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Cardiology Core Conference 7/18/19 - ACS

Updated: Jul 24, 2019


The Basics

What Is it?

- Acute discrepancy b/tw myocardial demand and supply

- Acutely decreased supply (plaque rupture, Type 1)

- Increased Demand (Type 2 NSTEMI vs Ischemia)


Stable Angina

Unstable Angina

NSTEMI

STEMI

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Characterize Chest Pain

1) substernal

2) w/w exertion

3) A/w rest a/o nitroglycerin

Cardiac Chest Pain = 3/3

vs

Atypical Chest Pain = 2/3

vs

Non-Cardiac Chest pain 0-1/3


ANGINAL EQUIVALENTS: SOB, Diaphoresis, Extreme Fatigue

Other Assd Sxs: pain in neck, jaw, arm. N/V, chest PRESSURE, palps, dizziness/lightheadedness.


Diagnosis of ACS in General:

1. Physical Exam

•Ischemia: new S4, new MR murmur 2/2 pap muscle dysfunction, paradoxical S2, diaphoresis

•Heart Failure: JVP, Crackles, S3, hypotension, cool extremities (cardiogenic shock).

•Other areas of Atherosclerosis: bruits (fem/carotid), decreased distal pulses


2. Diagnostics

•EKG + Cardiac Markers (troponin Tn > CK-MB)

•Troponin rises 2-6 hours after BEGINNING of insult

Other Aids

•TTE – for new WMA

•CT Angio Coronary / perfusion /stress test (low prob)

•Coronary Angiography – Gold Standard

If non-diagnostic initially from trop/ekg, repeat 3-6h


If normal and clinical suspicion for ACS remains high:

r/o Unstable Angina – stress test (vs CT angio for CAD)

Inpt or outpt?

Inpt for HIGH RISK

- >70 YO

- prior CAD, CVD, PAD

- resting angina

Outpt (w/in 72 hours) for LOW RISK


NSTEMI


ONLY 1/3 HAVE 1+ MM ST DEPRESSIONS IN CONTINUOUS LEADS


Characterization: 5 types - Type 1 = plaque rupture, type 2 = ischemic balance (fixed disease but increased demand), types 3-5 are procedural/surgical


Stratification: TIMI Score:

If score is 3+, benefit from Early angiography (<24 hours)

If <3, intervene (if appropriate) any time within 72 hours


*If pain is REFRACTORY to medical management, OR HD instability -> angio w/in 2 hours!


Type 2 NSTEMI vs Demand Ischemia


The same pathophysiologic precipitant (increased demand with a stable coronary artery lesion).


The difference is, in T2 NSTEMI, myocardial tissue is irreversibly damaged (is not viable, heals by scar) vs Demand Ischemia where the tissue can heal and work well again if blood flow is restored.


STEMI

Complete Total Occlusion of a coronary artery causing FULL THICKNESS INFARCTION.


For dx You need:

>= 2 contiguous leads w/ >= 1mm* (1.5 mm+ in V2-V3)

OR

New/presumed new LBBB


WITH OR WITHOUT Trop elevation


and...SYMPTOMS!!


Treatment

Emergent REPERFUSION = 1st line therapy

Door->balloon goal time: 90 minutes


If you are at a Non-PCI capable facility: fibrinolytics w/in 30 min presentation. unless

you can get to PCI within 120 minutes

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Prognosis in STEMI

Use the Killip and Forrester Classifications:

Medications in UA, T1 NSTEMI, and STEMI:


Antiplatelets

ASA

ADP blockers (clopid, ticagr)

GP 2b/3a – abciximab, eptifibatide, tirofiban

Anticoagulation

UFH, enox, bival, fondaparinux

BBs

Nitrates

Oxygen

Morphine

ACE-I = ARBs (NEJM 2003;349:20)


Additional Meds for STEMI that show benefit


Intensive Statin (decreases periprocedural myonecrosis, JACC 2007;49:1272)

Insulin for glucose >180


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Some EKG Practice Resources:


www.litfl.com


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Positive and Negative LRs in ACS






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