acute coronary syndromes jason ryan, m.d.. acute coronary syndromes unstable angina +...
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Acute Coronary Acute Coronary SyndromesSyndromes
Jason Ryan, M.D.Jason Ryan, M.D.
Acute Coronary SyndromesAcute Coronary Syndromes
Unstable Angina +Non-ST-Elevation MI +
ST-Elevation MI
Acute Coronary Syndromes (ACS)
UA + NSTEMI(life-threating but
not medical emergency)
STEMI(medical emergency)
Acute Coronary SyndromesAcute Coronary Syndromes
Generally, same symptoms for allGenerally, same symptoms for all– Squeezing, pressure-like, substernal chest Squeezing, pressure-like, substernal chest
painpain– Often associated with shortness of breath and Often associated with shortness of breath and
diaphoresisdiaphoresis– Pearl: If nausea and vomitting think inferior Pearl: If nausea and vomitting think inferior
wall MIwall MI– With UA/NSTEMI, often preceding history of With UA/NSTEMI, often preceding history of
exertional symptomsexertional symptoms
Remember the DDx for Chest PainRemember the DDx for Chest Pain
ACSACSAortic DissectionAortic DissectionPulmonary EmbolismPulmonary EmbolismAcute choleycystitisAcute choleycystitisPericarditisPericarditisCostocondritisCostocondritisEsophogeal spasmEsophogeal spasmMany othersMany others
The Can’t
Misses
ST-Elevation MIST-Elevation MI
ST-Elevation MIST-Elevation MI
ST-Elevation MIST-Elevation MI
ST-Elevation MIST-Elevation MI
Coronary Stenosis: Progression to STEMISerial Angiogrpahy in 239 Patients
StenosisPre-MI
0%25%50%75%
90-99%
CulpritFor MI
81056
1039
29
Nobuyoshi M et al., JACC 1991;18:904-10
ST-Elevation MIST-Elevation MI
If you suspect STEMI:If you suspect STEMI:– OMI: Oxygen, monitor, IV accessOMI: Oxygen, monitor, IV access– ABC: Ensure patient is stableABC: Ensure patient is stable– Call cardiologyCall cardiology– Pre-cath medication:Pre-cath medication:
Aspirin 325mg POAspirin 325mg POLopressor 25mg PO (if BP and Pulse will tolerate)Lopressor 25mg PO (if BP and Pulse will tolerate)
– Beware Beware cardiogenic shockcardiogenic shock
Heprin 5000U bolus (if no active bleeding issues)Heprin 5000U bolus (if no active bleeding issues)Discuss IIB/IIIA and Clopidogrel with cardiologyDiscuss IIB/IIIA and Clopidogrel with cardiology
Unstable Angina (UA) and Unstable Angina (UA) and Non ST Elevation Myocardial Infarction Non ST Elevation Myocardial Infarction
(NSTEMI)(NSTEMI)
• 5,315,000 annual ER presentations for chest pain
• 1,433,000 annual U.S. hospital admissions for UA/NSTEMI
• 50 patients per month at BIDMC coded as: AMI, SUBENDOCARDIAL ISCHEMIA
Placebo Event Rates in Recent Trials of UA and NSTEMIPlacebo Event Rates in Recent Trials of UA and NSTEMI
PRISMPRISM11 7.1% 7.1%
PRISM-PLUSPRISM-PLUS22 11.9%11.9%
PURSUITPURSUIT33 15.7%15.7%
GUSTO-IV ACSGUSTO-IV ACS44 8.0% 8.0%
PARAGON APARAGON A55 11.7%11.7%
Death/MI Death/MI
at 30 daysat 30 days
Death/MI Death/MI
at 30 daysat 30 days
1. PRISM Study Investigators. N Engl J Med 1998;338:1498-1505. 2. PRISM-PLUS Study Investigators. N Engl J Med 1998;338:1488-1497.3. Harrington RA. Am J Cardiol 1997;80:34B-38B.4. The GUSTO IV-ACS Investigators. Lancet 2001;357:1915-1924.5. The PARGON Investigators. Circulation 1998;97:2386-2395.
