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Masi noon conference 7 16-18
- 2. © 2016 Virginia Mason Medical Center
- 3. © 2016 Virginia Mason Medical Center
- 4. © 2016 Virginia Mason Medical Center ECG On Admission 5
- 5. © 2016 Virginia Mason Medical Center ECG After 3 hours 6
- 6. © 2016 Virginia Mason Medical Center ECG After 21 hours 7
- 7. © 2016 Virginia Mason Medical Center ECG After 21 hours 8
- 8. © 2016 Virginia Mason Medical Center Question 1 Patient presents with chest pain and elevated troponin I serum levels with ST depressions located to leads II, III, and aVF on ECG. Where is the ischemia localized to? A. Anterior wall B. Lateral wall C. Inferior wall D.Unable to localize. 9
- 9. © 2016 Virginia Mason Medical Center ECG Interpretation
- 10. © 2016 Virginia Mason Medical Center Question 2 What percent of non-ST segment elevation ACS patients in the PURSUIT trial had mild (<50% stenosis) or no disease detectable by angiography? A. 6% B. 12% C. 15% D.24% 11
- 11. © 2016 Virginia Mason Medical Center Summary Assessment An early middle-aged male with a distant smoking history presents with a 2 day hx of chest discomfort with increasing exertional intolerance found to have an elevated troponin I but no ECG changes at admission. 12
- 12. © 2016 Virginia Mason Medical Center 13 Objectives Causes of Tropininemia • Physiology of tropinin • Alternatives to tropinin • Tropininemia Differential • Illness Script Review • Flow chart for diagnosis
- 13. © 2016 Virginia Mason Medical Center Physiology of Troponin • Troponins • Ca2+ sensitive contractile protein found in cardiac and skeletal muscle • Three subunits: C, T, I • Unique cardiac isoforms • Released into systemic circulation during myofibril rupture or leak 14
- 14. © 2016 Virginia Mason Medical Center Physiology of Troponin Sander Streng eBook
- 15. © 2016 Virginia Mason Medical Center Physiology of Troponin • Troponins • Ca2+ sensitive contractile protein found in cardiac and skeletal muscle • Three subunits: C, T, I • Unique cardiac isoforms • Released into systemic circulation during myofibril rupture or leak 16
- 16. © 2016 Virginia Mason Medical Center Alternatives to Troponin • AST- “poor man’s troponin” • CK-MB • Lactate dehydrogenase LD • Natriuretic peptides BNP • Myoglobin • CRP • ESR 17
- 17. © 2016 Virginia Mason Medical Center Differential MI-NSTEMI vs STEMI Pulmonary Embolism Pericarditis/Myocarditis/Vasculitis Rhabdomyolysis Blunt force trauma of chest Renal Failure Sepsis CHF Robust Exercise Snake/Scorpion Venom 18
- 18. © 2016 Virginia Mason Medical Center Diagnostic Tools • ECG • Radiography: X-ray and CT • Chest- frontal and lateral views • CT- w/o contrast • Serial Labs: Tn, CBC, BMP • TTE/TEE • Serology: viral, autoimmune • Drug Screens • Blood culture • Specialized labs: D-dimer, BNP • Catheterization 19
- 19. © 2016 Virginia Mason Medical Center Diagnostic Tools • ECG • Radiography: X-ray and CT • Chest- frontal and lateral views • CT- w/o contrast • Serial Labs: Tn, CBC, BMP • TTE/TEE • Serology: viral, autoimmune • Drug Screens • Blood culture • Specialized labs: D-dimer, BNP • Catheterization 20
- 20. © 2016 Virginia Mason Medical Center Illness Scripts 21 Unstable Angina/NSTEMI Pulmonary Embolism Patho- physiology Transient ischemia or subendocardial ischemia due to partial coronary obstruction Thrombolic blockage of pulmonary vasculature reducing gas exchange area Epidemiology M, >65 yo, DM, HTN, HLD, Smoking, Obesity, CAD family hx, prior event M, Smoking, Cancer, OCP, Pregnancy, Surgery, Obesity Coagulopathy family hx, prior event, Immobility, Time course Variable, Sudden onset, often transient, present at rest, Variable, Sudden onset Possible stepwise progression Clinical presentation Chest Pain/Pressure Diaphoresis, Chills, Nausea, Syncope, Palpitations Chest Pain, Pleuric Pain, Dyspnea, Cough, Syncope, Palpitations Diagnostics (Transient) ECG changes (Elevated) serum troponin, Angiography Elevated serum Troponin with or without ECGs changes Elevated D-dimer, CT, VQ-Scan
- 21. © 2016 Virginia Mason Medical Center Illness Scripts 22 Unstable Angina/NSTEMI Pulmonary Embolism Patho- physiology Transient ischemia or subendocardial ischemia due to partial coronary obstruction Thrombolic blockage of pulmonary vasculature reducing gas exchange area Epidemiology M, >65 yo, DM, HTN, HLD, Smoking, Obesity, CAD family hx, prior event M, Smoking, Cancer, OCP, Pregnancy, Surgery, Obesity Coagulopathy family hx, prior event, Immobility, Time course Variable, Sudden onset, often transient, present at rest, Variable, Sudden onset Possible stepwise progression Clinical presentation Chest Pain/Pressure Diaphoresis, Chills, Nausea, Syncope, Palpitations Chest Pain, Pleuric Pain, Dyspnea, Cough, Syncope, Palpitations Diagnostics (Transient) ECG changes (Elevated) serum troponin, Angiography Elevated serum Troponin with or without ECGs changes Elevated D-dimer, CT, VQ-Scan
- 22. © 2016 Virginia Mason Medical Center Conclusion • Diagnosis: NSTEMI • Troponin levels matter! • Expect to find everything or nothing.
