ACS and the 12 Lead ECG

The 12 Lead ECG is at the center of the decision pathway in the management of patients with ischemic chest pain.The 12 Lead ECG is at the center of the decision pathway in the management of patients with ischemic chest pain. AHA Guidelines 2000

Scenario #1 55 y/o male c/o sub-sternal chest pressure that started while exerting himself. Pain radiates to his neck/jaw. Pain unrelieved with rest or patients own NTG.55 y/o male c/o sub-sternal chest pressure that started while exerting himself. Pain radiates to his neck/jaw. Pain unrelieved with rest or patients own NTG. Patient is cool, and pale.Patient is cool, and pale. DX?DX?

Scenario #2 60 y/o female c/o dull, aching, pain in her chest that radiates to her left breast. Sts pain has been constant for past hour, getting increasingly worse. Hx of HTN, NIDDM, Angina. Sts pain is like previous angina attack, just worse.60 y/o female c/o dull, aching, pain in her chest that radiates to her left breast. Sts pain has been constant for past hour, getting increasingly worse. Hx of HTN, NIDDM, Angina. Sts pain is like previous angina attack, just worse. Patient is cool, pale, diaphoretic.Patient is cool, pale, diaphoretic. DX?DX?

What similarities do these two scenarios share?What similarities do these two scenarios share? How can their treatment both be different.How can their treatment both be different. How will the 12 lead guide our treatment of these patients?How will the 12 lead guide our treatment of these patients?

Introduction Acute Coronary Syndrome is a group of disease process’s that signs and symptoms mimic each other.Acute Coronary Syndrome is a group of disease process’s that signs and symptoms mimic each other. Although similar, they are not the same.Although similar, they are not the same. The treatment for ACS is based on the patient’s current “stage” in the disease processThe treatment for ACS is based on the patient’s current “stage” in the disease process

ACSACS STAGESSTAGES

Stable Angina A flow/demand imbalance between reduced blood flow through a narrowed artery, and increased demand.A flow/demand imbalance between reduced blood flow through a narrowed artery, and increased demand.

Unstable Angina/Non-Q Wave Infarction Symptoms of angina that are new or increasing or that occur at rest. Seldom relieved with rest, O2, or NTG.Symptoms of angina that are new or increasing or that occur at rest. Seldom relieved with rest, O2, or NTG. Symptoms are usually due to platelet aggregation in narrowed arteries with chronic atherosclerotic occlusions.Symptoms are usually due to platelet aggregation in narrowed arteries with chronic atherosclerotic occlusions.

Unstable Angina/Non-Q Wave Infarction Unstable Angina can be complicated by the release of micro-emboli that occlude distal micro-vasculature.

Q-Wave Infarction Complete formation of thrombus in an artery.Complete formation of thrombus in an artery. Spontaneous lysis of the clot can occur, but often too late to salvage the heart muscle.Spontaneous lysis of the clot can occur, but often too late to salvage the heart muscle.

Indicative Changes Ischemia: Symmetrically inverted T waves or down sloping ST segment depression greater then 1mmIschemia: Symmetrically inverted T waves or down sloping ST segment depression greater then 1mm Injury: ST segment elevation greater then 1mmInjury: ST segment elevation greater then 1mm Infarct: Pathological Q wave formationInfarct: Pathological Q wave formation

Ischemia

Injury/Infarction

Indicative Changes Based on the patients 12 lead ECG, they will be placed into 1 of 3 treatment categories that are aimed at correcting the specific Acute Coronary Syndrome present.Based on the patients 12 lead ECG, they will be placed into 1 of 3 treatment categories that are aimed at correcting the specific Acute Coronary Syndrome present.

Treatment Categories

Why Do We Care? The only ACS disease process that benefits from Thrombolytic therapy are those that are caused by complete occlusion of an artery.The only ACS disease process that benefits from Thrombolytic therapy are those that are caused by complete occlusion of an artery. Recognition of ST Segment Elevation ACS is the first step in a race against the clock.Recognition of ST Segment Elevation ACS is the first step in a race against the clock.

Treatment Strategies

YES NO

Scenario Review

Scenario #1 55 y/o male c/o sub-sternal chest pressure that started while exerting himself. Pain radiates to his neck/jaw. Pain unrelieved with rest or patients own NTG.55 y/o male c/o sub-sternal chest pressure that started while exerting himself. Pain radiates to his neck/jaw. Pain unrelieved with rest or patients own NTG. Patient is cool, and pale.Patient is cool, and pale.

Scenario #1 Does this patient meet ECG requirements for thrombolysis?Does this patient meet ECG requirements for thrombolysis? What stage of ACS can you predict from the presenting 12 lead?What stage of ACS can you predict from the presenting 12 lead? What complications can you expect to see if the patient’s condition worsens?What complications can you expect to see if the patient’s condition worsens?

Scenario #2 60 y/o female c/o dull, aching, pain in her chest that radiates to her left breast. Sts pain has been constant for past hour, getting increasingly worse. Hx of HTN, NIDDM, Angina. Sts pain is like previous angina attack, just worse.60 y/o female c/o dull, aching, pain in her chest that radiates to her left breast. Sts pain has been constant for past hour, getting increasingly worse. Hx of HTN, NIDDM, Angina. Sts pain is like previous angina attack, just worse. Patient is cool, pale, diaphoretic.Patient is cool, pale, diaphoretic.

Scenario #2 Does this patient meet ECG requirements for thrombolysis?Does this patient meet ECG requirements for thrombolysis? What significance do the tall T waves suggest?What significance do the tall T waves suggest? What complications can you expect to see if the patient’s condition worsens?What complications can you expect to see if the patient’s condition worsens?

Exceptions to the Rules Some subsets of patients may be eligible for Fibrinolytic therapy even though they do not present with ST segment elevation.Some subsets of patients may be eligible for Fibrinolytic therapy even though they do not present with ST segment elevation. –Posterior current of injury –Tall, hyperacute t waves