Acute Coronary Syndromes

1
Acute Coronary Syndromes Or, heart attacks for
the would-be dumb ass
Brendan Munn Emergency Residents Academic
Day August 27 2009
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
2
Objectives

1. review terminology and pathophys
2. approach to risk stratification
3. discuss ACS management with cases
4. review the literature on management
5. prevent and manage complications

CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
3
Definitions and Pathophys
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
4
Chest pain suggestive of ischemia
Immediate assessment within 10 Minutes
Initial labs and tests
Emergent care
History Physical
IV access cardiac monitors MONA BHCG SA assess
reperfusion manage complications
12 lead ECG labs initial cardiac
enzymes electrolytes, cbc, bun/cr, glucose,
coags CXR
5
case 1
HPI 52F with 0.5h central chest pain no
associated sx or radiation CRF FHx,
smoker, HTN, T2DM BMI 35
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
6
Are Risk Factors Helpful?
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
7
Are Risk Factors Helpful?
gt17,000 post hoc with suspected ACS compared with
outcome of ACS limited clinical value in
diagnosing acute coronary syndromes, especially
in patients over 40 years useful lt 40 if no
risk factors (LR 0.17) or if 4 or more (LR 7.39)
Han J. Ann Emerg Med 2007
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
8
case 2
HPI 73yoM w hx exertional chest pain and SOB.
crescendo use of NTG spray over last 3 weeks. CP
in ED.
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
9
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
10
is this a NORMAL ecg?
what ABNORMAL findings would you expect in ACS?
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
11
NSSTT changes STE/STD lt 1mm /-T wave
morphology changes without inv or peak
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
12
Are ECG Changes Helpful?
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
13
Are ECG Changes Helpful?
1 of patients with normal ECG had AMI and 4 had
a final diagnosis of UA in another study, w
classic angina and normal ECG 3 had final
diagnosis of AMI 3-4 of patients with AMI and
over 20 of patients with UA have NSSTT findings
Lee TH. JAMA 1999 Zimetbaum P. NEJM 2003.
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
14
case 3
HPI 64F with 2h chest pain radiating to
both arms. O/E Diaphoretic, HR 120, BP 142/75
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
15
ECG ?STEMI
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
16
Is this ST Elevation?
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
17
Is this ST Elevation?
ACS Definition gt 1.0mm in 2 contiguous
precordial gt 2.0mm in 2 contiguous
limb method of calculation baseline, j
point other causes of ST segment elevation
Wang K. NEJM 2003
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
18
ST Elevation
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
19
Causes of ST Elevation
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
20
Causes of ST Elevation
Brady J. Am J Emerg Med 2001
(in 175 patients)
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
21
ECG Pearls in ACS
50 of patients with AMI will have a clearly
diagnostic ECG at presentation (STE or STD) ST
segment elevation identifies those who benefit
from reperfusion therapy (lytics) Mortality
increases with the number of leads showing STE,
presence of LBBB and anterior location Reciprocal
changes are seen in 70 of inferior and 30 of
anterior MIs, which demonstrates over 90
specificity and PPV for AMI RV infarcts
complicate 40 of inferior AMIs
Lee TH. JAMA 1999
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
22
ECG is an important tool!
guidelines say get one within 10 minutes
repeat every 15 mins prn
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
23
Are Cardiac Markers Helpful?
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
24
Are Cardiac Markers Helpful?
Troponin (TnT, TnI) very specific, gtCK
good sensitivity, gtCK guidelines draw 8-12h
prognostic value risk stratification false
positives
CK-MB less specific, earlier CK or
CK-MB peak predicts mortality and LVEF for both
STEMI and UA/NSTEMI post infarct and post PCI
Hamm C. Circulation 2002, Aviles RJ. NEJM 2002,
Alexander JH. JAMA 2000, Savonitto S. J Am Coll
Cardiol 2002
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
25
Chest pain suggestive of ischemia
Immediate assessment within 10 Minutes
Initial labs and tests
Emergent care
History Physical
IV access cardiac monitors MONA BHCG SA assess
reperfusion manage complications
12 lead ECG labs initial cardiac
enzymes electrolytes, cbc, bun/cr, glucose,
coags CXR
26
case 4
HPI 59F w 3h pleuritic CP, rad neck
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
27
Are Clinical Features Helpful?
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
28
Are Clinical Features Helpful?

