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ACS 071509

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ACS 071509

  1. 1. The Diagnosis of Acute Myocardial Infarction SFK House Staff July 2009
  2. 2. Coronary Atherosclerosis: A Chronic Disease * 0 – 20 yrs 20 – 40 yrs 40 – 60 + yrs † ∞
  3. 3. Coronary Atherosclerosis: A Chronic Disease
  4. 4. Coronary Atherosclerosis: A Chronic Disease * 0 – 20 yrs 20 – 40 yrs 40 – 60 + yrs † ∞
  5. 5. Nomenclature of ACS The spectrum of clinically manifest Coronary Artery Disease from UA to AMI is referred to as ACS. Antman et al. Acute myocardial infarction. In: Braunwald EB, ed. Heart disease: a textbook of cardiovascular medicine. Philadelphia, PA: WB Saunders, 1997.
  6. 6. Criteria for Acute Myocardial Infarction Laboratory evidence of myocardial necrosis with clinical myocardial ischemia. Any one of the following criteria meets the diagnosis for myocardial infarction: • Detection of rise and/or fall of biomarkers (preferably troponin) with at least one value above the 99th percentile of the upper reference limit (URL) together with myocardial ischemia with at least one of the following: • Symptoms of ischemia; • New ischemic ST-T changes or new LBBB; • New pathological Q waves; • New loss of viable myocardium or regional wall motion abnormality by imaging techniques. • Sudden unexpected death from cardiac arrest. • For PCI patients, new elevations of biomarkers greater than 3x 99th percentile URL. A subtype related to stent thrombosis is recognized. • For CABG patients, new elevations of biomarkers greater than 5x 99th percentile URL plus new pathological Q waves or new LBBB, or angiographically documented new graft or native coronary artery occlusion, or imaging of new loss of viable myocardium. Thygesen, et al. J. Am. Coll. Cardiol. 2007;50;2173-2195
  7. 7. Types of Myocardial Infarction Type 1: Spontaneous myocardial infarction related to ischemia due to a primary coronary event such as plaque erosion and/or rupture, fissuring, or dissection Type 2: Myocardial infarction secondary to ischemia due to either increased oxygen demand or decreased supply, e.g. coronary artery spasm, coronary embolism, anemia, arrhythmias, hypertension, or hypotension Type 3: Sudden unexpected cardiac death, including cardiac arrest, often with symptoms of myocardial ischemia, but death occurring before blood samples could be obtained or before the appearance of cardiac biomarkers in the blood Type 4a: Myocardial infarction associated with PCI Type 4b: Myocardial infarction associated with stent thrombosis as documented by angiography or at autopsy Type 5: Myocardial infarction associated with CABG Thygesen , et al. J. Am. Coll. Cardiol. 2007;50;2173-2195
  8. 8. “Ischemic” Symptoms • Not all chest pain is cardiac • Not all cardiac pain is coronary insufficiency • Not all coronary insufficiency is atherosclerosis • Not all coronary occlusion is thrombosis • Not all ACS requires immediate coronary angiography / reperfusion • 10-15% of myocardial infarctions are asymptomatic
  9. 9. "False-Positive" Cardiac Catheterization Laboratory Activation Among Patients With Suspected ST-Segment Elevation Myocardial Infarction D Larson, K Menssen, S Sharkey, et al. JAMA. 2007;298(23):2754-2760 1345 Patients over 3.5 Years 1048 Transferred from 30 non-PCI hospitals 297 Presented initially to PCI hospital 10 Excluded 5 Died 5 Angiography cancelled 1335 Underwent angiography 187 Had no culprit CAD
  10. 10. Biomarkers in Acute Myocardial Infarction Cardiac troponin-no reperfusion 100 Cardiac troponin-reperfusion CKMB-no reperfusion Multiples of the URL 50 CKMB-reperfusion 20 Troponin-I Normal = ≤ 0.09 ng/ml 10 CK-MB Fraction ULN = ≤6 ng/ml 5 2 URL = Upper Reference Limit 99%tile of Reference Control Group 1 0 1 2 3 4 5 6 7 8 Days After Onset of Myocardial Infarction Alpert et al. J Am Coll Cardiol 2000;36:959. Wu et al. Clin Chem 1999;45:1104.
