Presentation on theme: "Symptoms of Ischemic Heart Disease"— Presentation transcript:
1Symptoms of Ischemic Heart Disease Patient history is often diagnostic.Chest discomfort with variable characteristics-pain, pressure, tightness, crushing, squeezing,stabbing, choking sensations-substernal origin with variable radiation to arm,neck, or jaw-especially when associated with exertion-duration in minutes (5-30), not seconds or hoursAssociated symptoms or anginal equivalents (dyspnea, nausea/vomiting, indigestion, diaphoresis, syncope)
2Physical Findings in Ischemic Heart Disease Physical exam is most useful to rule out differential diagnoses and often is normal in ischemic heart disease.Diaphoresis or other sign of hypoperfusionCongestive signs: JVD, rales, S3Abnormal heart sounds: S3, new murmurHypoxiaArrhythmias, especially ventricular, although must rule out MI with new onset afib
3Etiologies of Ischemia AtherosclerosisCongenital coronary anomaliesCoronary arteritisRadiation therapyCocaineAortic stenosisHypertrophic cardiomyopathy
4Differential Diagnosis of Chest Pain Acute coronary syndromesOther cardiovascular causesAortic dissectionAortic stenosisPericarditisMyocarditisHypertrophic cardiomyopathyAortic regurgitationMitral valve prolapseSevere anemiaPulmonary causesPulmonary embolusPneumothoraxPleurisyGastrointestinal causesEsophageal spasm or refluxEsophageal rupturePeptic ulcer diseaseBiliary or pancreatic diseaseMusculoskeletal causesCostochondritisMuscle strainThoracic outlet syndromeDegenerative spine diseasePsychogenic causesAnxiety/depression/panic attackPsychosisSecondary gainIT IS IMPERATIVE TO ASSESS FOR POSSIBLE LIFE-THREATENINGALTERNATIVE DIAGNOSES, SUCH AS AORTIC DISSECTION, PE,TENSION PNEUMOTHORAX, OR RUPTURED VISCUS..
5Patient Education for Early Recognition and Response to Chest Pain Healthcare providers should instruct patients previously prescribed nitroglycerin (NTG) on use for chest discomfort or pain and to call if symptoms do not improve or worsen 5 minutes after ONE sublingual NTG dose*.(* Nitroglycerin Dose: 0.4 mg sublingually)STEMI: ACC/AHA guidelines at
6Prehospital Chest Pain Evaluation and TreatmentPrehospital EMS providers should administer 162 to 325 mg of aspirin (chewed) to chest pain patients suspected of having STEMI unless contraindicated or already taken by the patient. Although some trials have used enteric-coated aspirin for initial dosing, more rapid buccal absorption occurs with non–enteric-coated formulations.It is reasonable for all dispatchers to advise patients without a history of aspirin allergy who have symptoms of STEMI to chew aspirin (162 to 325 mg) while awaiting arrival of prehospital EMS providers. Although some trials have used enteric-coated aspirin for initial dosing, more rapid buccal absorption occurs with non–enteric-coated formulations.STEMI: ACC/AHA guidelines at
7Hospital fibrinolysis: Onset of symptoms of STEMI Options for Transport of Patients With STEMI and Initial Reperfusion TreatmentHospital fibrinolysis:Door-to-Needlewithin 30 min.Not PCIcapableCall 9-1-1Call fastEMS on-sceneEncourage 12-lead ECGs.Consider prehospital fibrinolytic if capable and EMS-to-needle within 30 min.Onset of symptoms of STEMI9-1-1EMSDispatchEMS Triage PlanInter-HospitalTransferPCIcapableGOALS5min.8min.EMS TransportPatientEMSPrehospital fibrinolysisEMS-to-needlewithin 30 min.EMS transportEMS-to-balloon within 90 min.Patient self-transportHospital door-to-balloonwithin 90 min.Dispatch1 min.STEMI: ACC/AHA guidelines at
8Emergent Diagnostic Testing 12-lead EKGCardiac enzymes (CPK, CKMB, Troponin)CBCBasic or comprehensive chemistry panelCoagulation studiesD-DimerPA and lateral CXR
9Cardiac Biomarkers in ACS CPK (creatine phosphokinase) – enzyme common in skeletal, smooth, and cardiac muscle as well as brain and kidney; three isoenzymes:MB – cardiac and some skeletal muscleMM – primarily in skeletal muscleBB – primarily in brain and kidneyTroponin – protein that regulates interaction of actin and myosinTroponin C – common to skeletal and cardiac muscleTroponin T and I – diagnostic & prognostic value in myocardial injuryCardiac biomarkers provide the most accurate diagnosis of acute myocardial injury and are the reference standard for the diagnosis of MI.