Goodacre S. Acad Emerg Med 2002
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
29
How Good Are We in ACS?
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
30
How Good Are We in ACS?
Analyzed clinical data from a multicentre
prospective trial of over 10,000 patients with
chest pain suggestive of ACS 17 ultimately met
the criteria for ACS (8 had AMI and 9 had
UA) 2.1 of those with AMI and 2.3 of those
with UA were mistakenly discharged from the ED
Pope J. NEJM 2000 EMRAP Jan 2008
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
31
Pope J. NEJM 2000
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
32
Chest pain suggestive of ischemia
Immediate assessment within 10 Minutes
Initial labs and tests
Emergent care
History Physical
read ECG establish diagnosis assess for
reperfusion identify complications
IV access cardiac monitors oxygen aspirin nitrates
12 lead ECG labs initial cardiac
enzymes electrolytes, cbc, bun/cr, glucose,
coags CXR
33
Approach
UA/NSTEMI
STEMI
reperfusion strategy lysis vs PCI
risk assessment ACC, TIMI choose
invasive vs conservative
medical therapy
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
34
case 5
HPI 68M 3h chest pressure diaphoresis,
N/V, SOB hx anterior MI, stent 2001 O/E
HR 110, BP 120/80, sat 94 RA
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
35
ecg ST depressionuse b williams, incl V4R
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
36
Risk Stratification
likelihood of ACS adverse outcome missed
diagnosis
ECG Clinical Hx Physical Exam Markers
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
37
Stratify Risk ACC Guidelines
Low lt10 minutes rest pain non-diagnostic
ECG no elevation cardiac markers age lt 70
High elevated markers ST depression
treatment failure CHF failed noninv
stress poor LV function hemodynamic
instability sustained VT PCI within 6
mos prior CABG
Moderate moderate to high likelihood CAD gt10
minutes rest pain now resolved T inv gt
2mm slight elevation cardiac markers
clinic conservative invasive
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
38

HIGH INTERMEDIATE LOW
history Chest or left arm pain or discomfort as chief symptom Reproduction of previous documented angina Known history of CAD/MI Chest or left arm pain or discomfort as chief symptom Age Probable ischemic symptoms Recent cocaine use
physical exam Diaphoresis, hypotension, pulmonary edema, new mitral regurgitation Extracardiac vascular disease Chest discomfort reproduced by palpation
ECG New transient ST-segment deviation (gt 0.05 mV) or T-wave inversion (gt 0.2 mV) with symptoms Fixed Q waves Abnormal ST Old abnormal T waves T-wave flattening or inversion in leads with dominant R waves Normal ECG
cardiac markers Elevated cardiac troponin T or I, or elevated CK-MB Normal Normal
39
TIMI score
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
40
routine invasive inc mortality TIMI3b early
invasive lt24h beneficial in TIMI gt 3
TACTICS unstable, refractory, CHF for early
invasive
41
TIMI score
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
42
GRACE score
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
43
using scores
BAD NEWS all scores for short term
prognosis (TIMI 14d, GRACE 30d) GOOD NEWS in
the ED we live in the short term!
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
44
Medical Treatment
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
45
Medical Treatment
M orphine B eta Blocker O xygen H
eparin N itrates C lopidogrel A SA G P
IIb/IIIa Statin ACEi / ARB
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
46
Morphine
LOE STEMI/NSTEMI class I/IIa, level C dose 2-4mg
IV then 2-8mg q5-15mins mech analgesia, dec
adrenergic tone, dec SVR, dec oxygen
demand care hypotension, hypovolemia, respiratory
depression
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
47
Oxygen
class I, level C 2-4L/min may limit ischemia by
inc O2 delivery mouth breathers, smokers
LOE dose mech care
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
48
Nitrates
class I, level B 0.4mg SLx3, infusion
0-640mcg/min analgesia, dilates coronary
vessels, dec SVR, dec preload careful with PDE5
inhibitors, hypotension, RV infarction
LOE dose mech care
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
49
ASA
class I, level A 160-325mg chewed and
swallowed irreversible inhibition of platelet
aggregation hypersensitivity, bleeding d/o, PUD
LOE dose mech care
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
50
ASA
ISIS2 Lancet 1988 17,200 pt DBRCT
streptoK vs ASA vs both in MI aspirin benefit
strepto (NNT 20) without increased
bleed META-ANALYSIS BMJ 2002 287
studies low daily dose of 75-150mg effective
secondary prevention minimum 150mg loading
dose in acute setting
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
51
Beta Blockers
class I, level A metoprolol 5mg IV q5, 50 po
q6h negative inotrope and chronotrope, dec
demand/inc perfusion, dec arrythmias, improved
diastolic relaxation careful with CHF,
brady/blocks, hypotension, asthma
LOE dose mech care
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
52
Beta Blockers
ISIS1 Lancet 1986 16,000pt IV
atenolol vs usual. benefit. COMMIT/CCS 2
Lancet 2005 45,000pt DBRCT IV/po metoprolol vs
none in MI. no benefit, inc cardiogenic
shock Guidelines 5mg IV q5 and 50mg q6h po in
first 24h if no contraindications or risk cardio
shock
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
53
Heparin
class I-IIa, level C depends direct thrombin
inhibitor bleeding d/o, PUD, low risk patients
LMWH less HIT, easier but not better renal dosing
LOE dose mech care
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
54
META-ANALYSIS JAMA 1996 33 reduction
MI/death heparin vs placebo w ASA in UA ESSENCE
J Am Coll Card 1999 3,200 pt DBRCT ASA
enox vs UFH in UA/NSTEMI SYNERGY JAMA
2004 10,000 pt DBRCT enox vs UFH in NSTEMI w
PCI, GPI ExTRACT - TIMI25 J Am Coll Card 2007
20,000 pt DBRCT enox vs UFH in STEMI w
lysis META-ANALYSIS Eur Heart J 2007
49,000 pt enox vs UFH in all ACS
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
55
Murphy S. Eur Heart J 2007
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
56
Fondaparinux 2.5mg
mech Anti-Xa OASIS 5 NEJM 2006 20,000 PT
DBRCT enox vs fonda for ACS cheaper,
equivalent, lower bleed rate irrespective of
switching antithrombotics, PCI Guidelines use
in UA/NSTEMI if non invasive or if undecided
in invasive/STEMI needs UFH to reduce cath
thrombus
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
57
Clopidogrel
class I, level B 300 - 600mg then 75mg
daily irreversible inhibition of platelet
aggregation via ADP CABG evidence for use in
support of cath, PCI or if unable to take aspirin
LOE dose mech care
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
58
CAPRIE Lancet 1996 19,500 pt DBRCT
clopidogrel vs ASA in prevention CURE NEJM
2001 12,500 pt DBRCT clopidogrel vs placebo in
UA/NSTEMI CLARITY - TIMI 28 NEJM 2005 3500
pt DBRCT clopidogrel vs placebo in STEMI w
lysis COMMIT Lancet 2005 45,500 pt DBRCT
clopidogrel vs placebo in STEMI w ASA /-
lytics, no PCI
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
59
Clopidogrel - Guidelines
UA/NSTEMI/STEMI loading dose 75mg daily for
min 14d no loading dose in gt 75y
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
60
Glycoprotein IIb/IIIa Inhibitors
class IIa, level B depends competitive binding
of GP receptor on platelets, preventing fibrin
crosslinkage with the healthcare budget few
indications unless for cath
LOE dose mech care
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
61
Statin
class X, level X atorvastatin 80mg unknown
acutely (pleiotropic?), long term HMG-CoA
reductase inhibition and dec plaque liver disease
LOE dose mech care
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
62
Statin
PROVEIT - TIMI 22 NEJM 2004 4000 pt
RCT prava 40 vs atorva 80 in MI MIRACL
JAMA 2001 3000pt RCT early atorvastatin 80 vs
placebo in NSTEMI ARMYDA-ACS J Am
Coll Card 2007 171 pt RCT atorvastatin 80 vs
placebo in PCI
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
63
ACE Inhibitor / ARB
class I, level A as low as 1.25 decreases
afterload, helps ventricular remodeling use in
HF, DM, LV dysfunction, HTN elevated Cr
LOE dose mech care
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
64
case 6
paramedics call enroute ?STEMI direct to
cath HPI 30 mins CP
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
65
Ecg 1
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
66
repeat Ecg 2
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
67
Reperfusion Strategy?
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
68
Contraindications to Thrombolysis
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
69
Contraindications to Thrombolysis
absolute prior ICH ischemic CVA lt 3 mos
AVM/neoplasm suspected dissection bleeding
diathesis
relative bleeding disorder anticoagulated
severe hypertension ischemic CVA gt 3 mos
prolonged CPR recent surg, trauma, PUD
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
70
23 trials.
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
71
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
72
Lytics vs PCI

