csim acs lecture

8/18/2019 CSIM ACS Lecture

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Acute coronary syndromes

Iftikhar Ul HaqConsultant Cardiologist


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Learning outcomes

• Demonstrate ability to both describe and recogniseappropriate features in clinical presentation (includingrele ant history! e"amination and in estigation# found inpatients $ith AC% s& other causes of chest pain&

• Demonstrate ability to interpret in estigations sufficientto establish a differential diagnosis of acute coronarysyndrome' including non %) ele ation *C+ changesand biomarkers&

• Demonstrate kno$ledge and understanding of the

pathophysiological processes contributing to thede elopment of acute coronary syndrome


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%elf directed learning

• )he *C+• ,ascular endothelial cell function• %hock• -uscle cell biology• Illness pre ention and smoking


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Uni ersal Definition of -I

• .)he term -I should be used $hen there ise idence of myocardial necrosis in a clinicalsetting consistent $ith myocardial ischaemia/ 0 )n 1 22th percentile of U3L ()ype 4 -I#

5LU% at least one of' 0 %ymptoms of ischaemia 0 *C+ changes indicating ischaemia 0 *C+ e idence of necrosis' ne$ pathological 6 $a es 0 Imaging ne$ loss of myocardium! or ne$ 37-A


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Uni ersal Definition of -I

• )ype 4 0 8usual -I9• )ype : imbalance in myocardial ; : supply and

demand → ischaemia $ithout definite CAD

• )ype < %udden death' other e idence of A-I orocclusi e thrombus

• )ype = 5CI associated -I' )n >"< U3L

• )ype ? CA@+ associated' )n >"? U3L ne$ 6$a esBL@@@! or angiographicBimaging e idence


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ACUTE CORONARY SYNDROMEACUTE CORONARY SYNDROME

No ST ElevationNo ST Elevation ST ElevationST ElevationST ElevationST Elevation

Unstable Angina NQMI QwMI Myocardial In arction

NSTEMI

Definitions


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Lipidpool Lipid-rich

plaque

Fissure Plaque

disruption

Occlusivethrombus

Subocclusivethrombus

Acute MI,Q-wave

nstablean!ina"

#on-Q-waveMI

5laque 3upture


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Days from randomi ation%a onitto % et al. JAMA& 4222 :E4'FGF

- o r t a

l i t y

( H #

4EGG :G =G G EG 4GG 4 GG

E

4G

:

=

4:G 4=G

T!wave inversion"#$% &n'()*("+

ST elevation wit, co!e-istingde.ression /#0% &n'0)*1/+

ST de.ression2#/% &n'$)(1"+

ST elevation

1#2% &n'")"1/+

AC%' mortality at months+U%); :@' %) segment depression 0 a high risk population


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Chest pain hospital admissions

• Chest pain is the biggest cause ofpresentation to A * in the UJ'

0 GG!GGG patients per year

0 4:?!GGG ha e K%)* AC% (4 in =# 4

0# airbairn I5& J R Coll Physicians Edinb :GG<


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Immediate assessments

• irst 0 5atient history 0 *C+ 0

5hysical e"amination• )hen 0 3isk stratification 0 @lood marker tests


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Diagnosis of AC%

3equires the presence of at least t$o of the follo$ingcriteria'

4& Chest pain (clinical manifestation#

:& *C+ changes consistent $ith ischaemia ornecrosis


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AC%' classical clinical symptoms at presentation

• Classical 0 DiscomfortBpain in the centre of the chest 0 Lasts for more than a fe$ minutes or recurs 0 3adiation to other areas! e&g& armsBMa$BneckBback

• Atypical presentations elderly or diabetic patients' 0 @reathlessness 0 )achycardia 0 Kausea or omiting

0 %$eating and clamminess


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3eat4res o stable angina

• Anginal pain is' 0 constricting discomfort in the front of the chest! neck! shoulders! Ma$ or arms

0 precipitated by physical e"ertion 0 relie ed by rest or +)K in about ? minutes&•5eople $ith typical angina ha e all the abo e anginal pain features! people $ith atypical anginaha e t$o of the features and people $ith non anginal chest pain ha e one or none of the features&•Do not define typical and atypical features of anginal and non anginal chest pain differently inmen and $omen or among ethnic groups&• actors making stable angina more likely'

