Title: Acute Coronary Syndromes
1Acute Coronary Syndromes
- EMS Professions
- Temple College
2The History of Paramedics Begins with Cardiac
Care
- The original Paramedic idea was based upon the
need for rapid response to, identification of and
emergency care for victims of
- Sudden Cardiac Death (SCD)
- Acute Myocardial Infarction (AMI)
3Ischemic Coronary Syndromes
- Acute Coronary Syndromes
- Angina Pectoris
- Unstable Angina
- Acute Myocardial Injury
- Acute Myocardial Infarction
- Presentation with suspected ischemia
- Non-diagnostic ECG
- ST segment depression
- ST segment elevation/New BBB
4Ischemic Coronary Syndromes
- Angina Pectoris
- Acute pain, usually in the chest, resulting from
an increased demand for oxygen and a decreased
ability to provide it
- Usually due to a partially occluded coronary
artery or vasospasm
5Ischemic Coronary Syndromes
- Angina Pectoris
- Typical Presentation
- Squeezing, Crushing, Heavy, Tight
- Fist to chest Levines sign
- Pain/Discomfort may radiate to shoulders, arms,
neck, back, jaw or epigastrium
- Usually lasts 3-5 min and rarely exceeds 15 min
- Not changed by swallowing, coughing, deep
breathing or positional changes
6Ischemic Coronary Syndromes
- Angina Pectoris
- Typical Presentation
- Anxiety
- Diaphoresis or clammy skin
- Nausea, vomiting
- Shortness of breath
- Weakness
- Palpitations
- Syncope
7Ischemic Coronary Syndromes
- Angina Pectoris
- Usually Provoked by
- Exercise
- Eating
- Emotion/Stress
- Usually Relieved by
- Rest Removal of provoking factor
- Nitroglycerin
8Ischemic Coronary Syndromes
- Stable Angina Pectoris
- Reasonably Predictable frequency, onset,
duration
- Relief predictable with rest, nitroglycerin
9Ischemic Coronary Syndromes
- Stable Angina Pectoris
- Treatment Goals
- Reduce myocardial oxygen demand
- Improve myocardial oxygen supply
10Ischemic Coronary Syndromes
- Stable Angina Pectoris
- Treatment
- Physical/Psychological rest
- Position of comfort, sitting or supine
- Oxygen
- ECG Monitor
- Assess the underlying rhythm
- Nitroglycerin, 0.4 mg SL q 5 min as long as BP
90 mm Hg
- Continue until pain relieved or contraindicated
11Ischemic Coronary Syndromes
- Stable Angina Pectoris
- Transport Considerations
- Many persons stay home and treat themselves
- Treat first-time angina, unstable angina or
angina requiring more than 3 NTG (15 min) as
AMI
- When in doubt, treat as AMI
12Ischemic Coronary Syndromes
- Stable Angina Pectoris
- Variant Angina (Prinzmetals Angina)
- Occurs at rest
- Episodes at regular times of day
- Results from coronary vasospasms
- Treated long term with calcium channel blockers
- May result in abnormal 12 lead ECG changes that
resolve with minimal treatment
13Ischemic Coronary Syndromes
- Unstable Angina
- Prolonged chest pain/ischemic symptoms or an
atypical presentation of angina without ECG or
laboratory evidence of AMI (Injury)
- Usually associated with significant or
progressing occlusion of a coronary artery or
severe vasospasm
- Considered Pre-infarction Angina
14Ischemic Coronary Syndromes
- Unstable Angina
- May have Typical or Atypical Signs Symptoms
- Atypical Presentation
- Increased frequency or duration of episodes
- Onset with less exertion than normal
- Increased severity of symptoms
- Requires greater number of NTG tablets to relieve
symptoms
15Ischemic Coronary Syndromes
- Unstable Angina
- Treatment same as Angina PLUS
- IV, NS (no dextrose), TKO
- Some exceptions to restricting fluid
- 12 Lead ECG
- Assess for RVI
- Morphine sulfate, 2 - 4 mg q 5-15 min slow IV
titrated to pain relief and BP 90
- Aspirin, 160-325 mg PO
- Chewed swallowed if possible
- Determine if hypersensitive to ASA
16Ischemic Coronary Syndromes
- Unstable Angina
- Treatment
- Metoprolol, 5 mg slow IV q 5 min to 15 mg total,
prn for ? HR/BP in absence of contraindications
- In longer or interfacility transports, consider
- Nitroglycerin IV infusion, 10-20 mcg/min
- Heparin
- GP IIB/IIIA inhibitors
- Thrombolytics Checklist (just in case)
- Transport, destination?
