Acute Coronary Syndromes

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Acute Coronary Syndromes

• Jason Ryan, M.D.

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Acute Coronary Syndromes
Unstable Angina Non-ST-Elevation MI
ST-Elevation MI Acute Coronary Syndromes (ACS)
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Acute Coronary Syndromes

• Generally, same symptoms for all
• Squeezing, pressure-like, substernal chest pain
• Often associated with shortness of breath and
  diaphoresis
• Pearl If nausea and vomitting think inferior
  wall MI
• With UA/NSTEMI, often preceding history of
  exertional symptoms

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Remember the DDx for Chest Pain

• ACS
• Aortic Dissection
• Pulmonary Embolism
• Acute choleycystitis
• Pericarditis
• Costocondritis
• Esophogeal spasm
• Many others

The Cant Misses
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ST-Elevation MI
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ST-Elevation MI
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ST-Elevation MI
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ST-Elevation MI
Coronary Stenosis Progression to STEMI Serial
Angiogrpahy in 239 Patients
Stenosis Pre-MI 0 25 50 75 90-99
Culprit For MI 8 10 5 6 10 39
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Nobuyoshi M et al., JACC 199118904-10
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ST-Elevation MI

• If you suspect STEMI
• OMI Oxygen, monitor, IV access
• ABC Ensure patient is stable
• Call cardiology
• Pre-cath medication
• Aspirin 325mg PO
• Lopressor 25mg PO (if BP and Pulse will tolerate)
• Beware cardiogenic shock
• Heprin 5000U bolus (if no active bleeding issues)
• Discuss IIB/IIIA and Clopidogrel with cardiology

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Unstable Angina (UA) and Non ST Elevation
Myocardial Infarction (NSTEMI)

• 5,315,000 annual ER presentations for chest pain

• 1,433,000 annual U.S. hospital admissions for
  UA/NSTEMI

• 50 patients per month at BIDMC coded as
  AMI, SUBENDOCARDIAL ISCHEMIA

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Placebo Event Rates in Recent Trials of UA and
NSTEMI
UA and NSTEMI
Death/MI at 30 days

• PRISM1 7.1
• PRISM-PLUS2 11.9
• PURSUIT3 15.7
• GUSTO-IV ACS4 8.0
• PARAGON A5 11.7

1. PRISM Study Investigators. N Engl J Med
19983381498-1505. 2. PRISM-PLUS Study
Investigators. N Engl J Med 19983381488-1497.3.
Harrington RA. Am J Cardiol 19978034B-38B.4.
The GUSTO IV-ACS Investigators. Lancet
20013571915-1924.5. The PARGON Investigators.
Circulation 1998972386-2395.
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UA and NSTEMI

• Definitions
• Unstable angina
• New onset angina
• Angina that occurs at rest
• Angina that occurs with accelerating frequency
  (crescendo angina)
• May have EKG changes (ST depression)
• Biomarkers will be negative

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UA and NSTEMI

• Definitions
• NSTEMI
• Typical rise and fall of cardiac biomarkers plus
  at least one of the following
• Anginal chest pain
• Ischemic EKG changes (ST-depression)
• Development of Q waves on EKG
• Coronary intervention
• Often cant tell UA from NSTEMI at presentation

Joint European Society of Cardiology/American
College of Cardiology committee
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NSTEMI

• The Biomarkers
• CK
• Rises 4-6 hours after MI
• Peaks and falls by 36-48 hours after MI
• Total CK is non-specific
• CK-MB is more specific for cardiac tissue
• (but there is still some in skeletal muscle!!)
• Remember this is one component in the diagnosis
  of NSTEMI
• CK alone cannot be used to diagnose NSTEMI

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NSTEMI

• The Biomarkers
• Troponin
• Rises 4-6 hours after MI
• Can remain elevated for up to two weeks!
• Very specific for cardiac damage
• Elevated in many other conditions than ACS
• Hypotension of any cause (80 patients)
• Renal failure
• Congestive heart failure
• Many others
• Always predicts worse outcomes

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NSTEMI

• Four pieces to NSTEMI
• Symptoms
• EKG changes
• CK
• Troponin

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ACC Guidelines for Management of UA/NSTEMI
Chest Pain
EKG
Follow ST Protocols
ST
No ST
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American College of Cardiology (ACC)2002
Guidelines for UA/NSTEMI
Medications with Class I indication

• First 24 hours
• Morphine
• Nitroglycerin
• Aspirin
• Beta Blocker
• Plavix
• Heparin
• IIB/IIIA Inhibitors