10Other BiomarkersNonspecific serum markers – elevated in MI but non-specificAST (aspartate aminotransferase)LDH (lactate dehyrogenase)Myoglobin – rapid release and return to baseline butelevated with muscle infarct and renal failureNewer biomarkers – predictive of risk in ACS but not commonly used for this purposeBNP (B-type natriuretic peptide)CRP (C-reactive protein)
11Cardiac Biomarkers in ACS 10050Cardiac troponin-no reperfusion20Cardiac troponin-reperfusionMultiples of the URLCKMB-no reperfusion10CKMB-reperfusion52Cardiac biomarkers in ST-elevation myocardial infarction (STEMI).Typical cardiac biomarkers that are used to evaluate patients withSTEMI include the MB isoenzyme of CK (CK-MB) and cardiac specific troponins. The horizontal line depicts the upper reference limit (URL)for the cardiac biomarker in the clinical chemistry laboratory. The URL is that value representing the 99th percentile of a reference control group without STEMI. The kinetics of release of CK-MB and cardiac troponin in patients who do not undergo reperfusion are shown in the solid green and red curves as multiples of the URL. Note that when patients with STEMI undergo reperfusion, as depicted in the dashed green and red curves, the cardiac biomarkers are detected sooner, rise to a higher peak value, but decline more rapidly, resulting in a smaller area under the curve and limitation of infarct size. Modified with permission from Alpert et al. J Am Coll Cardiol 2000;36:959 and Wu et al. Clin Chem 1999;45:1104.Upper reference limit1Days After Onset of STEMIURL = 99th %tile ofReference Control GroupAlpert et al. J Am Coll Cardiol 2000;36:959.Wu et al. Clin Chem 1999;45:1104.STEMI: ACC/AHA guidelines at
12Cardiac Biomarkers in STEMI Troponins- Now the Gold Standard!Rise after 3-6 hoursNegative Troponin within 6 hours of onset of S&S rules out the MIPeaks at about 20 hoursMay be raised for 14 days
13Cardiac Biomarkers: Troponin T & I Troponin I90% sensitivity for MI 8 hours after onset of S&S and 95% specificityNegative rules out MIObtain two negative troponin values hours apartNormally exceedingly lowEven a small elevation indicates myocardial damageTroponin TLevels may help to stratify riskLess specific than Troponin IIncreased in anginaIncreased in chronic renal failureHighly sensitive for detecting myocardial ischemia
15EKG Changes in STEMIST elevation of 1mm or more in the limb leads or of 2mm or more in precordial leads is significant.The pattern of ST elevation indicates the location of infarct and the involved coronary artery.Dynamic changes in the ST segment or the T wave represent an evolving infarct.A new left bundle branch block is significant.
17EKG Changes: InjuryST segment elevation of greater than 1mm in at least 2 contiguous leadsHeightened or peaked T wavesDirectly related to portions of myocardium rendered electrically inactive
18EKG Changes: Infarct Significant Q-wave where none previously existed Impulse traveling away from the positive leadNecrotic tissue is electrically deadCriteria for Q-wave significanceDepth of Q wave should be 25% theheight of the R waveWidth of Q wave is 0.04 secsDiminished height of the R wave
19Dynamic EKG Changes Baseline Hyperacute T wave ST elevation Inverted T waveQ wave1 Year
20EKG Changes: Anterior/Septal MI ST changes: V1,V2, V3, V4Culprit Vessel: LAD
21EKG Changes: Inferior MI ST Changes: II, III, aVFCulprit Vessel: RCA
22EKG Changes: Lateral MI ST Changes: I, aVL, V5, V6Culprit Vessel: Circumflex
23EKG Changes: Posterior MI ST Changes: Reciprocal in V1, V2Culprit Vessels: RCA or Cx
24Summary of EKG Changes Lat: I, aVL, V5, V6 Ant/Septal: V1, V2, V3, V4 Inf: II, III, aVF Post: Rec V1, V2
26Non-invasive Diagnostic Testing May be considered only after acute MIor other emergent process has been ruled out.EchocardiographyExercise stress testingPharmacologic stress testing-Adenosine-PersantineNuclear stress testingCTACardiac MRI
27Acute Pharmacologic Interventions in STEMI OxygenNitroglycerinAnalgesia (Morphine)AspirinBeta BlockersMONAMONAB
28OxygenSupplemental oxygen should be administered to patients with arterial oxygen desaturation (SaO2 < 90%).It is reasonable to administer supplemental oxygen to all patients with uncomplicated STEMI during the first 6 hours.IIIaIIbIIISTEMI: ACC/AHA guidelines at
29NitroglycerinPatients with ongoing ischemic discomfort should receive sublingual NTG (0.4 mg) every 5 minutes for a total of 3 doses, after which an assessment should be made about the need for intravenous NTG.Intravenous NTG is indicated for relief of ongoing ischemic discomfort that responds to nitrate therapy, control of hypertension, or management of pulmonary congestion.STEMI: ACC/AHA guidelines at