UA and NSTEMIUA and NSTEMI
UA and NSTEMIUA and NSTEMI
DefinitionsDefinitions– Unstable anginaUnstable angina
New onset anginaNew onset angina
Angina that occurs at restAngina that occurs at rest
Angina that occurs with accelerating frequency Angina that occurs with accelerating frequency (crescendo angina)(crescendo angina)
May have EKG changes (ST depression)May have EKG changes (ST depression)
Biomarkers will be negativeBiomarkers will be negative
UA and NSTEMIUA and NSTEMI
DefinitionsDefinitions– NSTEMINSTEMI
Typical rise and fall of cardiac biomarkers plus at Typical rise and fall of cardiac biomarkers plus at least one of the following:least one of the following:
– Anginal chest painAnginal chest pain– Ischemic EKG changes (ST-depression)Ischemic EKG changes (ST-depression)– Development of Q waves on EKGDevelopment of Q waves on EKG– Coronary interventionCoronary intervention
Often can’t tell UA from NSTEMI at Often can’t tell UA from NSTEMI at presentationpresentation
Joint European Society of Cardiology/American College of Cardiology committee
NSTEMINSTEMI
The Biomarkers:The Biomarkers:– CKCK
Rises 4-6 hours after MIRises 4-6 hours after MI
Peaks and falls by 36-48 hours after MIPeaks and falls by 36-48 hours after MI
Total CK is non-specificTotal CK is non-specific
CK-MB is more specific for cardiac tissueCK-MB is more specific for cardiac tissue– (but there is still some in skeletal muscle!!)(but there is still some in skeletal muscle!!)
– Remember this is Remember this is one componentone component in the diagnosis of in the diagnosis of NSTEMINSTEMI
– CK alone cannot be used to diagnose NSTEMICK alone cannot be used to diagnose NSTEMI
NSTEMINSTEMI
The Biomarkers:The Biomarkers:– TroponinTroponin
Rises 4-6 hours after MIRises 4-6 hours after MICan remain elevated for up to Can remain elevated for up to two weekstwo weeks!!Very specific for cardiac damageVery specific for cardiac damageElevated in many other conditions than ACSElevated in many other conditions than ACS
– Hypotension of any cause (~80% patients)Hypotension of any cause (~80% patients)– Renal failureRenal failure– Congestive heart failureCongestive heart failure– Many othersMany others
Always predicts worse outcomesAlways predicts worse outcomes
NSTEMINSTEMI
Four pieces to NSTEMI: Four pieces to NSTEMI: – SymptomsSymptoms– EKG changesEKG changes– CKCK– TroponinTroponin
Chest Pain
EKG
ST No ST
Possible UA/NSTEMI
MSO4NTGASA
Beta Blockers
Definite/Likely UA/NSTEMI
MSO4NTGASA
Beta BlockersHeparinPlavix
Definite/Likely UA/NSTEMI with cath
or PCI planned
MSO4NTGASA
Beta BlockersHeparinPlavix
IIB/IIIA Inhibitor
Follow STProtocols
ACC Guidelines for Management of UA/NSTEMIACC Guidelines for Management of UA/NSTEMI
American College of Cardiology (ACC)American College of Cardiology (ACC)2002 Guidelines for UA/NSTEMI2002 Guidelines for UA/NSTEMI
Medications with Class I indication
First 24 hours•Morphine •Nitroglycerin•Aspirin •Beta Blocker•Plavix•Heparin•IIB/IIIA Inhibitors
Discharge•Aspirin •Beta Blocker•Plavix•ACE Inhibitor•Statin
NRMI-4 NSTE MI NRMI-4 NSTE MI AcuteAcute CareCare: : 3rd Quarter 20013rd Quarter 2001
85%
71% 72%
24%
0%
20%
40%
60%
80%
100%
ASA Beta Blocker Heparin (all) GP IIb/IIIa
ACC 2002 Guidelines for UA/NSTEMIHow well do we do?
NRMI-4 NSTE MI Discharge Care: NRMI-4 NSTE MI Discharge Care: 3rd Quarter 20013rd Quarter 2001
84%75%
56%
71%
21%
0%
20%
40%
60%
80%
100%
ASA Beta Blocker ACEInhibitor *
Statins # CardiacRehab
* LVEF < 40%* LVEF < 40%# Known hyperlipidemia# Known hyperlipidemia* LVEF < 40%* LVEF < 40%# Known hyperlipidemia# Known hyperlipidemia
ACC 2002 Guidelines for UA/NSTEMIHow well do we do?
