MODULE 3

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MODULE 3
Acute Coronary Syndromes Part 1
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Acute Coronary Syndromes

• Definition
• Sudden ischemic disorders of the heart
• Include unstable angina and acute myocardial
  infarction
• Represent a continuum of a similar disease process

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Acute Coronary Syndromes
Acute Coronary Syndromes ACS
Q Wave Infarct QMI
Unstable Angina USA
Non-Q Wave Infarct NQMI
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Acute Coronary Syndromes

• Unstable angina (USA)
• Non-Q wave MI (NQMI)
• Q wave MI (QMI)

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Acute Coronary Syndromes

• All have sudden ischemia
• Can not be differentiated in the first hours
• All have the same initiating events

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Initiating Events

• Plaque rupture
• Thrombus formation
• Vasoconstriction

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Plaque Rupture
Stable
Vulnerable
Lipid Core
Lipid Core
Lumen
Fibrous Cap
Fibrous Cap
a
a
a
a
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Plaque Rupture
a
a
Lipid Core
Fibrous Cap
Lumen
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Thrombus Formation
a
a
Platelets Adhere
Lipid Core
Fibrous Cap
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Thrombus Formation
Lipid Core
Platelet Aggregation
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Thrombus Formation
Lipid Core
Platelet Aggregation
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Thrombus Formation
Lipid Core
Platelet Aggregation
Fibrin
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Vasoconstriction
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Will Infarct Occur?
Collateral Circulation
Thrombus Formation
Tissue Death?
Plaque Rupture
Coronary Vasoconstriction
Myocardial Oxygen Demand
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The Three Is

• Ischemia
• lack of oxygenation
• ST depression or T inversion
• Injury
• prolonged ischemia
• ST elevation
• Infarct
• death of tissue
• may or may not show in Q wave

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Well Perfused Myocardium
Epicardial Coronary Artery
Lateral Wall of LV
Septum
Left Ventricular Cavity
Positive Electrode
Interior Wall of LV
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Normal ECG
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Ischemia
Epicardial Coronary Artery
Lateral Wall of LV
Septum
Left Ventricular Cavity
Positive Electrode
Interior Wall of LV
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Ischemia

• Inadequate oxygen to tissue
• Subendocardial
• Represented by ST depression or T inversion
• May or may not result in infarct

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ST depression
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Injury
Thrombus
Ischemia
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Injury

• Prolonged ischemia
• Transmural
• Represented by ST elevation
• Usually results in infarct

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ST elevation
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Infarct

• Death of tissue
• Represented by Q wave
• Not all infarcts develop Q waves

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Infarction
Infarcted Area Electrically Silent
Depolarization
Many infarcts do not develop Q waves
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Q Waves
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Thrombus
Infarcted Area Electrically Silent
Ischemia
Depolarization
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Summary

• A normal ECG does NOT rule out ACS
• ST segment depression represents ischemia
• Possible infarct
• ST segment elevation is evidence of AMI
• Q wave MI may follow ST elevation or depression

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Acute Coronary Syndromes

• Rapid Recognition and
• Treatment of ACS

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Small Group Task

• List and rank risk factors
• Describe symptoms of the last AMI patient
  attended
• Describe the symptoms of a friend or relative
  when they suffered an AMI

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Goals for Module 3

• Rapidly recognize and treat patients with sudden
  myocardial ischemia

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Immediate Evaluation

• Story
• Risk factors
• ECG

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Clinical Presentations of ACS

• Classic anginal chest pain
• Atypical chest pain
• Anginal equivalents

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Classic Anginal Chest Pain

• Central anterior chest
• Dull, fullness, pressure, tightness, crushing
• Radiates to arms, neck, back

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Atypical Pain

• Musculoskeletal, positional or pleuritic features
• Often unilateral
• May be described as sharp or stabbing
• Includes epigastric discomfort
• Females often express atypical pain

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Anginal Equivalents

• Dyspnea
• Palpitations
• Syncope or pre-syncope
• General weakness
• DKA

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Atypical Presentations

• Often seen in
• Female
• Diabetics
• Elderly

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Important Notation

• Note EXACT time symptoms began
• Duration of symptoms may effect therapeutic
  options and destination decisions

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Review Group Activity

• How many had presentations with classic anginal
  pain?
• How many had atypical pain?
• How many were anginal equivalents?