• Discharge
• Aspirin
• Beta Blocker
• Plavix
• ACE Inhibitor
• Statin

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NRMI-4 NSTE MI Acute Care 3rd Quarter 2001
ACC 2002 Guidelines for UA/NSTEMI How well do we
do?
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NRMI-4 NSTE MI Discharge Care 3rd Quarter 2001
ACC 2002 Guidelines for UA/NSTEMI How well do we
do?
100
84
75
80
71
56
60
40
21
20
0
ASA
Beta Blocker
ACE
Statins
Cardiac
Inhibitor
Rehab
LVEF lt 40 Known hyperlipidemia
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Gap between Leading and Lagging US Hospitals
ACC 2002 Guidelines for UA/NSTEMI How well do we
do?
Performance Quality
Indicator Bottom 10 Top 10 ASA use lt 24
h 54 99 ? blocker use lt 24 h 33 98 Heparin
use lt24 h 50 92 GP IIb-IIIa lt 24 h 0 51 D/C
ASA use 54 99 D/C ? blocker use 44 96 D/C
ACE-I use 21 83 D/C lipid lowering 33 99
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Benefits of Using Evidence-Based Therapies
(Non-ST ? ACS Patients from GUSTO IIb)
ACC 2002 Guidelines for UA/NSTEMI Does doing well
matter?

• Additional Lives
• Discharge Saved per 1,000
• Therapy Current Use (ideal use)
• Aspirin 86 9
• Beta blockers 59 11
• ACE inhibitors 52 23

Alexander K, JACC, 1998
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Case 1

• A 54 year old man with DM, HTN, and high
  cholesterol presents to the ER complaining of
  substernal chest pain. The pain feels like his
  chest is being squeezed. He first noted it two
  months ago when carrying packages up a flight of
  stairs. Last week he noticed it when walking to
  work. The past two days, the pain has occurred
  whenever he climbs the stairs in his house. This
  morning it occurred while driving to work.
• His initial EKG shows sinus tachycardia with
  anterior ST depressions.
• His initial cardiac biomarkers are negative.
• He becomes pain free during his first few minutes
  in the ER and his EKG changes resolve.

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Case 1

• Is this an ACS?
• YES!!!
• How should this patient be managed?
• Morphine and NTG to make him pain free
• Aspirin, Beta blocker, Heparin, Integrillin
• Plan for catheterization with 24-48 hours

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Case 2

• A 75 yom with HTN presents to the ER complaining
  of squeezing, substernal chest pain. The pain
  began this morning while taking a shower and has
  waxed and waned all day (10 hours time).
• Initial EKG shows sinus tachycardia without ST
  changes
• Initial biomarkers
• CK 300, MB 20, Trop T 0.5

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Case 2

• Is this an ACS?
• YES!!!
• How should this patient be managed?
• Morphine and NTG to make him pain free
• Aspirin, Beta blocker, Heparin, Integrillin
• Plan for catheterization within 24-48 hours

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Case 3

• A 82 yof is transferred to the ED from her
  nursing home where she was noted to be lethargic.
  For the past two days, she has had decreased POs
  and one episode of vomiting. The patient is
  unable to give a history.
• On initial ED eval, her blood pressure is 72/45
  and her temp is 101.4
• Initial EKG shows sinus tachycardia
• Initial biomarkers show CK 110, MB 6, Trop 0.5

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Case 3

• In this an ACS?
• Unlikely
• How should this patient be managed
• ASA if no contraindication
• No BB given hypotension
• No heparin or IIB/IIIA as this is not likely ACS
• Work up fever and hypotension
• Cycle biomarkers
• Repeat EKG in 6-12 hours

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Case 4

• A 62 yom with a history of ESRD on HD, Ischemic
  CM with EF 20 presents with lethargy and altered
  mental status for two days
• Initial vitals are remarkable for a room air O2
  sat of 88
• EKG shows sinus rhythm with old anterior Q waves
  (see on EKG 1 year prior). No new ST changes.
• Initial cardiac markers
• CK 200 MB 9 Trop 0.8

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Case 4

• In this an ACS?
• Unlikely
• Troponin is his only marker of ACS and he has at
  least two reasons for false positive (CRF, CHF)
• How should this patient be managed
• ASA if no contraindication
• BB if not in CHF
• No heparin or IIB/IIIA unless further evidence of
  ACS develops
• Work up lethargy and altered mental status
• Cycle biomarkers
• Repeat EKG in 6-12 hours

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Case 5

• A 55 yom presents to the ED c/o episodic chest
  pain for one week. The pain is sharp, left sided,
  and lasts 10-15 minutes. The pain occurs when
  walking and never at rest, although sometimes he
  can walk without symptoms. He is pain free now.
• EKG shows sinus rhythm without ST changes.
• Initial biomarkers
• CK 90, MB not done, Trop lt0.01

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Case 5

• In this an ACS?
• Cant tell
• Some features consistent, some not
• How should this patient be managed
• ASA and BB
• No heparin or IIB/IIIA unless biomarkers become
  elevated
• Cycle biomarkers
• Repeat EKG in 6-12 hours
• If rules out, consider exercise stress test