0 increasing age 0 $hether the person is male 0 cardio ascular risk factors 0 a history of established CAD (e&g& pre ious -I! coronary re ascularisation#&• %table angina is unlikely if the pain is'

0 continuous or ery prolonged and5or 0 unrelated to acti ity and5or 0 brought on by breathing in and5or

0 associated $ith di iness! palpitations! tingling or difficulty s$allo$ing&


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Cardiac 3isk actors

• -odifiable 0 @5 0 Lipids

0 Diabetes 0 %moking status

• i"ed 0 5atients se" 0 Age

0 amily history 0 *thnicity 0 5re ious anginaB-I

0 C,AB5,D


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Chest 5ain 0 differential diagnosis

CA3DIAC

Angina

-yocardial Infarction

5ericarditis

Aortic dissection

5UL-;KA3N

5ulmonary *mbolus

5leurisy

5neumothora" +A%)3;

Ulcer or 3eflu"

+allstones5ancreatitis

-U%CUL;%J*L*)AL

Chostochondritis

)rauma

K;K ;3+AKIC

An"iety


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S4s.ected ACS• Check immediately if chest pain is current! or $hen the last episode $as! particularly if in the last4: hours&• Check if the chest pain may be cardiac& Consider'

0 history of the painO any cardio ascular risk factorsO history of ischaemic heart disease and any pre ious treatmentO pre ious in estigations for chest pain&• Check if any of the follo$ing symptoms of ischaemia are present& )hese may indicate an AC%'

0 5ain in the chest andBor other areas (for e"ample! the arms! back or Ma$# lasting longer than4?minutes&

0 Chest pain $ith nausea and omiting! marked s$eating or breathlessness (or a combination of

these#! or $ith haemodynamic instability& 0 Ke$ onset chest pain! or abrupt deterioration in stable angina! $ith recurrent pain occurringfrequently $ith little or no e"ertion and often lasting longer than 4? minutes&

• Central chest pain may not be the main symptom&• Do not use response to glyceryl trinitrate (+)K# to make a diagnosis of AC%&• Do not assess symptoms of an AC% differently in men and $omen or among different ethnicgroups&• Ad ise people about seeking medical help if they ha e further chest pain&• If the chest pain is non cardiac! e"plain this to the person and refer for further in estigation ifappropriate&


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Diagnosis of AC%





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5erform an *C+ immediately especially if thepatient is still in pain

0 If *C+ is normal or non diagnostic in a patient $ithcontinuing symptoms repeat after


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3isk %tratification by *C+

)he risk of death or -I at


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Kormal *C+


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Anterolateral %) depression


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Anterior %) segment depression


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A $ith infero lateral %) depression and L,H


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%) depression , : , ! ) in ersion in a,L

L l %) d i


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Lateral %) segment depression

) $


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Anterior ) $a e in ersion

$ $


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Deep arro$head anterolateral ) $a e in ersion

A t i di l i f ti $ith g %) g t l ti


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Anterior myocardial infarction $ith gross %) segment ele ation(sho$ing PtombstoneP 3 $a es#

An inferolateral myocardial infarction $ith reciprocal changes in


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An inferolateral myocardial infarction $ith reciprocal changes inleads I! a,L! ,4! and ,:

L f b dl b h bl k


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Left bundle branch block


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Diagnosis of AC% (K%)*-I#





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G 4: 4E := : < = ? F E 2 4G

3elatie concentration

DaysHours)ime after infarct

Kormal

)roponin-yoglobin

CJ! A%)

LDH

)roponin I Le els and -ortality in 5atients


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) p y$ith K%)* AC%

G

:

=

E

G QG&= G&= Q4&G 4&G Q :&G :&G Q?&G ?&G Q2&G 12&G

H -

o r t a l i t y a

t = : D a y s

Antman *A! )anasiMe ic -R! )hompson @! et al& Cardiac specific troponin I le els to predict the risk of mortalityin patients $ith acute coronary syndromes& N Engl J Med. 422


