acute coronary syndrome
DESCRIPTION
How to diagnose heart attack(MI) in ECG, a brief but comprehensive presentation on Acute Coronary Syndrome and its management.TRANSCRIPT
ACUTE CORONARY SYNDROME
By: Dr. Muhammad Alauddin Sarwar
Medical officer,Sindh Government Qatar Hospital,Karachi.
ACSACSAny constellation of clinical symptoms that are compatible with myocardial ischemia. It encompasses
Acute ST elevated myocardial infarction (STEMI)Non ST elevated myocardial infarction ( NSTEMI)Unstable Angina
Each year:• > 4 million patients are admitted with unstable
angina and acute MI • > 900,000 patients undergo PTCA with or
without stent
Worldwide StatisticsWorldwide Statistics
ACC/AHA and National Guidelines for USA & NSTEMI 2003
PATHOPHYSIOLOGY OF ACSPATHOPHYSIOLOGY OF ACS
Video clip explaining Atheromatous pathology of ACS
ACSACS
ACC/AHA and National Guidelines for USA & NSTEMI 2003
DIAGNOSIS OF ACS
It can be made on the basis of
HistoryECGCardiac (Bio Markers)
1) HISTORY
DIAGNOSIS OF ACS
Likelihood of ACSLikelihood of ACS Unlikelihood of ACS Unlikelihood of ACS
Chest or left arm pain as chief symptom.K/C of CAD, including MIAge >70 yrsMale sexD/MRecent cocaine useTransient MR, hypotension, diaphoresis, pulmonary edema.
Pleuritic painLocalized middle or lower abdominal pain.Pain that may be localized by the tip of 1 finger.Pain with movement or palpation of chest wall.Constant chest pain for many hoursVery brief episodes of pain that last a few seconds or less.Pain that radiates into the lower extremities.
ACC/AHA and National Guidelines for USA & NSTEMI 2003
DIAGNOSIS OF ACS
ECG:ECG:
High likelihood of High likelihood of ACSACS
Intermediate Intermediate Likelihood of ACSLikelihood of ACS
Low Likelihood of Low Likelihood of ACSACS
New, transient ST-segment deviation (0.05 mV), orT wave inversion (0.2 mV)
Fixed Q wavesAbnormal ST segment or T waves
T waves flattening or inversion in leads with dominant R wavesNormal ECG
ACC/AHA and National Guidelines for USA & NSTEMI 2003
DIAGNOSIS OF ACS
3) Cardiac ( Bio Markers)3) Cardiac ( Bio Markers)
High likelihood of High likelihood of ACSACS
Intermediate Intermediate Likelihood of ACSLikelihood of ACS
Low Likelihood of Low Likelihood of ACSACS
Elevated cardiac TnI, TNT, or CKMB
Normal Normal
ACC/AHA and National Guidelines for USA & NSTEMI 2003
Definite ACS
No ST elevation ST elevation
Non diagnostic ECG normal initial serum cardiac marker
ST & T wave changes on going pain positive cardiac
markers hemodynamic abnormalities
Evaluate for reperfusion
therapy
Observe, follow up 4-8 hrs: ECG, Cardiac markers
No recurrent pain, negative follow up studies
Recurrent ischemic pain or positive follow up studies
diagnosis of ACS confirmed
Stress study to provoke ischemiaConsider evaluation of LV function if ischemia is present
Positive: diagnosis of ACS confirmed
Negative: Non-ischemic discomfort, Low risk ACS
OPD follow up Admission, manage via acute ischemic pathway
See AHA guidelines for
Ac. MI
ACC/AHA & NationalGuidelines 2003.
EVALUATION OF ACS
In the early conservative strategy, coronary angiography is reserved for patients with evidence of recurrent ischemia (angina or ST-segment changes at rest or with minimal activity) or a strongly positive stress test despite vigorous medical therapy.
In the early invasive strategy, patients without clinically obvious contraindications to coronary revascularization are routinely recommended for early coronary angiography and angiographically directed revascularization, if possible.
EVALUATION OF ACS
STRATEGIESSTRATEGIES
ACC/AHA Guidelines 2003
SAARC Guidelines: Adopted from ACC/AHA
EVALUATION OF ACS
ACC/AHA and National Guidelines for USA & NSTEMI 2003
NST-AMI ACS Task Force. C 2003 European Society of Cardiology
EARLY INVASIVE STRSTEGY FOR ACS
ACS (STEMI)ACS (STEMI)
STEMI is the most important component of ACS.
It needs to be dealt urgently & efficiently.Time is muscle (Thrombolysis is preferred if
onset of pain to presentation is under 3 hours)
Every GP should be able to pick ST elevation in the ECG & to provide proper emergency medication & referral.
ACC/AHA and National Guidelines for STEMI 2006
The ECGThe ECG
Recognition of AMI Recognition of AMI
• Know what to look for—– ST elevation >1 mm– 2 contiguous leads
• Know where to look– I, AVL, V5, V6 = Lateral
– V1 V2 V3 V4 = Anterior
– II, III & AVF = InferiorPR baseline
ST-segment Elevation= 4.5 mm
J point
12-Lead ECG Variations in AMI and Angina
12-Lead ECG Variations in AMI and Angina
Baseline
Ischemia—tall or inverted T wave (infarct),ST segment may be depressed (angina)
Injury—elevated ST segment, T wave may invert
Infarction (Acute)—abnormal Q wave,ST segment may be elevated and T wavemay be inverted
Infarction (Age Unknown)—abnormal Q wave,ST segment and T wave returned to normal
NSR, ST elevation II, III and avF.ST depression in I, avL and V2 – V6
Acute Inferior wall MI
A 45 years old male patient on Bed -5 in Cardiac WardA 45 years old male patient on Bed -5 in Cardiac Ward
ECG at 11/2/085 days before admission
NSR,Poor R waves and T inversion II, III and avF.
ECG at admission5 days after MI
Upper} NSR, ST elevation in I, avL, V2 – V5, ST depression in II,III and avFANTERIOR WALL MI
NSR,ST elevation in I, avL and V1 to V6ST depression in II, III & avF.Anterior Wall MI
NSR, ST depression V1 to V3 with R wave and upright T waves, ST elevation in V5 & V6.Postero Lateral wall MI.
ER Management of STEMIER Management of STEMI
ReassuranceTargeted historyECG to be interpreted within 10 minOxygen @ 2-4 L/minI/V access with two wide bore cannulaeASA (Disprin) 300mg chewableClopidogrel (Loclog 75mg) 4 stat+LMWH S/C if Thrombolytic therapy is not near.
ACC/AHA and National Guidelines for STEMI 2006
STEMI Management
Sublingual nitroglycerin (Angised) 500mcg sos Streptokinase to be given stat after ECG confirms
ST elevation Morphine I/V to relieve pain and anxiety. Oral beta blocker, if no sign of heart failure
DRUGS to be used in first 24 hrs• Clopidogrel 75 mg OD• ACE inhibitor / ARBs if ACEI intolerance• Atorvastatin 20 mg at night.
ACC/AHA and National Guidelines for STEMI 2006