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- 2. The moment of maximal educational mediocrity will begin in...
- 3. 1
- 4. Acute Coronary Syndrome Bogus Chest Pain to STEMI and Beyond…. Mr. Dr. Jodi Wieters 2
- 5. The Problem…. •CV disease still #1 killer in USA •5-6 million CP pts/yr • 2nd most common “cc” • 1.1 million dx’d with AMI annually • 550,000 dx’d in the ED 3
- 6. The Problem… •434,877 patients with confirmed MI • 33% without Chest Pain •Cantos JG. JAMA. 2000;283:3223-3229. 4
- 8. Missed? 20% of malpractice awards Most dollars paid in malpractice in EM
- 9. The EKG 13
- 10. Normal EKG •1-8% AMI have a normal ECG •Approx 50% of AMI patients have diagnostic changes on their initial ECG •Peter J. Zimetbaum, M.D., N Engl J Med 2003;348:933-40. 14
- 11. 2
- 12. 2
- 13. Cath Lab? CVICU? Rule-‐out Inpatient? ED Rule-‐out? Cath Lab Options? Bogus Chest Pain
- 15. Her EKG
- 16. •History and Exam Suggestive of AMI •It Doesn’t Sound Cardiac? • Pain in Chest or Left Arm • CP Radiation • Right Shoulder • Left Arm • Both Left & Right Arm • Diaphoresis • 3rd Heart Sound • SBP < 80 mm Hg • Pulmonary Crackles LR 2.7 LR 2.9 (1.4-6.0) LR 2.3 (1.7-3.1) LR 7.1 (3.6-14.2) LR 2.0 (1.9-2.2) LR 3.2 (1.6-6.5) LR 3.1 (1.8-5.2) LR 2.1 (1.4-3.1) 7
- 17. Atypical pain… • Clinical Examination – • Pleuritic Chest Pain • Sharp or Stabbing Pain • Positional Chest Pain • Reproducible Chest Pain Against AMI • LR 0.2 (0.2-0.3) • LR 0.3 (0.2-0.5) • LR 0.3 (0.2-0.4) • LR 0.2-0.4 Panju AA. JAMA. 1998;280:1256. 8 Josh Sonnier facebook archives circa 2011
- 18. • Shry EA. AM J Card. Vol 90; 2002 • with ACS 88% responded • without ACS 92% responded • Henrickson CA. Ann Int Med.Vol 139; 2003 • with ACS, 35% responded • without ACS, 41% responded • Chandra A. 5, 10, 15 minutes on a VAS. • sensitivity 33%, 33%, and 42% • specificity 76%, 45%, and 44% 9 •NTG Response…..Not so good
- 19. There is no combination of historical and physical exam characteristics which can, by themselves, exclude ACS. 10
- 20. 15
- 21. Md calc Timi Grace Heart Talk about each.
- 24. Md calc Timi Grace Heart Talk about each. More interested in Drink/food– Wears Sunglasses-‐ Values Dilaudid > ASA-‐ Explitavies:English ratio >0.5 Wants to have a cig before cath-‐ If score >2 pt has 99% chance of bogus Chest pain Wieters Bogus Chest Pain Score
- 25. Low risk chest pain? •Age •RF •Symptomatology •EKG •EKG •Enzymes •Enzymes 17
- 26. I think I want to send them home… ☑Very atypical symptoms in low risk patient ☑NORMAL EKGs ☑Negative enzymes after 8 hrs of onset symptoms ☑Very good follow up/ DC instructions ☑Shared decision making ☑Understand you will still miss some… 18
- 27. • Acc guidelines with stress test • What does a stress test test?