17Ischemic Coronary Syndromes
- Acute Myocardial Injury
- Presentation of Unstable Angina or Acute Ischemia
with potential for myocardium salvage (penumbra)
- Diagnostic evidence of Injury (ECG or elevated
Enzymes)
- Does not necessarily imply necrosis of the
myocardium
- Presentation, Signs and Symptoms are the same as
Acute MI
18Ischemic Coronary Syndromes
- Acute Myocardial Infarction (AMI)
- Necrosis of myocardial tissue caused by a lack of
oxygenation and blood flow resulting from an
occluded coronary artery
- Often also used to describe acute injury when
extent of necrosis is unknown but imminent
- Diagnostic evidence of injury is present
(elevated enzymes and possibly ECG)
19Ischemic Coronary Syndromes
- Acute Myocardial Infarction (AMI)
- Precipitating Factors
- Coronary thrombosis (most common)
- Coronary vasospasm
- Microemboli
- Severe Hypotension/Shock
- Acute Hypoxia
- Acute Volume Overload
20Ischemic Coronary Syndromes
- Acute Myocardial Infarction (AMI)
- Location, size of infarct and severity depends on
site of vessel occlusion
- majority involve left ventricle
- LCA
- anterior, septal, lateral
- RCA
- inferior, right ventricle
21Ischemic Coronary Syndromes
- Acute Myocardial Infarction (AMI)
- Often defined further as
- subendocardial involves only subendocardial
muscle
- transmural full thickness of ventricular wall
involved
22Evolution of AMI
23Evolution of AMI
24Evolution of AMI
25Coronary Artery Without Evidence of Plaque
Source University of Utah WebPath
26Coronary Artery with Significant Plaque Formation
In addition to reduced Lumen size, there is also
a calcified portion (right side of photo)
Source University of Utah WebPath
27Coronary Artery with Significant Plaque Formation
Source University of Utah WebPath
28Rupture of Atheromatous Plaque Results in
Thrombus Formation
- Rupture of Vulnerable plaques soft lipid core
is the initiating event in most acute ischemic
coronary events
- Occlusion is dependent on clot formation and and
accompanying fibrinolysis
- A thrombotic occlusion that is relatively
persistent (i.e., 2 to 4 hours or longer) may
result in acute myocardial infarction
29Rupture of Atheromatous Plaque Results in
Thrombus Formation
- Repeated thrombus formations may further
decrease the lumen size
- Intermittent non-occlusive thrombus formation
results in Unstable Angina
- Incomplete occlusion may also result in MI
possibly due to coronary artery spasm
30Coronary Artery With Plaque and Thrombus
Formation
A - Coronary Artery cross-section
B - Lumen C - Fissured Plaque w/o Cap D -
Acute thrombus
Source Emergency Cardiovascular Care Library
(CD-ROM), American Heart Association, Dallas 1997
31Plaque and Thrombus Formation Resulting in
Occlusion
Source University of Utah WebPath
32Coronary Artery Thrombus
The external anterior view of the heart shows a
dark clot formation in this artery
Source University of Utah WebPath
33Evolution of Infarction/Necrosis
34Ischemic Coronary Syndromes
- Acute Myocardial Infarction (AMI)
- Presentation
- Similar to Angina but
- Last longer
- Not easily relieved with rest or NTG
- Sx/Sx may be more severe (feeling of impending
doom)
- Pain often radiates to arms, neck, jaw, back,
epigastrium
- Some present atypically with complaints of only
weakness or shortness of breath
- Dysrhythmias
- Sudden Cardiac Death
35Ischemic Coronary Syndromes
- Acute Myocardial Infarction (AMI)
- Presentation
- 10-20 have silent MI (no chest pain)
- common in elderly, older women, diabetics
- If adding chest pain to the patients list of
Sx/Sx completes a clear picture of AMI, then the
patient is having an AMI!!
- Vital Signs and monitoring ECG leads DO NOT
provide DIAGNOSTIC evidence of AMI!!
