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Objectives
Scope of Problem
(2004 stats)
1,200,000 new & recurrent coronary attacks per year 38% of those who with coronary attack die within a year of having it Annual cost > $300 billion
Age-- > 45 for male/55 for female Chronic Kidney Disease Lack of regular physical activity Obesity Lack of Etoh intake Lack of diet rich in fruit, veggies, fiber
Unstable Angina
Similar pathophysiology
Similar presentation and early management rules STEMI requires evaluation for acute reperfusion intervention
Diagnosis of Angina
Atypical angina
1 of the above
Unstable Angina
Non occlusive thrombus
NSTEMI
Occluding thrombus sufficient to cause tissue damage & mild myocardial necrosis ST depression +/T wave inversion on ECG Elevated cardiac enzymes
STEMI
Complete thrombus occlusion ST elevations on ECG or new LBBB Elevated cardiac enzymes More severe symptoms
Acute Management
Evaluation
Occurs simultaneously
History & Physical Establish diagnosis Read ECG Identify complications Assess for reperfusion
Focused History
Reperfusion questions
Palliative/Provocative factors Quality of discomfort Radiation Symptoms associated with discomfort Cardiac risk factors Past medical history especially cardiac
Timing of presentation ECG c/w STEMI Contraindication to fibrinolysis Degree of STEMI risk
Targeted Physical
Examination
Vitals Cardiovascular system Respiratory system Abdomen Neurological status
ECG assessment
ST Elevation or new LBBB STEMI
ST Depression or dynamic T wave inversions
NSTEMI
Non-specific ECG
Unstable Angina
ST-Segment Elevation MI
New LBBB
QRS > 0.12 sec L Axis deviation Prominent R wave V1-V3 Prominent S wave 1, aVL, V5-V6 with t-wave inversion
Cardiac markers
Troponin ( T, I)
CK-MB isoenzyme
Very specific and more sensitive than CK Rises 4-8 hours after injury May remain elevated for up to two weeks Can provide prognostic information Troponin T may be elevated with renal dz, poly/dermatomyositis
Rises 4-6 hours after injury and peaks at 24 hours Remains elevated 36-48 hours Positive if CK/MB > 5% of total CK and 2 times normal Elevation can be predictive of mortality False positives with exercise, trauma, muscle dz, DM, PE
7 6 5 4 3 2 1 0
3.4 % 1.0 %
831
1.7 %
174 148 134 50 67
9.0
0 to <0.4 0.4 to <1.0 1.0 to <2.0 2.0 to <5.0 5.0 to <9.0 Cardiac troponin I (ng/ml)
Risk Stratification
STEMI Patient?
Based on initial Evaluation, ECG, and Cardiac markers
YES
NO
- Assess for reperfusion - Select & implement reperfusion therapy - Directed medical therapy
UA or NSTEMI
- Evaluate for Invasive vs. conservative treatment - Directed medical therapy
amount of myocardial necrosis Preserve LV function Prevent major adverse cardiac events Treat life threatening complications
STEP 1: Assessment
Fibrinolysis indications
ST segment elevation >1mm in two contiguous leads New LBBB Symptoms consistent with ischemia Symptom onset less than 12 hrs prior to presentation
Any prior ICH Known structural cerebral vascular lesion (e.g., AVM) Known malignant intracranial neoplasm (primary or metastatic) Ischemic stroke within 3 months EXCEPT acute ischemic stroke within 3 hours Suspected aortic dissection Active bleeding or bleeding diathesis (excluding menses) Significant closed-head or facial trauma within 3 months
History of chronic, severe, poorly controlled hypertension Severe uncontrolled hypertension on presentation (SBP greater than 180 mm Hg or DBP greater than 110 mmHg) History of prior ischemic stroke greater than 3 months, dementia, or known intracranial pathology not covered in contraindications Traumatic or prolonged (greater than 10 minutes) CPR or major surgery (less than 3 weeks) Recent (within 2-4 weeks) internal bleeding Noncompressible vascular punctures For streptokinase/anistreplase: prior exposure (more than 5 days ago) or prior allergic reaction to these agents Pregnancy Active peptic ulcer Current use of anticoagulants: the higher the INR, the higher the risk of bleeding
<3 hours from onset PCI not available/delayed door to balloon > 90min door to balloon minus door to needle > 1hr Door to needle goal <30min No contraindications
PCI available Door to balloon < 90min Door to balloon minus door to needle < 1hr Fibrinolysis contraindications Late Presentation > 3 hr High risk STEMI
Killup 3 or higher
STEMI dx in doubt
Comparing outcomes
Comparing outcomes
(class IIa, level B) Inhibition of platelet aggregation at final common pathway In support of PCI intervention as early as possible prior to PCI
Post-STEMI patients
no significant renal failure (cr < 2.5 men or 2.0 for women) No hyperkalemis > 5.0 LVEF < 40% Symptomatic CHF or DM
Review guidelines for specific management of complications & other specific clinical scenarios
Decision making for risk stratification at hospital discharge and/or need for CABG
of actual ACS TIMI risk score ACS risk categories per AHA guidelines
Low
Intermediate
High
INTERMEDIATE
likelihood of ACS in absence of highlikelihood findings
History
Chest or left arm pain or discomfort as chief symptom Reproduction of previous documented angina Known history of coronary artery disease, including myocardial infarction New transient mitral regurgitation, hypotension, diaphoresis, pulmonary edema or rales
Chest or left arm pain or discomfort as chief symptom Age > 50 years
Physical examination
ECG
New or presumably new transient ST-segment deviation (> 0.05 mV) or Twave inversion (> 0.2 mV) with symptoms Elevated cardiac troponin T or I, or elevated CK-MB
T-wave flattening or inversion of T waves in leads with dominant R waves Normal ECG Normal
Normal
Non-diagnositic ECG
Non-elevated cardiac markers Age < 70 years
Low risk
Intermediate
risk
High risk
Conservative therapy
Invasive therapy
Coronary angiography and revascularization within 12 to 48 hours after presentation to ED For high risk ACS (class I, level A) MONA + BAH (UFH) Clopidogrel
20% reduction death/MI/Stroke CURE trial 1 month minimum duration and possibly up to 9 months
Early revascularization or PCI not planned MONA + BAH (LMW or UFH) Clopidogrel Glycoprotein IIb/IIIa inhibitors
Surveillence in hospital
Secondary Prevention
Disease
Behavioral
Cognitive
Blood Pressure
Goals < 140/90 or <130/80 in DM /CKD Maximize use of beta-blockers & ACE-I
Lipids
LDL < 100 (70) ; TG < 200 Maximize use of statins; consider fibrates/niacin first line for TG>500; consider omega-3 fatty acids
Diabetes
A1c < 7%
Smoking cessation
Physical Activity
Goal 30 - 60 minutes daily Risk assessment prior to initiation
Diet
DASH diet, fiber, omega-3 fatty acids <7% total calories from saturated fats
Patient education
Antiplatelet agent
Antihypertensive agent
Beta blocker* ACE-I*/ARB Aldactone (as appropriate)
Prevention news
From 1994 to 2004 the death rate from coronary heart disease declined 33%... But the actual number of deaths declined only 18% Getting better with treatment But more patients developing disease need for primary prevention focus
Summary