  11. 11. Elevated Troponin Without Overt Ischemic Heart Disease Cardiac contusion or other trauma, including surgery, ablation, pacing, etc. Congestive heart failure—acute and chronic Aortic dissection Aortic valve disease Hypertrophic cardiomyopathy Tachy- or bradyarrhythmias, or heart block Takotsubo stress cardiomyopathy (Apical ballooning syndrome) Rhabdomyolysis with cardiac injury Pulmonary embolism, severe pulmonary hypertension Renal failure Acute neurological disease, including stroke or subarachnoid hemorrhage Infiltrative diseases, e.g. amyloidosis, hemochromatosis, sarcoidosis, scleroderma, neoplasia Inflammatory diseases, e.g. myocarditis, endocarditis or pericarditis Drug toxicity or toxins Critically ill patients, especially with respiratory failure or sepsis Burns, especially if affecting 30% of body surface area Extreme exertion Modified from Jaffe et al. (4) and French and White (5).
  12. 12. ECG Manifestations of Acute Myocardial Ischemia (in Absence of LVH and LBBB) ST elevation New ST elevation at the J-point in two contiguous leads >0.2 mV in men or >0.15 mV in women in leads V2–V3, or >0.1 mV in other leads ST depression and T-wave changes New horizontal or down-sloping ST depression >0.05 mV in two contiguous leads; or T inversion >0.1 mV in two contiguous leads with prominent R-wave or R/S ratio ≥1
  13. 13. QRS Changes Associated With Myocardial Infarction Any Q-wave ≥0.02 sec or QS complex in “anterior leads” V2 -- V3 Q-wave ≥0.03 sec and ≥0.1 mV deep or QS complex in any two leads of a contiguous lead group: “lateral leads” I, aVL,V6 “anterolateral leads” V2–V6 “inferior leads” II, III, aVF R-wave ≥0.04 sec in “posterior leads” V1–V2 and R/S ≥1 with a concordant positive T-wave (in the absence of a conduction defect)
  14. 14. ECG Pitfalls in Diagnosing Myocardial Infarction False positives Benign early repolarization LBBB Pre-excitation Brugada syndrome Pericarditis, myocarditis Pulmonary embolism Subarachnoid hemorrhage Metabolic disturbances such as hyperkalemia Failure to recognize normal limits for J-point displacement Lead transposition or misplacement Cholecystitis Takotsubo stress cardiomyopathy False negatives Prior myocardial infarction with Q-waves and/or persistent ST elevation Paced rhythm LBBB Thygesen et al. JACC Vol. 50, No. 22, 2007
  15. 15. 1 sec (25 mm / sec) 200 msec 40 msec
  16. 16. 1 sec (25 mm / sec) 200 msec 40 msec 1 mv 0.1 mv or “1 mm”
  17. 17. 1 sec (25 mm / sec) 200 msec 40 msec 0 300 150 100 75 60 50 BPM 1 mV (10 mm / mV) 0.1 mv or “1 mm”
  18. 18. ?Ant-STEMI ?LVH ?HyperK+ ?LBBB ?WNL ?Pericarditis ? Takotsubo ?RBBB+STEMI ?Brugada ?Pul Embolism
  19. 19. Normal Normal (Early Repolari- zation) Normal (Repolari- zation Variant)
  20. 20. ?Ant-STEMI ?LVH ?HyperK+ ?WNL ?LBBB ?Pericarditis ?Takotsubo ?RBBB+STEMI ?Brugada ?Pul Embolism
  21. 21. I tis I EM BB i K+ EM ST da H rd r T + ga LV B a pe t-S L ric Hy n BBB Bru e A
  22. 22. Pulmonary Embolism DC Cardio- version
  23. 23. RZ: 54 Latin-American male in ED (NOT SFK)
  24. 24. DR: 71 y male with chest pain in the Cardiac Procedures Unit
  25. 25. VP 32 y South Asian male surgical resident sought ED evaluation for chest pain and extreme fatigue. No significant past history. FH positive for premature CAD. CK and troponin-I elevated.
  26. 26. VP 32 y South Asian male surgical resident sought ED evaluation for chest pain and extreme fatigue. No significant past history. FH positive for premature CAD. CK and troponin-I elevated. Onset of pain after running a marathon, without training. Left AMA after overnight observation and IV hydration.
  27. 27. AR 96 y female with acute onset epigastric and substernal pain, nausea, onset 3:30 PM. In ED 6:54 PM, no history of coronary disease, +HTN, +PAF. Systolic murmur Ao valve. Trop-I 15.54 ng/ml, echocardiogram LVH, mild AS, inferoapical akinesis. CCL 7:20 PM.
