ACS(Acute Coronary Syndrome)   By Dr. Ahmed Azhad
ACS     (Acute Coronary Syndrome)                            IH D          CAD                      ACS( s t a b le a n g ...
Coronary Arteries
UA/NSTEMI - DefinitionUA diagnosis is mainly clinical:      Chest pain or discomfort:               1.   Occurring at re...
UA/NSTEMI - PathophysiologyReduction in oxygen supply ORIncrease in myocardial oxygen demand    superimposed on an ather...
UA/NSTEMI – Pathophysiology                (continued)2. Dynamic obstruction (coronary spasm)3. Progressive mechanical obs...
UA/NSTEMI – Clinical featuresHistory and Examination:      Chest pain – in substernal region or epigastrium, radiating  ...
UA/NSTEMI – InvestigationsECG:     UA : ST-segment depression , transient ST-elevation and/or         T-wave inversion (...
UA/NSTEMI – ECG
UA/NSTEMI – Investigations (2)Cardiac Biomarkers:   CK-MB, Troponin-T   Direct relationship between degree of Troponin-...
UA/NSTEMI – Enzyme assays
UA/NSTEMI – DiagnosisAHA 2010 AlgorithmHigh-likelihood of ACS:       H/o typical ischemic discomfort       Established...
UA/NSTEMI – Diagnosis (2)Intermediate-likelihood of ACS:      Age > 70 years      Male gender      Diabetes Mellitus  ...
UA/NSTEMI – TreatmentBed Rest with continuous ECG monitoring for ST-  deviation and cardiac rhythmAmbulation allowed whe...
UA/NSTEMI – Rx anti-ischemic   Nitrates (upto 3 doses, 5 minutes apart; then IV      nitroglycerin 5-10 µg/min with non-a...
UA/NSTEMI – Rx anti-thrombotic   Aspirin 162 – 325 mg loading, then 75 – 162 mg/d   Clopidogrel – 300mg loading, then 75...
UA/NSTEMI – Rx AdditionalHigh-risk patients (multiple risk factors, ST-segment   deviation and/or postive biomarkers)   ...
UA/NSTEMI – PrognosisWide spectrum:      30 day risk of Death: 1-10%      30 day risk of new or recurrent infarct: 3-10...
UA/NSTEMI – DischargeTeachable momentRisk-factor modification: smoking cessation, optimal  weight, daily exercise, diet,...
STEMIOccurs when there is thrombotic occlusion of a  coronary artery.Thrombus develops rapidly.Cardiac biomarkers can b...
STEMI - PathophysiologyThrombotic occlusion of a coronary artery previously  affected by atherosclerosis.Occurs due to r...
STEMI - Pathophysiology
STEMI – Pathophysiology (2)Occurs when the surface of an atherosclerotic plaque  becomes disrupted and conditions favour ...
STEMI – Clinical FeaturesHalf of the cases have a precipitating factor:      Vigourous physical exercise      Emotional...
STEMI – Clinical Features (2)   Similar to angina pectoris, but is usually more severe and      lasts longer   Central p...
STEMI – DD of chest painAcute pericarditis (radiation of pain to trapezius)Pulmonary embolismAcute aortic dissectionCo...
STEMI – Other presentationsSTEMI in Diabetes – painlessSTEMI in elderly - sudden-onset breathlessness →  pulmonary edema...
STEMI – Physical findingsAnxious, restlessnessPallorPain > 30 minutes + diaphoresis -> STEMIBP/Pulse: can be normal or...
STEMI - Investigations1. ECG – ST elevation, Q waves (ideal time: within 10      minutes)2. Cardiac biomarkers:     1.   T...
STEMI – ECG (1)1.   ST-segment elevation or presumed new LBBB         ST-segment elevation in 2 or more contiguous leads ...
STEMI – ECG (2)2. Ischemic ST-segment depression > 0.05mV or        dynamic T-wave inversion with pain or        discomfor...
STEMI – ECG (3)3. Non-diagnostic ECG with non-specific ST-segment        or T-wave changes = non-conclusive for        isc...
STEMI – Other Investigations2-D Echo – wall motion abnormalitiesRadio-nuclide imaging with 99m-Tc labelled blood    red ...
STEMI – Initial RxPrehospital careManagement in the Emergency Department      Goals:            Control of cardiac dis...
STEMI – Initial Rx (2)Control of discomfort      Sublingual nitroglycerin 0.4mg at 5-min intervals             Abolishe...
STEMI – Initial Rx (3)Control of discomfort      Morphine 2-4mg i.v. repeated in 5-min intervals as needed      I.v. be...
STEMI - RxLimiting infarct size:      Primary PCI (Door-balloon time – 90 minutes)      Thrombolysis (Door-needle time ...
STEMI – Post reperfusionPharmacotherapy:      Antiplatelet + Antithrombotic therapy            Aspirin            Clop...
ReferencesHarrison’s Principles of Internal Medicine 17th  EditionCirculation (journal of AHA)      http://circ.ahajour...
Thank You
Acute Coronary Syndrome
Upcoming SlideShare
Loading in...5
×