- 23. © 2016 Virginia Mason Medical Center Acknowledgements Aleksandra Kardasheva Martha Fitzpatrick Katherine Adler Mike Milligan David Liskey Alvin Calderon 24
Editor's Notes
- Title your presentation “Noon Conference” Prevents inadvertently giving away the case.
- First ecg at asmission
- Second ECG
- 3rd ECG Are these the Twave inversions/flattenings?
- 3rd ECG Are these the Twave inversions/flattenings?
- D. Localization of infarct based on ECG results are only possible for STEMIs (reference….) Can J Cardiol. 2001 Jan;17(1):57-62. Localization of maximal ST segment displacement in various ischemic settings by orthogonal ECG: Implications for lead selection and the mechanism of ST shift. Nasmith JB1, Pharand C, Dubé B, Matteau S, LeBlanc A, Nadeau R.
- B. 12% uptodate Pursuit trial
- Patient arrives with Chest Pain: Need Chest Xray to eliminate Esophageal Rupture, Pneumothorax, Aortic dissection and also need to rule out MI and Pulmonary Embolism TnI= inhibits ATPase activity of actomyosin TnC= ca binding region, enables Ca sensitive contraction of mysosin TnT= interacts with thin filaments (actin) Elevated within 2-3 hours of event and peaks then returns to normal after 5 to 10 days, https://en.wikipedia.org/wiki/Troponin
- http://www.digitaalproefschrift.nl/ebooks/Sander%20Streng%20eBook/mobile/index.html#p=4
- Patient arrives with Chest Pain: Need Chest Xray to eliminate Esophageal Rupture, Pneumothorax, Aortic dissection and also need to rule out MI and Pulmonary Embolism TnI= inhibits ATPase activity of actomyosin TnC= ca binding region, enables Ca sensitive contraction of mysosin TnT= interacts with thin filaments (actin) Elevated within 2-3 hours of event and peaks then returns to normal after 5 to 10 days, https://en.wikipedia.org/wiki/Troponin
- AST= aspartate aminotransferase C Reactive protein= acute phase reactant, binds phosphocholine, so tracks to damaged cells and foreign pathogens, a pentraxin part of innate immune system, both humoral and cellular immune initiator Creatine Kinase MB (not MM or BB) isozyme- can be released from noncardiac cells, present in all skeletal/striated muscle (most dominant in heart), released with muscle cell breakdown, increased dramatically in plasma after reperfusion, increased B chain production in cases of polymyositis, elevated 4 to 6 hours after event (may take 12hrs), gone after 36-48hrs More troponin than CK MB per gram of myocardium Erythrocyte sedimentation rate Natriuretic peptides Brain (BNP) = released from myocardial cells in response to volume expansion and wall stress Lactate dehydrogenase- Muscle H heart subunits 5 isozymes L1 and L2 heart dominant, rises 10 hrs after event and peakswithin 24 to 48 hrs, baseline after 6 to 8 days Myoglobin- ½ plasma 9 min, heme protein, elevated later than troponin so no longer useful but is still an acute marker
- http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742016000300011
- Viral: ARA for syphillis, ANCA, Respiratory panel to
- Viral: ARA for syphillis, Respiratory panel to myositis Autoimmune: ESR, ANA, CRP
- Where to get images to import in here????? Want chest xray EKGs ECHO/Cather