  28. 28. 10275665: NC 25 year old male with abrupt onset of severe chest pain. No substance abuse, no medications, no CV history. Cigarettes ½ ppd. Chol 157 mg/dl, LDL-C 80 mg/dl. CK 81 IU/L, troponin-I 0.05 ng/ml.
  29. 29. 10275665: NC 25 year old male with abrupt onset of severe chest pain. No substance abuse, no medications, no CV history. Cigarettes ½ ppd. Chol 157 mg/dl, LDL-C 80 mg/dl. CK 81 IU/L, troponin-I 0.05 ng/ml. Repeat CK 7668 IU/L, troponin-I >100 ng/ml. Echo LVEF 35% with apical clot. Symptoms began while driving home from first-time skydiving.
  30. 30. 1-31-2006 0920 Hrs 34 y Asian F RN from UCSF. Presented to ED with acute onset severe chest pain 1 hr earlier. No CV history. Rare migraine headaches, most recently 5 d earlier. No medications. No illicit drug use, trauma, tobacco or alcohol. No hypertension, no diabetes, never obese, no FH atherosclerotic nor connective tissue vascular disease. No nocturnal chest pain nor palpitation. G2 P2 3 ½ yr post-partum, LMP 2 wks ago, HCG negative, no oral contraceptives. Total choesterol 165 mg/dl, triglycerides 175 mg/dl, HDL-C 31 mg/dl, LDL-C 99 mg/dl. Troponin I 0.04 ng/ml (nl 0.0-0.09), CK-MB fxn 2.9 (nl <7.8).
  31. 31. 1-31-2006 1356 Hrs Chest pain resolved, rhythm and hemodynamics normal. CK-MB index 5.9 CK-MB fxn 191.5 ng/ml CK 3240 U/L Trop I >22.8 ng/ml
  32. 32. DL 64y female hospital ward clerk with abrupt onset of chest pain and dyspnea while rushing to meet son at airport. No CV disease history. Maximum CK xxx IU/L, troponin-I 44.6 ng/ml. Cardiogenic shock required IABP.
  33. 33. RC 83 y male in CV – ICU, immediately post-op from aorto-coronary bypass
  34. 34. RF 82 y female in ED with acute onset epigastric pain and nausea and substernal chest pressure
  35. 35. JC 27 y male with no CV disease history presented to ED in RWC with acute chest pain and shortness of breath. Substance abuse denied, toxicology studies negative.
  36. 36. JC 27 y male with no CV disease history presented to ED in RWC with acute chest pain and shortness of breath. Substance abuse denied, toxicology studies negative. CK 1372 IU/L, troponin-I >50 ng/ml. Platelet count 1472 K/mm3. Emergent transfer to the CCL. Follow-up ECG 30 minutes later:
  37. 37. NW 36 y male alcoholic fell unconscious at home, ambulance to ED, intubated. CK 775 IU/L, troponin-I 0.14 ng/ml.
  38. 38. NW 36 y male alcoholic fell unconscious at home, ambulance to ED, intubated. CK 775 IU/L, troponin-I 0.14 ng/ml. Repeat ECG 9 minutes later:
  39. 39. 42 y Asian female on chemotherapy for metastatic breast carcinoma, acute onset chest pain and dyspnea, troponin-I 1.11 ng/ml
  40. 40. 42 y Asian female on chemotherapy for metastatic breast carcinoma, acute onset chest pain and dyspnea, troponin-I 1.11 ng/ml. Echocardiography revealed large pericardial effusion due to carcinomatosis.
  41. 41. AG 81 y male with chest pain worse with inspiration, sternal tenderness, elevated troponin-I.
  42. 42. AG 81 y male with chest pain worse with inspiration, sternal tenderness, elevated troponin-I. Brought to ED by EMT from MVA. X-ray diagnosis of sternal fracture.
  43. 43. RH: 56 y male in ED with chest pain
  44. 44. DG: 58 y male in ED with lightheadedness and near syncope
  45. 45. JS: 84 y male in CV - ICU
  46. 46. How to Avoid Misdiagnosis • Talk to the patient, take a history • Examine the patient • Obtain and review original documents • Do not believe everything in the computer • Consider the differential diagnosis • Re-examine the patient • Think
  47. 47. Questions to Ask Yourself • Is my diagnosis correct? • Is my treatment plan appropriate for this diagnosis? • Is my treatment plan appropriate for this patient? • Does my patient understand and agree with the treatment plan? • Do I need help?
  48. 48. Betelgeux Bellatrix Great Nebula Rigel Saiph

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