Acute Coronary Syndrome

2,704

Published on

A presentatation on Acute coronary syndrome made while in Emergency Department. If you are making a presentation on ACS, you may want to add more on TIMI score as it is important. Some problems with display of pictures/diagrams due to ?conversion problems. Based on AHA Guidelines 2010 and from Harrison's 18th Ed.. Made using OpenOffice.

Published in: Health & Medicine
0 Comments
2 Likes
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total Views
2,704
On Slideshare
0
From Embeds
0
Number of Embeds
0
Actions
Shares
0
Downloads
325
Comments
0
Likes
2
Embeds 0
No embeds

No notes for slide

Acute Coronary Syndrome

  1. 1. ACS(Acute Coronary Syndrome) By Dr. Ahmed Azhad
  2. 2. ACS (Acute Coronary Syndrome) IH D CAD ACS( s t a b le a n g in a ) STEM I U A /N S T E M I
  3. 3. Coronary Arteries
  4. 4. UA/NSTEMI - DefinitionUA diagnosis is mainly clinical:  Chest pain or discomfort: 1. Occurring at rest or minimal exertion (>10 minutes) 2. Severe and of new onset (within past 4-6 weeks) 3. Crescendo pattern 4.  NSTEMI:  C/F of UA + Evidence of myocardial necrosis (elevated biomarkers)
  5. 5. UA/NSTEMI - PathophysiologyReduction in oxygen supply ORIncrease in myocardial oxygen demand superimposed on an atherosclerotic plague with varying degrees of obstructionContributors to the above are:1. Plague rupture or erosion with superimposed non- occlusive thrombus (most common cause)
  6. 6. UA/NSTEMI – Pathophysiology (continued)2. Dynamic obstruction (coronary spasm)3. Progressive mechanical obstruction (rapidly advancing coronary atherosclerosis or restenosis following PCI)4. Secondary UA related to increased myocardial oxygen demand or decreased supply (anemia/tachcardia)
  7. 7. UA/NSTEMI – Clinical featuresHistory and Examination:  Chest pain – in substernal region or epigastrium, radiating to neck, left shoulder, and left arm  Diaphoresis  Pale cool skin  Sinus tachycardia  3rd and 4th heart sounds on auscultation  Basilar rales  Hypotension
  8. 8. UA/NSTEMI – InvestigationsECG:  UA : ST-segment depression , transient ST-elevation and/or T-wave inversion (30-50%)  C/F + new ST-segment deviation of 0.05mV is an important predictor of adverse outcome  T-wave changes are sensitive for ischaemia but less specific (exception: new, deep T-wave inversions ≥ 0.3 mV
  9. 9. UA/NSTEMI – ECG
  10. 10. UA/NSTEMI – Investigations (2)Cardiac Biomarkers:  CK-MB, Troponin-T  Direct relationship between degree of Troponin-T and mortality (not available in IGMH)  Patients without clinical history of ischemia: minor troponin elevations can be caused by:  Congestive heart failure  Myocarditis  Pulmonary embolism  False-positive readings  Unclear history + small troponin elevations = not diagnostic of ACS
  11. 11. UA/NSTEMI – Enzyme assays
  12. 12. UA/NSTEMI – DiagnosisAHA 2010 AlgorithmHigh-likelihood of ACS:  H/o typical ischemic discomfort  Established CAD by angiography  Prior MI  Congestive heart failure  New ECG changes  Elevated cardiac biomarkers
  13. 13. UA/NSTEMI – Diagnosis (2)Intermediate-likelihood of ACS:  Age > 70 years  Male gender  Diabetes Mellitus  Peripheral arterial disease / Cerebrovascular disease  Old ECG abnormalities
  14. 14. UA/NSTEMI – TreatmentBed Rest with continuous ECG monitoring for ST- deviation and cardiac rhythmAmbulation allowed when no recurrence of ischemia and non-elevation of biomarkers 12-24 hoursRx: anti-ischemic + anti-thrombotic therapy
  15. 15. UA/NSTEMI – Rx anti-ischemic Nitrates (upto 3 doses, 5 minutes apart; then IV nitroglycerin 5-10 µg/min with non-absorbing tubing, can be increased 10 µg/min every 3-5 minutes  Until symptoms relieved OR  Systolic BP < 100 mm Hg  Contraindications: 1) Hypotension 2) Sildenafil use within past 24 hours β – blockers ACE inhibitors Statins Morphine if pain not responding to nitroglycerin and β- blockers