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Review Group Activity

• How many risk factors did you list?
• How did you rate them?

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Consider Risk Factors

• Patients with severe or multiple risk factors
  should be evaluated with a high index of
  suspicion for acute coronary syndrome

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Risk Factors of ACS

• Diabetes
• Smoking
• Hypertension
• Age

• Family history of CAD
• Obesity
• Stress
• Sedentary

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Age

• Males over 35
• Females over 40
• Infarct can occur at any age
• Increasing age increasing risk

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Summary

• Unstable angina and acute myocardial infarction
  are indistinguishable in the first few hours
• Atypical presentations are common
• Risk factor evaluation helps identify ACS
  patients

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Chronic Stable Angina versus ACS

• Not chronic stable angina if
• New onset
• Lower exertion threshold
• Change in pattern of relief
• New or different associated symptoms

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General Therapy for ACS

• Assessment
• Expose the chest
• Story and risks
• Monitor 12-lead
• Vital signs Sa02
• Lab draw/cardiac markers

• Treatment
• Oxygen
• IV access
• Aspirin
• NTG
• Morphine

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General Therapy for ACS

• Assessment and therapy occur simultaneously
• Findings may alter therapeutic path

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Expose the Chest

• Expose the chest immediately
• Avoids delays in obtaining ECG
• Prevents entanglement of IV lines, monitor wires,
  etc.
• Use reasonable judgement
• Have gowns available

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Oxygen

• 4 lpm nasal cannula if respiratory rate normal
  and Sa02gt95
• High flow mask if hypoxia or tachypnea are
  evident or suspected
• Advanced airway care for continued or severe
  hypoxia

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Vital Signs

• Respiratory rate and effort
• Pulse rate, rhythm, force
• Blood pressure in both arms, manual then
  automatic
• Sa02 monitor
• Cardiac monitor and 12-lead ECG

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12-Lead ECG

• Obtain and transmit with the first set of vital
  signs
• Repeat with each set of vital signs
• Repeat as often as necessary

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IV Access

• Adequate line in a suitable vein
• Draw initial blood as indicated
• Point of care cardiac markers
• Blood glucose

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Aspirin

• 160-325 mg - chew or swallow
• Only absolute contraindication is known
  hypersensitivity to ASA
• Issues
• Asthma patients may have been told to avoid ASA
• Patients on anti-coagulants
• Taken ASA already today

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Nitroglycerin

• Dilates conduit arteries
• Antagonizes vasospasm
• Improves collateral circulation
• Inhibits venous return
• Reduces intramyocardial wall tension

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Nitroglycerin

• 0.4mg sublingual
• Repeat every five minutes
• Contraindications include
• Hypotension
• Viagra within 24 hours

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NTG Precautions

• Avoid hypotension
• Limit systolic drop
• Dont use NTG as an analgesic
• Watch for RVI

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Morphine

• 2 - 4mg every 5 minutes PRN
• May require several doses for adequate relief of
  pain
• Decreases myocardial oxygen requirements
• Watch for respiratory depression and hypotension

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General Therapy for ACS

• Outcomes to general therapy equal reperfusion
  therapy
• Some components are time dependent
• Monitor compliance and outcomes via quality
  assurance program

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Module 3 Case 1

• 48 year old male
• Dull central CP 2/10, began at rest
• Pale and wet
• Overweight, smoker
• Vital signs RR 18, P 80, BP 180/110, Sa02 94 on
  room air

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Module 3 Case 1
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Module 3 Case 1

• Story
• Risk factors
• ECG
• Treatment

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Module 3 Case 2

• 68 year old female
• Sudden onset of anxiety and restlessness,
• States she cant catch her breath
• Denies chest pain or other discomfort
• History of IDDM and hypertension
• RR 22, P 110, BP 190/90, Sa02 88 on NC at 4 lpm.

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Module 3, Case 2
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Module 3 Case 2

• Story
• Risk factors
• ECG
• Treatment

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Lab for Module 3

• Study each ECG
• Fill in the blanks
• Provide your impression
• Examine the case studies
• Discuss the case