PerformanceQuality Indicator Bottom 10% Top 10%
ASA use < 24 h 54% 99%
blocker use < 24 h 33% 98%
Heparin use <24 h 50% 92%
GP IIb-IIIa < 24 h 0% 51%
D/C ASA use 54% 99%
D/C blocker use 44% 96%
D/C ACE-I use 21% 83%
D/C lipid lowering 33% 99%
PerformanceQuality Indicator Bottom 10% Top 10%
ASA use < 24 h 54% 99%
blocker use < 24 h 33% 98%
Heparin use <24 h 50% 92%
GP IIb-IIIa < 24 h 0% 51%
D/C ASA use 54% 99%
D/C blocker use 44% 96%
D/C ACE-I use 21% 83%
D/C lipid lowering 33% 99%
Gap between ‘Leading and Lagging’ US HospitalsGap between ‘Leading and Lagging’ US Hospitals
ACC 2002 Guidelines for UA/NSTEMIHow well do we do?
Additional Additional LivesLivesDischargeDischarge Saved per Saved per 1,0001,000TherapyTherapy Current UseCurrent Use (ideal use)(ideal use)
AspirinAspirin 86%86% 99
Beta blockersBeta blockers 59%59% 1111
ACE inhibitorsACE inhibitors 52%52% 2323
Additional Additional LivesLivesDischargeDischarge Saved per Saved per 1,0001,000TherapyTherapy Current UseCurrent Use (ideal use)(ideal use)
AspirinAspirin 86%86% 99
Beta blockersBeta blockers 59%59% 1111
ACE inhibitorsACE inhibitors 52%52% 2323
Alexander K, JACC, 1998Alexander K, JACC, 1998Alexander K, JACC, 1998Alexander K, JACC, 1998
Benefits of Using Evidence-Based Therapies Benefits of Using Evidence-Based Therapies (Non-ST (Non-ST ACS Patients from GUSTO IIb) ACS Patients from GUSTO IIb)
Benefits of Using Evidence-Based Therapies Benefits of Using Evidence-Based Therapies (Non-ST (Non-ST ACS Patients from GUSTO IIb) ACS Patients from GUSTO IIb)
ACC 2002 Guidelines for UA/NSTEMIDoes doing well matter?
Case 1Case 1
A 54 year old man with DM, HTN, and high cholesterol A 54 year old man with DM, HTN, and high cholesterol presents to the ER complaining of substernal chest pain. presents to the ER complaining of substernal chest pain. The pain feels like his chest is being squeezed. He first The pain feels like his chest is being squeezed. He first noted it two months ago when carrying packages up a noted it two months ago when carrying packages up a flight of stairs. Last week he noticed it when walking to flight of stairs. Last week he noticed it when walking to work. The past two days, the pain has occurred work. The past two days, the pain has occurred whenever he climbs the stairs in his house. This morning whenever he climbs the stairs in his house. This morning it occurred while driving to work.it occurred while driving to work.His initial EKG shows sinus tachycardia with anterior ST His initial EKG shows sinus tachycardia with anterior ST depressions.depressions.His initial cardiac biomarkers are negative.His initial cardiac biomarkers are negative.He becomes pain free during his first few minutes in the He becomes pain free during his first few minutes in the ER and his EKG changes resolve.ER and his EKG changes resolve.
Case 1Case 1
Is this an ACS?Is this an ACS?– YES!!!YES!!!
How should this patient be managed?How should this patient be managed?– Morphine and NTG to make him pain freeMorphine and NTG to make him pain free– Aspirin, Beta blocker, Heparin, IntegrillinAspirin, Beta blocker, Heparin, Integrillin– Plan for catheterization with 24-48 hoursPlan for catheterization with 24-48 hours
Case 2Case 2
A 75 yom with HTN presents to the ER A 75 yom with HTN presents to the ER complaining of squeezing, substernal complaining of squeezing, substernal chest pain. The pain began this morning chest pain. The pain began this morning while taking a shower and has waxed and while taking a shower and has waxed and waned all day (~10 hours time). waned all day (~10 hours time). Initial EKG shows sinus tachycardia Initial EKG shows sinus tachycardia without ST changeswithout ST changesInitial biomarkers: Initial biomarkers: – CK 300, MB 20, Trop T 0.5CK 300, MB 20, Trop T 0.5
Case 2Case 2
Is this an ACS?Is this an ACS?– YES!!!YES!!!