  16. 16. UA/NSTEMI – Rx anti-thrombotic Aspirin 162 – 325 mg loading, then 75 – 162 mg/d Clopidogrel – 300mg loading, then 75mg/day IV antiplatelet therapy: Abciximab, Eptifibatide, Tirofiban Heparins: UFH 60-70 U/kg (max: 5000 U), then 12-15 U/kg/hr (init. Max: 1000 U/hr – titrated to a PTT 50-70s) Enoxaparin 1mg/kg s.c. Q12h, first dose preceded by 30mg iv-bolus. (If CC < 30 cc/min, 1mg/kg OD) Fondiparinux, Bivalirudin
  17. 17. UA/NSTEMI – Rx AdditionalHigh-risk patients (multiple risk factors, ST-segment deviation and/or postive biomarkers)  Coronary ateriography within 48 hours of admission followed by coronary revascularisation (PCI or CABG)Low-risk patients: Watchful waiting; arteriography if:  Rest pain  ST –segment changes  Evidence of ischemia on stress test
  18. 18. UA/NSTEMI – PrognosisWide spectrum:  30 day risk of Death: 1-10%  30 day risk of new or recurrent infarct: 3-10%TIMI Trials:  7 independent risk factorsCRP and BNP (marker of increased myocardial wall tension) correlate independently with increased mortality
  19. 19. UA/NSTEMI – DischargeTeachable momentRisk-factor modification: smoking cessation, optimal weight, daily exercise, diet, BP control, control of hyperglycemia, lipid managementDrugs: beta blockers, statins, ACE inhibitors, aspirin + clopidogrel 9-12 months, then aspirin alone thereafter
  20. 20. STEMIOccurs when there is thrombotic occlusion of a coronary artery.Thrombus develops rapidly.Cardiac biomarkers can be used to distinguish UA from NSTEMI and to assess the magnitude of STEMI.
  21. 21. STEMI - PathophysiologyThrombotic occlusion of a coronary artery previously affected by atherosclerosis.Occurs due to rapid development of a thrombus at the site of vascular injury.Facilitating factors:  Cigarette smoking  Hypertension  Lipid accumulation
  22. 22. STEMI - Pathophysiology
  23. 23. STEMI – Pathophysiology (2)Occurs when the surface of an atherosclerotic plaque becomes disrupted and conditions favour thrombogenesisCoronary artery gets occluded by a thrombusRarely by coronary emboli, congenital abnormalities, coronary spasm, inflammatory diseases
  24. 24. STEMI – Clinical FeaturesHalf of the cases have a precipitating factor:  Vigourous physical exercise  Emotional stress  Medical or Surgical illnessUsually in the morning / within a few hours of waking up – but can occur anytimeC/o:  Pain – deep, “heavy”, “squeezing”, “crushing”, stabbing or burning
  25. 25. STEMI – Clinical Features (2) Similar to angina pectoris, but is usually more severe and lasts longer Central portion of the chest and/or epigastrium Radiation upto occipital area but not below umblicus Associated with weakness, sweating, nausea, vomiting, anxiety and a sense of impending doom Does not subside with rest
  26. 26. STEMI – DD of chest painAcute pericarditis (radiation of pain to trapezius)Pulmonary embolismAcute aortic dissectionCostochondritisGastrointestinal disorders
  27. 27. STEMI – Other presentationsSTEMI in Diabetes – painlessSTEMI in elderly - sudden-onset breathlessness → pulmonary edemaOthers with or without pain:  Sudden loss of consciousness, sudden profound weakness, arrhythmia, unexplained drop in arterial pressure
  28. 28. STEMI – Physical findingsAnxious, restlessnessPallorPain > 30 minutes + diaphoresis -> STEMIBP/Pulse: can be normal or increased (sympathetic hyperactivity); decreased in inferior infarcts3rd and 4th heart soundsMid-systolic or late systolic murmur