- Clinical diagnosis in absence of 12 Lead ECG or
Enzyme changes
36Therapies
37Ischemic Coronary Syndromes
- Acute Myocardial Infarction (AMI)
- Treatment Goals
- Decrease myocardial oxygen demand
- Remove physical/psychological stressors
- Relieve pain
- Reduce workload of the heart (BP, HR)
- Inhibit further clot formation
- Rapid identification/diagnosis
- Transport for reperfusion therapy
38Ischemic Coronary Syndromes
- Acute Myocardial Infarction (AMI)
- Treatment same as Angina PLUS
- IV, NS, large bore
- TKO with some exceptions
- No dextrose containing solutions
- Fluid boluses appropriate in some cases
- 2nd line if time permits
- Minimize number of attempts
- 12 Lead ECG
- Diagnostic evidence of AMI present
- Assess for RVI
39Ischemic Coronary Syndromes
- Acute Myocardial Infarction (AMI)
- Treatment
- Morphine sulfate, 2 - 4 mg q 5-15 min slow IV
- Maintain BP 90 mm Hg
- Titrated to Pain relief
- Reduce PVR and workload on the heart
- Aspirin, 160-325 mg PO
- Chewed swallowed if possible
- Determine if hypersensitive to ASA
- MONA greets all patients
40Ischemic Coronary Syndromes
- Acute Myocardial Infarction (AMI)
- Treatment
- Metoprolol, 5 mg slow IV q 5 min to 15 mg total,
prn for ? HR/BP in absence of contraindications
- In longer or interfacility transports, consider
- Nitroglycerin IV infusion
- Heparin
- Thrombolytics Checklist
- Exclusions for thrombolysis
41Ischemic Coronary Syndromes
- Acute Myocardial Infarction (AMI)
- Treatment
- Transport for reperfusion therapy Destination?
- Thrombolysis vs Coronary Artery Catheterization
- For patients with associated pulmonary edema,
hypotension or cardiogenic shock, consider
transport to facility with capability of
angiography revascularization
42Considerations for Fibrinolytics
43Contraindications for Fibrinolytics
- Lack of diagnostic 12 Lead ECG changes
- Chest pain 12 hours
- Not oriented, can not cooperate
- History of stroke or TIA
- Known bleeding disorder
- Active internal bleeding in past 2-4 weeks
- Surgery or trauma in past 3 weeks
- Terminal illness
- Jaundice, hepatitis, kidney failure
- Use of anticoagulants
- Systolic BP
- Diastolic BP
44Ischemic Coronary Syndromes
- Ischemic and injured tissue have reduced blood
flow but may be salvaged. The area of the
Penumbra may be viable for several hours after
onset of occlusion. - Source Emergency Cardiovascular Care Library
(CD-ROM), American Heart Association, Dallas, 1997
45Ischemic Coronary Syndromes
- Sudden Cardiac Death (SCD or SCA)
- Sudden, unexpected biologic death presumably
resulting from cardiovascular disease
- Most common rhythm of SCA is Ventricular
Fibrillation
- May be primary or secondary VF
- Chain of Survival is the greatest determinant of
outcome
- Treatment based on ECG rhythm arrest events
46Time is Muscle!!!
47References and Resources
- Advanced Cardiac Life Support, Edited by R O
Cummins, MD, American Heart Association, Dallas,
1997
- Emergency Cardiovascular Care Library (CD-ROM),
American Heart Association and ProEducation
International, Dallas, 1997
- Eisenberg, M S, Life in the Balance Emergency
Medicine and the Quest to Reverse Sudden Death,
Oxford University Press, New York, 1997
- A Definition of Advanced Types of
Atherosclerotic Lesions and a Histological
Classification of Atherosclerosis, A Report
From the Committee on Vascular Lesions of the
Council on Arteriosclerosis, American Heart
Association, 1995 - Coronary Artery Calcification Pathophysiology,
Epidemiology, Imaging Methods, and Clinical
Implications, A Statement for Health
Professionals From the American Heart
Association, 1995 - Cardiovascular Disease Statistics, American Heart
Association, Dallas, 1997
- Diagnosis and Therapy of Acute Myocardial
Infarction Todays Look at Tomorrows Therapies
and Outcomes, DuPont Pharma, 1997
- University of Utah WebPath, http//medstat.med.uta
h.edu/webpath/