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)roponin 5itfalls

)roponin can be ele ated in• 5*• %epsis•

5ost op• A• L,

3ate of death or -I in relation to %)


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3ate of death or I in relation to %)de iation and troponin

%abatine et al. Am Heart J :GG

5QG&GGG4 (globalχ:

test

1G&4G G&G4 G&4GQG&G4

Kone

%) de G&G? G&G2 m,

%) de 1 G&4G m,

0"#*%06#$%

07#7%

0(#2%0(#6%

"#0%

/#1%

1#7%

$#0%

G

:

=

E

4G

4:

4=

4

D e a

t , o r

M I

a t 1 8 o n

t , s

& % +

Tro.onin T &ng58l+

EC9


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3isk and 3isk %tratification

)I-I risk score for K%)* AC%


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*Entry criteria: UA or NSTEMII defined as ischemic pain at rest within past 24H, withe idence of !A" #ST se$ment de iation or positi e mar%er&

Antman et a' JAMA 2000; 2(4: () +(42

# +-&.IS/ S!0.E 1 Tota' oints

43356-3ST de iation 7 8 mm

25323 !ardiac mar%ers

2-43.ecent #924H& se ere an$ina

3)).ESENTATI0N

()23ASA se in past - days

)633/nown !A" #stenosis ;


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7hat is the riskS

A : year old $oman presents $ithunstable angina& ;n e"amination! the pulseis 4GGbpm! blood pressure 44GBFG! and shehad crepitations at the lung bases& )he*C+ sho$ed some %) depression in theanterior leads& @lood tests sho$ed serumcreatinine $as 4=? µmolBL& )n) $as

undetectable


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Acute Coronary %yndromes


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Acute Coronary %yndromes)herapeutic +oals

• 3educe myocardial ischaemia

• Control of symptoms

• 5re ention of -I and death

Acute Coronary %yndromes


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Acute Coronary %yndromes -edical -anagement

• Anti ischaemic agents • Anti platelet agents

• Anti thrombin agents

• ( ibrinolytics#

• Coronary re ascularisation

5athogenesis of AC%'


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5athogenesis of AC%)he integral role of platelets

5laqueissure or

3upture

5latelet Aggregation

5latelet Acti ation

5latelet Adhesion

)hrombotic;cclusion

E ine rine Collagen Arac,idonic


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AD;

•)iclopidine•Clopidogrel

•Heparin•L-7 Heparin

•Direct )hrombinInhibitors

• Aspirin

E.ine.,rine g ,Acid

T,ro8bin

IIbBIIIareceptors

fibrin

)he5latelet

•+5 IIbBIIIa inhibitors

Drug therapies in K%)* AC% management


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Drug therapies in K%) AC% management

• Aspirin• Clopidogrel• L-7H• +5IIbBIIIa receptor antagonists

• @eta blockers• Kitrates (if ongoing painBL,D#• %tatins

*%C AC% )ask orce& Eur Heart J :GG: :


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• ;ffer a single loading dose of


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Use established scoring system such as +3AC* to predict month mortality and assess risk

of future ad erse cardio ascular e ents 4 & Assess bleeding risk and pertinent comorbiditybefore considering treatments and at each stage of management

• Lo$est risk ( ≤ 4&? #• Lo$ risk (14&? 0


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Lo$est risk (T 4&? # 4(1 4&?0


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Highest risk(1 2&G #4

Intermediate risk(1


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;ffer coronary angiography ($ith follo$ on 5CI if indicated# $ithin 2 hours of firstadmission unless contraindicated& 5erform as soon as possible if patient is clinically

unstable or at high ischaemic risk

Discuss management strategy $ith inter entional cardiologist and cardiac surgeon

-anagement of intermediate risk! high riskand highest risk continued

Coronary angiogram


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3CA stenosis


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5ost Hospital Discharge Care


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5ost Hospital Discharge Care

A Antiplatelets and AC* I@ @eta blockers and @lood 5ressureC Cholesterol and CigarettesD Diet and Diabetes* *ducation and *"ercise

Learning outcomes


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Learning outcomes

• Clinical presentation of AC% 0 History! *"amination

• In estigations

0 *C+! biomarkers• 5athophysiology• 3isk assessment in AC%

csim acs lecture

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