  29. 29. STEMI - Investigations1. ECG – ST elevation, Q waves (ideal time: within 10 minutes)2. Cardiac biomarkers: 1. Troponin-T (preffered) – lasts till 7-10 days after STEMI 2. CK/CK-MB: Rises within 4-8 hours, returns to normal in 48- 72 hours (can also rise due to cardiac surgery, myocarditis, electrical cardioversion). CKMB mass:CK ≥ 2.5 suggestive of cardiac muscle damage.Should be noted that recanalisation would cause earlierand higher peak of enzymes.3. TLC rise: 12,000 – 15,000/µL. Few hours upto 3-7 days.4. ESR rise – peaking in 1st week, raised for upto 2 weeks.
  30. 30. STEMI – ECG (1)1. ST-segment elevation or presumed new LBBB  ST-segment elevation in 2 or more contiguous leads = STEMI  Threshold values:  Men ≥ 40 yrs : J-point elevation (V2 and V3) - 0.2 mV : and 0.1mV in all other leads  Men < 40 yrs : J-point elevation (V2 and V3) - 0.25 mV : and 0.1mV in all other leads  Women: L-point elevation (V2 and V3) – 0.15 mV : and 0.1mV in all other leads
  31. 31. STEMI – ECG (2)2. Ischemic ST-segment depression > 0.05mV or dynamic T-wave inversion with pain or discomfort = UA/NSTEMI  Non-persistent/transient ST-elevation ≥ 0.5mm for < 20 minutes is also included in this category.  Threshold values: J-point depression 0.05mV in leads V2 and V3, and 0.1mV in all other leads (men and women)
  32. 32. STEMI – ECG (3)3. Non-diagnostic ECG with non-specific ST-segment or T-wave changes = non-conclusive for ischemia  Threshold values:  Normal ECGs  ST-segment deviation < 0.5mm, T-wave inversions ≤ 0.2 mm
  33. 33. STEMI – Other Investigations2-D Echo – wall motion abnormalitiesRadio-nuclide imaging with 99m-Tc labelled blood red cells
  34. 34. STEMI – Initial RxPrehospital careManagement in the Emergency Department  Goals:  Control of cardiac discomfort  Rapid identification of patients for reperfusion  Avoidance of inappropriate discharge of patients with STEMI  Rx:  Aspirin – 160 – 325 mg chewable tablets  O2 at 2-4L/min for hypoxemic patients
  35. 35. STEMI – Initial Rx (2)Control of discomfort  Sublingual nitroglycerin 0.4mg at 5-min intervals  Abolishes chest pain  Decreases myocardial oxygen demand (by lowering preload)  Increases myocardial oxygen supply (by dilating coronary vessels)  If chest discomfort returns, consider IV nitroglycerin  Avoid nitrates in patients with systolic BP <90mm Hg or clinical suspicion of right ventricular infarction, patients taking sildenafil within preceding 24 hours  Idiosyncratic reaction to nitrates – hypotension – can be reversed with atropine i.v.
  36. 36. STEMI – Initial Rx (3)Control of discomfort  Morphine 2-4mg i.v. repeated in 5-min intervals as needed  I.v. beta blockers (metoprolol 5mg every 2-5 minutes – total 3 doses;; HR > 60, SBP > 100mm Hg. After this 50mg Q6H oral x 48 hrs, then 100mg Q12H.
  37. 37. STEMI - RxLimiting infarct size:  Primary PCI (Door-balloon time – 90 minutes)  Thrombolysis (Door-needle time – 30 minutes)  Tissue plasminogen activator  Streptokinase (1.5 MU over 60 minutes)  Tenecteplase  Reteplase  Contraindications: Active internal bleeding, Recent CVA, Intraspinal or intracranial surgery, intracranial neoplasm, severe uncontrolled hypertension  Complications: Hemorrhagic stroke (0.5 – 0.9%)
  38. 38. STEMI – Post reperfusionPharmacotherapy:  Antiplatelet + Antithrombotic therapy  Aspirin  Clopidogrel  Heparin  Beta blockers  ACE Inhibitors
  39. 39. ReferencesHarrison’s Principles of Internal Medicine 17th EditionCirculation (journal of AHA)  http://circ.ahajournals.org/content/122/18_suppl_3/S787
  40. 40. Thank You
  1. Gostou de algum slide específico?

    Recortar slides é uma maneira fácil de colecionar informações para acessar mais tarde.

×