. electrolytes, BUN, creatinine
3. ABG or pulse oximetry
4. CXR
-SHOULD NOT DELAY EKG!

Front 17

EKG

Back 17

-Classic: ST elevation, T wave inversion, Q waves ("transmural"). DON’T WAIT FOR Q!!
-non‑Q wave with ST elevation ("subendocardial") “STEMI”
-Other ST-T wave changes with chest pain: Unstable Angina/Non-ST elevation MI (UA/NSTEMI)

Front 18

Unstable angina

Back 18

1. Rest angina: Angina occurring at rest and usually prolonged >20 minutes occurring within a week of presentation.
2. New onset angina: Angina of at least CCSC III severity with onset within 2 months of trial presentation*.
3. increasing angina: Previously diagnosed angina that isdistinctly more frequent, longer in durationor lower in threshold.

Front 19

features not characteristic of MI

Back 19

1. pleuritic pain
2. Primary or sole location of discomfort in the middle or lower abdominal region
3. Pain that may be localized at the tip of 1 finger, particularly over the LV apex
4. Pain reproduced with movement or palpation
5. Episodes of pain that last a few seconds or less
6. pain that radiates into the lower extremities

Front 20

Localization of infarct

Back 20

Anterior: I, V2‑4
Anterolateral: I, aVL, V5‑6
Inferior: II, III, aVF
Posterior: large R wave and upright T wave V1

Front 21

Serum markers

Back 21

1. AST, LDH
2. CK-MB
3. myoglobin- goes up first
4. troponin-I
5. troponin- T
-slide 58

Front 22

history: associated sx

Back 22

1. dyspnea
2. diaphoresis
3. weakness
4. nausea/vomiting
5 dizziness/syncope
6. angor animi (profound sense of impending doom)

Front 23

how presentations vary

Back 23

-Women present with more co-morbidities at a later age, with different types of complaints
-The elderly (esp. > 75 yo) and diabetics often present without “chest pain”

Front 24

circadian pattern of onset of ischemic events

Back 24

-in the morning more common

Front 25

physical exam

Back 25

-appearance: anxious, restless, pallor, diaphoresis
-vital signs: pulse, BP variable; fever within 24-48 hrs
-pulmonary: inc rate, cough, rales, wheeze
-JVD/edema
-Cardiac exam: ? muffled sounds, SEM (systolic ejection murmur), rub, paradoxical split S2 (LBBB), S3, S4

Front 26

diagnostic tests

Back 26

1. CBC, plts, ESR, coag profile
2. electrolytes, BUN, creatinine
3. ABG or pulse oximetry
4. CXR
-SHOULD NOT DELAY EKG!

Front 27

EKG

Back 27

-Classic: ST elevation, T wave inversion, Q waves ("transmural"). DON’T WAIT FOR Q!!
-non‑Q wave with ST elevation ("subendocardial") “STEMI”
-Other ST-T wave changes with chest pain: Unstable Angina/Non-ST elevation MI (UA/NSTEMI)

Front 28

Unstable angina

Back 28

1. Rest angina: Angina occurring at rest and usually prolonged >20 minutes occurring within a week of presentation.
2. New onset angina: Angina of at least CCSC III severity with onset within 2 months of trial presentation*.
3. increasing angina: Previously diagnosed angina that isdistinctly more frequent, longer in durationor lower in threshold.

Front 29

Localization of infarct

Back 29

Anterior: I, V2‑4
Anterolateral: I, aVL, V5‑6
Inferior: II, III, aVF
Posterior: large R wave and upright T wave V1

Front 30

Serum markers

Back 30

1. AST, LDH
2. CK-MB
3. myoglobin- goes up first
4. troponin-I
5. troponin- T
-slide 58

Front 31

CK-MB

Back 31

Twice normal in six hours, peaks 12-24 hours, gone in 4-5 days
Useful in ruling out AMI in ED
Prognostic utility in predicting complications
>90% sensitive three hour s/p presentation
problems: also in s. muscle, bone, brain; wide range of nmls; requires sig damage to raise levels

Front 32

myogobin

Back 32

Twice nl. in two hours, peaks 4-6 hours, gone by 12 hours
91% sensitivity one hour after presentation
99% NPV within one hour after presentation
problem: found in all types of muscle

Front 33

troponin

Back 33

Regulates tropomyosin's interaction with actin/myosin
Samples left sitting may lose detectable troponin
Presence in even small amounts suggests injury
Twice nl. in six hours
peak 12-24 hours
Elevated up to 14 days