31AnalgesiaMorphine sulfate (2 to 4 mg intravenously with increments of 2 to 8 mg intravenously repeated at 5 to 15 minute intervals) is the analgesic of choice for management of pain associated with STEMI.STEMI: ACC/AHA guidelines at
32AspirinAspirin should be chewed by patients who have not taken aspirin before presentation with STEMI. The initial dose should be 162 mg (Level of Evidence: A) to 325 mg (Level of Evidence: C)Although some trials have used enteric-coated aspirin for initial dosing, more rapid buccal absorption occurs with non–enteric-coated formulations.STEMI: ACC/AHA guidelines at
33STEMI: ACC/AHA guidelines at www.acc.org NSAIDsNSAIDS (except ASA) should not be given during the acute hospitalization due to increased risk of mortality, reinfarction, HTN, heart failure, and myocardial rupture.This restriction includes both nonselective as well as COX-II forms of NSAIDs.STEMI: ACC/AHA guidelines at
34Beta-BlockersOral beta-blocker therapy should be administered promptly to those patients without a contraindication, irrespective of concomitant fibrinolytic therapy or performance of primary PCI.It is reasonable to administer intravenous beta-blockers promptly to STEMI patients without contraindications, especially if a tachyarrhythmia or hypertension is present.STEMI: ACC/AHA guidelines at
35General Considerations Primary PCI for STEMI:General ConsiderationsPatient with STEMI (including posterior MI) or MI with new or presumably new LBBBPCI of infarct artery within 12 hours of symptom onsetBalloon inflation within 90 minutes of presentationSkilled personnel available (individual performs > 75 procedures per year)Appropriate lab environment (lab performs > 200 PCIs/year of which at least 36 are primary PCI for STEMI)Cardiac surgical backup availableSTEMI: ACC/AHA guidelines at
36Specific Considerations Primary PCI for STEMI:Specific ConsiderationsMedical contact–to-balloon or door-to-balloon should be within 90 minutes.PCI preferred if > 3 hours from symptom onset.Primary PCI should be performed in patients with severe congestive heart failure (CHF) and/or pulmonary edema (Killip class 3) and onset of symptoms within 12 hours.STEMI: ACC/AHA guidelines at
37Times to remember 10 minutes time for ED eval 30 minutes door to needle90 minutes door to balloon3 hours (symptom onset) Fibrinolytic vs. PCI therapy12 hours (symptom onset) Time limit for revascularization therapies as supported by data
38STEMI: ACC/AHA guidelines at www.acc.org Caveat on ReperfusionGiven the current literature, it is not possible to say definitively that a particular reperfusion approach is superior for all pts, in all clinical settings, at all times of day.The main point is that some type of reperfusion therapy should be selected for all appropriate pts with suspected STEMI.The appropriate & timely use of some reperfusion therapy is likely more important than the choice of therapy.STEMI: ACC/AHA guidelines at
39STEMI: ACC/AHA guidelines at www.acc.org Caveat on ReperfusionThe medical system goal is rapid recognition and treatment of patients with STEMI such that either:1. Door-to-needle time for initiation of fibinolytic therapycan be achieved within 30 miutesOR2. Door-to-balloon time for PCI can be kept within 90minutes.STEMI: ACC/AHA guidelines at
40Maintenance Management of the Patient after MI AspirinPlavixBeta BlockerACE inhibitor/ARBStatin therapy
41AspirinA daily dose of aspirin (initial dose of 162 to 325 mg orally; maintenance dose of 75 to 162 mg) should be given indefinitely after STEMI to all patients without a true aspirin allergy.STEMI: ACC/AHA guidelines at
42Thienopyridines (Plavix) In patients for whom PCI is planned, clopidogrel (Plavix) should be started and continued:≥ 1 month after bare-metal stent≥ 3 months after sirolimus-eluting stent≥ 6 months after paclitaxel-eluting stentUp to 12 months in absence of high risk for bleeding.STEMI: ACC/AHA guidelinesDuration of Plavix use varies among interventional cardiologists.Use of generic Plavix was strongly discouraged,but the generic form is no longer available.
43Thienopyridines (Plavix) 2007 STEMI guidelines now include long-term use of Plavix regardless of reperfusion therapy (ie-fibrinolysis, PCI, or neither):Plavix 75mg po daily (LOE A) for at least 14 days (LOE B) or one year if patients under 75 years of age (LOE C).Plavix should be held for 5-7 days prior to to CABG.STEMI: ACC/AHA guidelines
44Maintenance Management Beta blockers should be continued indefinitely in all patients who have no known contra- indications.ACE inhibitor (or ARB) if necessary should be continued indefinitely in all patients post MI.Aggressive lipid management with a statin should be initiated promptly and continued.