How should this patient be managed?How should this patient be managed?– Morphine and NTG to make him pain freeMorphine and NTG to make him pain free– Aspirin, Beta blocker, Heparin, IntegrillinAspirin, Beta blocker, Heparin, Integrillin– Plan for catheterization within 24-48 hoursPlan for catheterization within 24-48 hours
Case 3Case 3
A 82 yof is transferred to the ED from her A 82 yof is transferred to the ED from her nursing home where she was noted to be nursing home where she was noted to be lethargic. For the past two days, she has had lethargic. For the past two days, she has had decreased POs and one episode of vomiting. decreased POs and one episode of vomiting. The patient is unable to give a history.The patient is unable to give a history.
On initial ED eval, her blood pressure is 72/45 On initial ED eval, her blood pressure is 72/45 and her temp is 101.4and her temp is 101.4
Initial EKG shows sinus tachycardiaInitial EKG shows sinus tachycardia
Initial biomarkers show CK 110, MB 6, Trop 0.5Initial biomarkers show CK 110, MB 6, Trop 0.5
Case 3Case 3
In this an ACS?In this an ACS?– UnlikelyUnlikely
How should this patient be managedHow should this patient be managed– ASA if no contraindicationASA if no contraindication– No BB given hypotensionNo BB given hypotension– No heparin or IIB/IIIA as this is not likely ACSNo heparin or IIB/IIIA as this is not likely ACS– Work up fever and hypotensionWork up fever and hypotension– Cycle biomarkersCycle biomarkers– Repeat EKG in 6-12 hoursRepeat EKG in 6-12 hours
Case 4Case 4
A 62 yom with a history of ESRD on HD, A 62 yom with a history of ESRD on HD, Ischemic CM with EF 20% presents with Ischemic CM with EF 20% presents with lethargy and altered mental status for two dayslethargy and altered mental status for two daysInitial vitals are remarkable for a room air O2 sat Initial vitals are remarkable for a room air O2 sat of 88%of 88%EKG shows sinus rhythm with old anterior Q EKG shows sinus rhythm with old anterior Q waves (see on EKG 1 year prior). No new ST waves (see on EKG 1 year prior). No new ST changes.changes.Initial cardiac markers: Initial cardiac markers: – CK 200 MB 9 Trop 0.8 CK 200 MB 9 Trop 0.8
Case 4Case 4
In this an ACS?In this an ACS?– UnlikelyUnlikely– Troponin is his only marker of ACS and he has at Troponin is his only marker of ACS and he has at
least two reasons for false positive (CRF, CHF)least two reasons for false positive (CRF, CHF)
How should this patient be managedHow should this patient be managed– ASA if no contraindicationASA if no contraindication– BB if not in CHFBB if not in CHF– No heparin or IIB/IIIA unless further evidence of ACS No heparin or IIB/IIIA unless further evidence of ACS
developsdevelops– Work up lethargy and altered mental statusWork up lethargy and altered mental status– Cycle biomarkersCycle biomarkers– Repeat EKG in 6-12 hoursRepeat EKG in 6-12 hours
Case 5Case 5
A 55 yom presents to the ED c/o episodic chest A 55 yom presents to the ED c/o episodic chest pain for one week. The pain is sharp, left sided, pain for one week. The pain is sharp, left sided, and lasts 10-15 minutes. The pain occurs when and lasts 10-15 minutes. The pain occurs when walking and never at rest, although sometimes walking and never at rest, although sometimes he can walk without symptoms. He is pain free he can walk without symptoms. He is pain free now.now.
EKG shows sinus rhythm without ST changes.EKG shows sinus rhythm without ST changes.
Initial biomarkersInitial biomarkers– CK 90, MB not done, Trop <0.01CK 90, MB not done, Trop <0.01
Case 5Case 5
In this an ACS?In this an ACS?– Can’t tellCan’t tell– Some features consistent, some notSome features consistent, some not
How should this patient be managedHow should this patient be managed– ASA and BBASA and BB– No heparin or IIB/IIIA unless biomarkers become No heparin or IIB/IIIA unless biomarkers become
elevatedelevated– Cycle biomarkersCycle biomarkers– Repeat EKG in 6-12 hoursRepeat EKG in 6-12 hours– If rules out, consider exercise stress testIf rules out, consider exercise stress test