2 Introduction The spectrum clinical conditions ranging from : ST elevation MI ( 1/3 cases )Non ST elevation MI ( 2/3 cases )Characterized by the common physiopathology of disrupted atherosclerotic plaque
4 Diagnosis of ACSHistory of cardiac chest pain: accompanied by SOB , diaphoresis , palpitation , nausea , lightheadedness- radiates to arm , neck , jaw – is worse with exertion- may improve with NG administrationCardiac risk factor : Age ( men >55 , women >65 )-DM-Smoking-HTN- Hypercholesterolemia – Family history early of CAD .Approximately one half of all pts with ACS have no established risk factors other than age & gender .Physical examination : vital signs – heart failure .Atypical presentation : absence of chest pain “ silent MI ” , SOB , cardiogenic shock , altered mental stastus , epigastric pain , fatigue , nausea , palpitation ( especially in DM , elderly patients , post operations ) .
5 Diagnosis of ACS Differential diagnosis : Non cardiac life threatening causes : Aortic dissection , PE , Tension pneumothoraxCardiac causes : pericarditis , tamponade , myocarditis .Common non cardiac causes: GI ( GERD , cholecystitis , pancreatitis )- Musculoskeletal ( costeochondritis) – Pulmonary ( Pleurisy , pneumonia )- Psychiatric ( Panic attacks )
7 ST elevation MI Cardiac biomarkers: An elevated level of Troponine correlates with increased risk of death , greater elevation predict greater risk of adverse outcome .They are insensitive during the first 4-6 hrs of presentation .Serial marker testing over time improves sensitivity but remains insensitive in the first 4-6 hrs
8 Conditions that cause an increased level of Troponine I ,T outside ACS Renal insufficiencyPEMyopericarditisDecompensated HFCoronary spasmCritical illness ( including burns & sepsis )Cardiac contusion , trauma, surgeryElectrocardioversion/ defibrillationElectrophysiological procedures ( including arrhythmia ablation procedures )
9 STEMIECG :The 12 lead ECG is central to the triage of pts with chest discomfort .A 12 lead ECG should be performed & shown to an experienced EP within 10 mins of ED arrival of all pts with chest discomfort .A normal ECG doesn’t preclude the diagnosis of ACS . Serial assessments improve sensitivity & specificity for detecting ACS .
11 Difficult ECG interpretations ST elevation in absence of AMI : early repolarization , LVH , pericarditis , myocarditis , LV aneurysm , hypertrophic CM , ventricular paced rhythms , LBBB , hypothermiaST depression in absence of ischemia : hypokalemia , digoxin effect , cor pulmonale , LVH , LBBBT waves inversion without ischemia : CNS hemorrhage , mitral valve prolapse , pericarditis , PE , LVH , RBBB , LBB
12 STEMI ECG criteria for diagnosis of MI in the presence of LBBB. ST elevation of ≥ 1mm in leads with positive QRSST depression ≥ 1mm in leads V1 to V3ST elevation > 5mm in leads with a negative QRS
13 NSTEMIPresentation :Rest angina : prolonged (>20 min ) discomfort during lack of physical activityNew onset angina: newly diagnosed severe discomfort causing marked limitation of physical activityWorsening angina : intense prolonged with less strenous activity
15 High risk patients with NSTEMI Refractory ischemic chest painRecurrent/ Persistent ST deviationVentricular tachycardiaHemodynamic instabilitySigns of pump failurePositive cardiac biomarkersTIMI ≥ 5 Early invasive strategies.
21 Initial general therapy Aspirine: mgNitroglycerine: No apparent impact on mortality in pts with ACS.Indication : ongoing chest discomfort , HTN , pulmonary congestion .CI: hypotension , severe bradycardia < 50bpm, tachycardia > 100 bpm , RV infarction .Morphine Sulphate
22 Reperfusion therapies FibrinolyticsPercutaneous Coronary Intervention :Superior to fibrinolytics in combined end points of deah , stroke & reinfarction in many studies ( with skilled providers at a skilled PCI facility )Preferred in patient with STEMI , symptoms duration ≤ 12hs , door to balloon time ≤90 mins.Preferred in patients with CI of fibrinolytics , cardiogenic shock , HF .
25 Adjunctive therapies Clopidogrel : oral loading dose 300 mg B Adrenergic Receptor BlokersLow Molecular Weight Heparin : Enoxaparin ( Lovenox )NSTEMI 1mg/kg SC bid CrCl <30ml/min 1mg/kg qdSTEMI:<75ys 30mg single bolus plus 1mg/kg SC then 1mg/kg SC q12h<75ys CrCl <30ml/min 30mg single bolus then 1mg/kg then 1mg qd≥ 75ys 0.75mg/kg SC q12h ( no initial bolus )≥75ys CrCl <30ml/min 1mg SC qdGlycoprotein IIB/IIIA InhibitorsACE InhibitorStatins
26 Complications Cardiogenic shock , LV failure , CHF RV infarction : should be suspected in inferior and or/ posterior MI.Mechanical complications: rupture of free wall , IV septum , papillary muscle .Arrythmias :VF&VT : majority of early death , highest in the first 4 hrs , lidocaine plays no role in prophylaxis .AFBradyarrythmias : sinus bradycardia, AV block
28 ConclusionsOnce the pts with ACS contacts with the health care system. Health care providers must focus on support of cardiopulmonary function , rapid transport , early classification based on ECG characteristics .Patients with STEMI require prompt reperfusion , the shorter the interval from onset to reperfusion , the greater the benefit .Patients with NSEMI require risk stratification , appropriate monitoring & therapy .Health care providers can improve survival rates, myocardial function of ACS patients by providing skilled , efficient , coordinated out of hospital & in hospital care