Acute Coronary Syndromes

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MODULE 4

• Acute Coronary Syndromes
• Part 2

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Goals for Module 4

• Rapidly identify and treat patients eligible for
  acute reperfusion therapy

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Acute Reperfusion Therapy

• Thrombolytics
• Retaplase (rPA)
• Actiplase (tPA)
• Streptokinase

• Percutaneous Transluminal Coronary Angioplasty
  (PTCA)
• Balloon
• Stent
• Atherectomy

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Acute Reperfusion Therapy
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The 12-Lead ECG

• ST elevation - the key to the acute reperfusion
  therapy subset
• You cant see ST elevation without a 12-lead ECG

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The 12-Lead ECG

• Perform on every patient suspected of ACS
• Obtain early
• with the first vital signs
• Repeat frequently
• every 5-10 minutes
• each change of symptoms

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The 12-Lead ECG

• The three ECG subsets
• Nondiagnostic no ST or T wave abnormalities
• Suspicious for ischemia ST depression or T wave
  inversion
• Suspicious for injury ST elevation

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The 12-Lead ECG

• Nondiagnostic no ST or T wave abnormalities
• Does NOT rule out MI or other acute coronary
  syndromes
• Not a candidate for acute reperfusion therapy

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Non-Diagnostic ECG
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The 12-Lead ECG

• Suspicious for ischemia ST depression or T wave
  inversion
• Does NOT rule out MI or other acute coronary
  syndromes
• NOT a candidate for acute reperfusion therapy

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Ischemic ECG
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The 12-Lead ECG

• Suspicious for injury ST elevation
• Evidence of acute myocardial infarction
• Candidate for acute reperfusion therapy

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12-Lead ECG

• Evidence of Acute MI
• Persistent anginal chest pain or its equivalents
• ST segment elevation of 1mm or more in two
  anatomically contiguous leads
• These patients should receive acute reperfusion
  therapy

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Injury
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Bundle Branch Block (BBB)

• New or presumably new
• Candidate for acute reperfusion therapy
• May mask or mimic acute ECG changes

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BBB
AV Node
Block
RBB
LBB
LV Depolarization
RV Depolarization
Asynchronous depolarization of the ventricles
widens the QRS (120ms)
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BBB Identification

• Supraventricular rhythm
• Wide QRS (120ms or more)

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BBB

• May be old
• If not proven to be old, assume it is new
• If story and risk factors suggest MI, treat new
  or assumed to be new BBB as ST elevation
• Seek most recent ECG

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BBB
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Fibrinolytic Therapy Trialists (FIT)
Collaborative Group, 1994
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12-Lead ECG Subsets
Chest pain or anginal equivalent suspicious of
ischemia
Immediate assessment and initial general treatment
Assess initial ECG
ST elevation or new BBB
ST depression or T inversion
Nondiagnostic - no ST-T deviation
Prepare and evaluate for reperfusion therapy
Thrombolytics or primary PTCA
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Summary

• ECGs are placed into one of three subsets
• Infarct may be occurring in any of the subsets
• ST elevation and BBB
• Evidence of infarct
• Subject to acute reperfusion therapy

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Prep for Reperfusion Therapy

• Notify the hospital
• Transmit the ECG
• Screen for thrombolytics
• Start 2nd or 3rd lines or locks
• Draw additional labs
• Defibrillation electrodes

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Prep for Reperfusion Therapy

• Notify the hospital
• Transmit the ECG

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Prep for Reperfusion Therapy

• Screen for thrombolytics
• General contraindications for thrombolysis
• Pregnancy
• Bleeding
• Recent stroke
• Recent surgery
• Blood clotting disorders

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Prep for Reperfusion Therapy

• Sample check-off lists

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Prep for Reperfusion Therapy

• Establish multiple IV access sites
• Suitable lines in suitable vessels
• At least two
• Locks or IV fluid
• Multi-lumen caths
• Compressible vessels

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Prep for Reperfusion Therapy

• Draw additional labs
• Point of care cardiac markers and glucometer
  check
• Initial serum cardiac markers
• Electrolyte studies
• Coagulation studies
• Type cross match

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Prep for Reperfusion Therapy

• Apply defibrillation electrodes
• High risk for lethal dysrhythmias
• Helps avoid unnecessary CPR
• Standby pacing

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Reperfusion Decisions

• Select reperfusion strategy
• Thrombolytic (in field or hospital)
• PTCA
• Select transport destination
• If thrombolytics contraindicated, is emergency
  PTCA available?
• Local protocols

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Transport Destination
ST elevation or new BBB
Contraindications for thrombolysis?
Yes
No
Thrombolysis
PTCA
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Module 4 Case 1

• 71 year old female, c/o weakness x 4h. No other
  symptoms
• P 68, RR 16 and effortless, BP 160/110
• Awake and alert, skin warm and dry

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Module 4 Case 1

• Risk factors
• Advanced age

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Module 4 Case 1
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Evaluate Case 1

• Story
• Risks
• ECG

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Module 4 Case 2

• 58 year old female, sudden onset of central,
  dull, chest pain rated as 4/10. Onset 12 minutes
  prior to your arrival
• Also c/o brief dizziness at onset of pain
• History of hysterectomy and peptic ulcer each
  over 10 years ago
• RR 18, P 80, B/P 140/70, Sa02 98

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Module 4 Case 2

• Risk factors
• Smokes two packs per day
• Extensive family history of early coronary artery
  disease

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Module 4 Case 2
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Evaluate Case 2

• Story
• Risk factors
• ECG

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Module 4 Case 3

• 67 year old female
• C/O left sided chest pain 7/10 for 2 hours,
  unrelieved by 3 NTG
• R 18, P 80, BP 150/76, Sa02 95

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Module 4 Case 3

• Risk factors
• Diagnosed coronary artery disease
• Hypertension

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Module 4 Case 3
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Evaluate Case 3

• Story
• Risk factors
• ECG

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Module 4 Case 4

• 68 year old male, c/o chest pressure 8/10 for 15
  minutes. Accompanied by mild dyspnea and a sense
  of doom
• R 20, P 70, BP 160/110, Sa02 88 on room air,
  slight basilar rales
• Skin moist, pale

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Module 4 Case 4

• Risk factors
• Age
• History of hypertension
• Obese (255 lbs. at 5 ft. 8 in.)
• Nonsmoker
• Has never had lipid profile

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Module 4 Case 4
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Evaluate Case 4

• Story
• Risks
• ECG

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Summary

• Story
• Risk factors
• ECG
• Treatment