1. ACUTE CORONARY SYNDROME Jarrod D. Frizzell, MD, MS Fellow, Cardiovascular Medicine July 10, 2014

2. A Case 37yoM awoke with chest pressure Radiating to left shoulder Still present after 1h. Tachy, “JVD to ears”, lungs clear Just diagnosed with DM last night iStat Tn: 0

6. Outline Definitions ACS MI STEMI NSTEMI UA Pearls

7. Acute Coronary Syndrome

9. Syndrome Chest pain (angina?) Most common: upper body discomfort & SOB Diaphoresis Nausea/vomiting Dizziness Isolated atypical sx are uncommon (women, elderly, DM) Entire picture must be set in clinical context ECG or isolated Tn alone does not make it

10. Acute Coronary Syndrome Goldacre, Acad Emer Med 2003

11. Acute Coronary Syndrome ACS typically implies “type I event” Divided into: STEMI NSTEMI UA

12. Braunwald, AJRCCM 2012

13. Types of MI

14. Universal Definition of MI Detection of rise and/or fall of cardiac biomarkers with at least 1 value above the 99 th %ile reference limit and with at least 1 of the following Sx of ischemia New or presumed new significant ST-T changes or LBBB Development of pathologic Q waves Imaging evidence of new loss of viable myocardium or new WMA Identification of an intracoronary thrombus (cath or autopsy) Circulation 2012

15. Features Braunwald, 9 th ed.

16. ECG

17. STEMI ST elevations—measured at the J point V2-V3—age/gender dependent Women: 1.5mm Men ≥40: 2mm Men <40: 2.5mm 1mm in all other leads “Injury pattern”

18. STEMI ECG.utah.edu

19. STE Ecginterpretation.blogspot.com

20. ECG

24. STEMI vs everything else Why? Very specific for transmural ischemia (diagnosis & location) “Time is muscle”

25. THE Graph Gersh, JAMA 2005

26. 2013 STEMI Guidelines

28. STEMI Meds—Before Cath Anti-platelet load ASA Thienopyridine (clopidogrel) Anticoagulation Heparin/LMWH Bivalirudin (if PCI—started in cath lab) Not fonda IIb/IIIa fallen out of favor except special circumstances Pain relief NTG Morphine? If need beyond, call fellow (for boards: CCB, BB)

29. Back to ACS

30. NSTEMI Still presentation of ACS, but not STE Elevated Tn TIMI Score

31. Braunwald, AJRCCM 2012

32. NSTEMI

33. If low risk, probably go with noninvasive imaging Dob echo Dipy/cardiolite Initial meds overall similar to STEMI ASA/clopidogrel Heparin/LMWH Time is less pressing Urgent (<120min) Early invasive (<72h) Conservative (not cath)

34. Unstable Angina Definition CP that occurs at rest or with minimal exertion, lasts >20min Onset within past month Crescendo pattern A dying breed? Broadly speaking, treat like NSTEMI

35. “Routine Medical Therapy” Within 24h: Beta-blocker ACEI High-intensity statin Also get TTE

36. When to call? Whenever you feel uncomfortable Not the resident’s job to “rule out STEMI” on ECG You will only regret not calling If cannot get CP-free

37. Miscellany Elevated Tn—when to heparinize? DAPT—duration DES: 1y BMS: at least 1mo, up to 1y ACS but no intervention—1 year “No breakfast on 7S” (NPO for tests) “No coffee at the VA” (NPO for nuc, caffeine interferes)

38. Boards Odds & Ends RV Infarct Inferior STE (get right-sided ECG) +JVD but clear lungs (Borderline) Hypotensive  fluids Avoid NTG STEMI is not only cause of STE If STEMI at non-PCI OSH: Transfer if PCI within 120min Lytics if transfer outside window Idioventricular rhythm post reperfusion Looks like VT, but slower No additional therapy