Front 34

Acute Cardiac Imaging When Dx. Unclear

Back 34

1. 2D echo
wall motion
LV function
aneurysm
MR, VSD, etc.
2. Radionucleotide imaging
-perfusion, ventriculography studies. Non-specific
3. CT/CTA, MRI/MRA, PET

Front 35

slide 74

Back 35

slide 74

Front 36

morphine

Back 36

-(2 - 4 mg IV with increments of 2 - 8 mg IV, repeated at 5 - 15 minute intervals) is the analgesic of choice for STEMI-associated pain management

Front 37

beta blockers

Back 37

-Oral beta-blocker therapy should be initiated in the first 24 hours for patients who do not have the following:
1. signs of HF
2. inc risk for cardiogenic shock
3. inc time since onset of sx

Front 38

C/I to bblocks

Back 38

1. PR interval >.24 sec
2. sec or 3rd degree heart block
3. active asthma or reactive airway dz

Front 39

STEMI <12 hrs duration- reperfusion options

Back 39

-invasive (PCI) (within 90 min)- angioplasty or stenting
-fibrinolytics (door to needle 30 min)
Choice based on: time, risk, availability

Front 40

Fibrinolytics

Back 40

-non-selective plasmin produces: ? higher incidence of bleeding. Lower risk of ICH (stop heparin): Streptokinase
-relatively clot-selective cont low-dose heparin: rt-PA

Front 41

Reteplase

Back 41

-recombinant protein derivative of human tissue plasminogen activator
-catalyzes conversion of plasminogen to plasmin
-10 U IV bolus, repeated 30 min later

Front 42

contraindications to fibrinlytic therapy

Back 42

Any prior intracranial hemorrhage
Known structural cerebral vascular lesion (eg, AVM)
Known malignant intracranial neoplasm
Ischemic stroke within 3 months EXCEPT acute ischemic stroke within 3 hours
Suspected aortic dissection
Active bleeding or bleeding diathesis (x menses)
Significant closed head trauma or facial trauma within 3 months

Front 43

finbrinolytics- complications

Back 43

1. bleeding
2. arrhythmias
3. hypotension
4. nausea, vomiting, fever, chilld, rash

Front 44

STEMI <12 hrs- adjunctive therapies

Back 44

1. ACEs
2. ARBs
3. Statins

Front 45

UA/NSTEMI or STEMI >12 hrs

Back 45

1. No fibrinolytics!
2. Glycoprotein IIb/IIa inhibitor
3. Risk Stratify
4. Early Invasive Strategy if High Risk

Front 46

AHA high risk indicators

Back 46

1. New ST-segment depression and positive troponin
2. persistent or recurrent sx
3. hemodynamic instability or VT
4. depressed LV function (ejection fraction <40%)
5. ECG or functional study that suggest multivessel CAD

Front 47

common arrhythmias after MI

Back 47

PVCs
Bradycardias
2nd degree Type I AV block (Inferior MI)
2nd degree Type II AV block (Anteroseptal MI)
3rd degree AV block (Inferior/Anterior MI)
Tachycardias

Front 48

post-hospital discharge care

Back 48

A Aspirin & Anticoagulants
ACEI if CHF, ST elev., LBBB
B Beta blockers and BP
C Cholesterol/ Cigarettes
D Diet and Diabetes
E Education and Exercise
ERT (HRT) not to be initiated p MI, but should be continued in women already on it

Front 49

intra-aortic balloon pump (IABP)

Back 49

-inflates during diastole to support coronary vessel perfusion
-deflates during systole to allow flow through the aorta to systemic circulation
-significantly decreases afterload, and therefore myocardial wall stress

Front 50

secondary prevention

Back 50

1. stop smoking, no exposure to enviornmental tobacco smoke
2. control BP <140/90 or <130/80 if pt has DM or chronic kidney disease
3. physical activity: 30 min, 7 days/week
4. wt mgmt: BMI 18.5-24.9 and waist circumferance <40 in men and <35 in women
5. HbA1c < 7%
6 flu vaccine

Front 51

reperfusion strategies for STEMI

Back 51

-PLan A: PCI
-Plab B: thrombolytics

Front 52

barriers to timely reperfusion

Back 52

1. the pt: failure to recognize sx, hesitate to seek med attention
2. time to transport
3. decision process on arrival
4. time to implement treatment strategy