Challenging case in acute coronary syndrome
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Challenging case in acute coronary syndrome
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Challenging case in acute coronary syndrome
- 1. Challenging cases in acute coronary syndrome
- 2. Identity • Name : Mr. Y • Age : 63 years old • Chief complaint : chest pain
- 3. History • He felt chest pain 6 hours before admission. Characteristic: felt at rest >30 minutes, heaviness on the chest, radiating to the back. • The pain was accompanied by diaphoresis and nausea without shortness of breath, palpitation, or loss of consciousness • First chest pain • Risk factor: smoking
- 4. Physical examination • He was fully alert • BP = 120/80 mmHg • HR = 88 x/min, • RR = 20 x/minute • Normal JVP • Cardiac, lung, and abdominal examination was unremarkable
- 5. ECG
- 6. ECG, 1 hour later
- 7. Discussion • What is the diagnosis? a. STEMI b. NSTEMI c. NSTEACS d. Non ACS
- 8. Laboratory resultCardiac marker Normal Value CKMB 177 U/L < 25 U/L Troponin T 0.58 ng/mL 0-0.03 ng/mL Hemoglobin 15.2 g/dL 13.5-17,5 g/Dl Ht 46 % 40-52 % Leucocyte 13.400/mm3 4.400-11.300/mm3 Erythrocyte 5.12 mil/µL 3,6-5,8mil/µL Thrombocyte 230.000/mm 3 150.000- 450.000/mm3 MCV 90.2 fl 80-100 fl MCH 29.7 pg 26-34 pg MCHC 32.9% 32-36% Ureum 20 mg/dL 15-50mg/dL Creatinine 0.76 mg/dL 0,7-1.2 mg/dL eGFR 106 ml/min >90ml/min GDS 139 mg/dL < 200 mg/dL Natrium 136 mEq/L 135-145 mEq/L Kalium 4.0 mEq/L 3,6-5,5 mEq/L
- 9. Chest X-ray
- 10. Discussion • What is the diagnosis? a. STEMI b. NSTEMI c. NSTEACS d. Non ACS
- 11. Discussion • Risk stratification ? a. Very high risk b. High risk c. Moderate risk d. Low risk
- 12. GRACE score Predictor Score Age, years <40 0 40-49 18 50-59 36 60-69 55 70-79 73 80 91 Predictor Score Heart Rate, beats/min <70 0 70-89 7 90-109 13 110-149 23 150-199 36 >200 46 Predictor Score SBP, mmHg <80 63 80-99 58 100-119 47 120-139 37 140-159 26 160-199 11 >200 0 Predictor Score Creatinine, µmol/L 0-34 2 35-70 5 71-105 8 106-140 11 141-176 14 177-353 23 ≥354 31 Predictor Score Cardiac arrest at admission 43 ST deviation 15 Elevated cardiac marker 30 Predictor Score Killip Class I 0 II 21 III 43 IV 64 Total 149
- 13. Very high-risk criteria Haemodynamic instability or cardiogenic shock Recurrent or ongoing chest pain refractory to medical treatment Life-threatening arrhythmias or cardiac arrest Mechanical complications of MI Acute heart failure Recurrent dynamic ST-T wave changes, particularly with intermittent ST-elevation High-risk criteria Ride or fall in cardiac troponin compatible with MI Dynamic ST- or T-wave changes (symptomatic or silent GRACE score ≥140 Intermediate-risk criteria Diabetes mellitus Renal insufficiency (eGFR < 60 mL/min/1.73 m2) LVEF < 40% or congestive heart failure Early post-infaction angina Prior PCI Prior CABG GRACE score >109 and <140 Low-risk criteria Any characteristics not mentioned above
- 14. CRUSADE Hematocrit, % Score <31 9 31 – 33.9 7 34 – 36.9 3 37-39.9 2 ≥ 40 0 Creatinine clearance, mL/min Score ≤ 15 39 15- 30 35 30-60 28 60-90 17 90-120 7 >120 0 Heart rate, bpm Score ≤ 70 0 71- 80 1 81-90 3 91-100 6 101-110 8 111-120 10 >120 11 Sex Score Male 0 Female 8 Signs of CHF Score No 0 Yes 7 Prior vascular disease Score No 0 Yes 6 Diabetes mellitus Score No 0 Yes 6 SBP, mmHg Score ≤ 90 10 91- 100 8 101-120 5 121-180 1 181-200 3 >200 5 Total : 15
- 15. Discussion • What is the treatment strategy? a. Immediate invasive b. Early invasive c. Invasive d. Non-Invasive
- 16. DAPT for initial treatment a. Clopidogrel 600 mg + aspirin 320 mg b. Ticagrelor 180 mg + aspirin 320 mg c. Clopidogrel 300 mg + aspirin 320 mg d. Clopidogrel 300 mg + cilostazol
- 17. What’s ESC Guidelines NSTEACS 2015 say on P2Y12 inhibitor ? A P2Y12 inhibitor is recommended, in addition to aspirin, for 12 months unless there are contraindications such as excessive risk of bleeds. Ticagrelor is recommended, in the absence of contraindications,for all patients at moderate-to-high risk of ischaemic events (e.g. elevated cardiac troponins), regardless of initial treatment strategy and including those pretreated with clopidogrel (which should be discontinued when ticagrelor is started). Prasugrel is recommended in patients who are proceeding to PCI if no contraindication). Clopidogrel is recommended for patients who cannot receive ticagrelor or prasugrel or who require oral anticoagulation. 1B 1B 1B 1A Roffi M et al. European Heart Journal 2015. doi:10.1093/eurheartj/ehv320
- 18. Angiography
- 19. Angiography
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- 24. Angiography