- 29. His EKG
- 30. •STEMI •ST morphology. Most benign elevation presents with concave (scooped) ST segments; convex (rounded) elevation is a fairly specific for STEMI. •Changes on serial ECGs •Brady et al. Electrocardiographic ST-segment elevation: the diagnosis of acute myocardial infarction by morphologic analysis of the ST segment. Acad Emerg Med. 2001 Oct;8(10):961-7. 23
- 31. 24
- 32. •Conditions that can mimic or conceal ST elevation •A few STEMI mimics •BBB •Left ventricular hypertrophy •Benign early repolarization •Pericarditis •WPW •Brugada Syndrome •Ventricular aneurysm •Hyperkalemia 25
- 34. 27
- 35. •K 6.8 not STEMI 28 K 6.8 Not STEMI
- 36. •High lateral STEMI D1 branch of the LAD 29
- 37. 30
- 38. •High lateral STEMI proximal LAD 31
- 39. 32
- 40. •Pericarditis 33
- 42. •High lateral STEMI 35
- 43. 36
- 45. brugadda
- 47. •POST STEMI- L Circumflex 38
- 48. 39
- 50. Scarbosa critera
- 51. 51 How accurate is Scarbossa? Larson et al: 44% false activation Chang et al: 80.8% false activation Jain et al: 86% false activation
- 52. 52
- 53. 53 >0.25 more concerning Modified Scarbossa
- 54. LBBB
- 55. 55 Brugadda
- 57. •LMCA 40
- 58. 41
- 59. •I think it’s a STEMI… Now What? •Oxygen •Nitrates •ASA •Beta blockers •2 options •Thrombolytics •PCI •Heparin/Lovenox? •Plavix/Effiant? •Iib/IIIa or Bivalirudin? 42
- 60. •325mg •Reduces mortality by 23% •Greatest mortality benefit of all treatments. 43
- 61. •Decrease cardiac work and myocardial O2 requirements •Use Cautiously in MI’s involving the Right ventricle •Side effects: • Headaches • Hypotension • Hypoxemia from V/Q mismatch • Bradycardia 44
- 62. •ACC/AHA Guidelines •Start PO (not IV) BB in pts with STEMI or NSTEMI within 24 hrs provided the patient has none of the following: • 1) Heart failure • 2) Evidence of low EF • 3) Increased risk of Cardiac Shock • 4) Standard relative contraindications to BB 45 •COMMIT/CCS-2 •Increase rate of cardiogenic shock, •No improved mortality •Did decrease re-infarction and VF
- 63. •Reduced mortality when used with Fibrinolytic therapy, heparin, and aspirin in acute MI •CLARITY-TIMI 28 and COMMIT trail show improved 30 day outcomes when clopidogrel is added to standard therapy •Pt’s with aspirin allergy show receive 600mg loading dose of clopidogrel as soon as possible in setting of acute MI •Triton-TIMI 38: Prasugrel (Effiant) compares more favorably to clopidogrel (Plavix) may see increase use •Esp. diabetic pts 46
- 64. •Anticoagulants •Lovenox •Less reversible •Less monitoring •IV and SQ dosing •Debate about benefit over heparin 47
- 65. •Anticoagulants •Heparin •IV dosing, reversible •Modest reduction in mortality in USA/STEMI •Monitoring intensive 47
- 66. •Thrombolytics •Indications •ST elevation 1 mm in 2 contiguous limb leads •ST elevation 2 mm in 2 contiguous chest leads •New left bundle branch block •Chest pain consistent with AMI < 12 hours duration •No contraindications to thrombolysis or anticoagulation •Guided by regional protocols. 50
- 67. •Might not when…. • Absolute Contraindications • Hx of any hemorrhagic cerebrovascular event • Hx of non-hemorrhagic cerebrovascular event or TIA in last year • Intracranial neoplasm • Active internal bleeding except menses • Suspected aortic dissection ❿ Relative Contraindications ❿ Recent 9within 10 days) puncture of non- compressible vessel ❿ Uncontrolled hypertension DBP>110, SBP> 180 ❿ Diabetic retinopathy or ocular hemorrhage ❿ Anticoagulated with INR>2-3 ❿ Pregnancy ❿ Predisposition to bleeding ❿ > 5min of CPR or intubation trauma ❿ Within 4 weeks of surgery at non- compressible site 51
- 68. •Timing is everything… •ACC, AHA, ESC recommend PCI as the preferred method of reperfusion if the door to balloon time is <90 minutes (evidence showing that 120 minutes shows favor of PCI vs Fibrinolysis) •Door to balloon time of 90 minutes 52
- 69. •PCI •Cardiac cath plus procedure to restore patency •Angioplasty •Stents •Glycoprotein (GP) IIb/IIIa inhibitors •Bivalirudin •Improved survival rates over thrombolytics •Only available 18% US hospitals 53
- 70. •Strategies for reducing door-to-balloon time •1. EM physicians activate Cath Lab •2. Central Pager for all personel •3. Activate Cath Lab when pt is still in route •4. Except Cath Lab staff to arrive within 20 mins •5. Attending Cardiologist always on site •6. Feedback Data 54
- 71. •Complications •Cardiogenic Shock •CHF •Acute Mitral Regurgitation •Ventricular septal rupture •Myocardial rupture •Pericarditis •Seizure, Coma, Death 55
- 72. 72
- 73. •References not listed in slides •ACC.org •Peer IV/ Peer IV •http://lifeinthefastlane.com/ecg-library/lateral-stemi/ •Interview with Dr Bruce Bollinger “Why you shouldn’t dick around!” •http://www.radiologyassistant.nl •Learntheheart.org • CDEMCurriculum.org • Dr. Sonnier facebook page circa 2005 56