• PCI preferred if
• PCI available
• Door to balloon lt 90min
• Door to balloon minus door to needle lt 1hr
• Fibrinolysis contraindications
• Late Presentation gt 3 hr
• High Risk STEMI
• Killip 3 or cardiogenic shock
• STEMI dx in doubt

• Fibrinolysis preferred if
• lt3 hours from onset
• PCI not available/delayed
• door to balloon gt 90min
• door to balloon minus door to needle gt 1hr
• Door to needle goal lt30min
• No contraindications

CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
73
case 7
You are working in Lethbridge ED HPI 64yoM
crushing chest pain for 6h
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
74
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
75
lysis? follow up of lysis? transfer for PCI?
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
76
other indications for cath
cardiogenic shock killip gt 3 rescue PCI new -
any lysed patient within 6h
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
77
Rescue PCI
repeat ECG at 90 mins lt 50 ST
resolution persist/worsen chest
pain cardiogenic shock heart failure
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
78
TRANSFER AMI
1000 patients randomized to lysis plus PCI vs
conservative / rescue PCI within 6h 46 RRR in
death/MI at 30 days
Cantor W. NEJM 2009
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
79
Review

• is this a STEMI?
• check ECG lt 10mins, repeat q15 prn
• rapid reperfusion for STEMI
• thrombolytics vs direct PCI
• rescue / transfer in lysis
• risk stratification for UA/NSTEMI
• conservative vs invasive strategy
• TIMI score helpful

CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
80
Review

• medical therapy MONA BHCG SA
• heparin for high risk
• fondaparinux 2.5mg if UA/NSTEMI
• UFH if STEMI or early invasive
• beta blocker and statin early if possible

CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
81
References

1. Tintinalli
2. Up To Date
3. EMRAP
4. ACC Guidelines 2004/2007
5. Selected megatrials

CALGARY EMERGENCY MEDICINE TEACHING ROUNDS