diagnosis acs-pib unhas
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8/16/2019 Diagnosis ACS-PIB Unhas
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DIAGNOSIS OF ACUTECORONARY SYNDROME
Pendrik Tandean
Cardiology Department Medi!alFa!"lty o# $a%an"ddin Uni&er%ityMaka%%ar
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Cla%%i'!ation A!"te !oronary %yndrome% in!l"de
ST(ele&ation MI )STEMI*
Non ST(ele&ation MI ) NSTEMI*
Un%ta+le Angina
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A!"te Coronary SyndromeIschemic Discomfort
Unstable Symptoms
No ST-segment
elevation
ST-segment
elevation
Unstable Non-Q Q-Wave
angina AMI AMI
ECG
Acute
eperfusion
!istory
"hysical E#am
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Un%ta+le Angina angina at re%t ), -. min"te%*
ne/(on%et )0 - mont1%* e2ertional
angina )at lea%t CCSC III in %e&erity* re!ent )0 - mont1%* a!!eleration o#
angina )in!rea%e in %e&erity o# at
lea%t one CCSC !la%% to at lea%tCCSC !la%% III*
Agency for !ealth Care "olicy esearch - $%%&
Cana'ian Car'iovascular Society Classification
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CANADIAN CARDIO3ASCU4ARSOCIETY FUNCTIONA4
C4ASSIFICATION C4ASS I No angina /it1 ordinary
a!ti&ity5 Angina /it1 %tren"o"% rapid orprolonged e2ertion5
C4ASS II Slig1t limitation o# ordinarya!ti&ity 6 angina /1en /alking "p %tair%+ri%kly or /alking on a !old or /indy day5
C4ASS III Marked limitation 6 angina
/1en /alking at normal pa!e "p 7ig1t o#%tair% or /alking 8(- +lo!k% di%tan!e5 C4ASS I3 Angina on minimal e2ertion or
at re%t5
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Clini!al Feat"re% o# MI Cr"%1ing 1ea&y %"+%ternal !1e%t
pain radiating to t1e ne!k andmedial a%pe!t o# t1e le#t arm
Pain may +e atypi!al )like a
+"rning* lo!ali9ed )only in t1e :a/* or a+%ent
Sta+le angina i% "%"ally !a"%ed+y e2er!i%e or an2iety i% %1ort(li&ed and i% relie&ed +y re%t
and;or NTG Un%ta+le angina o!!"r% at re%t
and la%t% longer<ne/ painaltered %ta+le angina patternna"%ea;%/eating and radiation tone/ %ite% al%o %"gge%t% "n%ta+le
angina
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Clini!al #eat"re% !ont< Myo!ardial in#ar!tion %ign%;%ymptom%
A+r"pt on%et o# %e&ere prolonged pain
A"tonomi! %ymptom% )%/eating na"%ea* Dy%pnea
An2iety
Ta!1y!ardia or +rady!ardia depending on
%ite o# MI $ypoten%ion
Gallop 1eart r1yt1m
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Determining;!on'rming an
MI Serial E=G>% Angina
T /a&e in&er%ion ST depre%%ion Cond"!tion de#e!t% )eg(+"ndle +ran!1 +lo!k%*
MI S"+endo!ardial )doe%n>t go all t1e /ay t1r" t1e m"%!le*
ST depre%%ion T /a&e in&er%ion
Tran%m"ral )goe% all t1e /ay t1r" t1e m"%!le* Pre%en!e o# ? /a&e Ele&ated ST %egment
Cardia! en9yme% Myo!ardial ne!ro%i% relea%e% !ardia! en9yme% into t1e
pla%ma<CTT and C=(M@ peak /it1in - 1o"r%<4D$(8 peak%at B( day% o"t
In!rea%ed !ardia! troponin T )CTT* at 8- 1r% make% diagno%i% In!rea%ed 4D$(8%"gge%t% late pre%entation MI Do"+ling o# +a%eline C=(M@ !on'rm% MI
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Ele!tro!ardiogram A normal ECG doe% not e2!l"de ACS
$ig1 pro+a+ility in!l"de ST %egment
ele&ation in t/o !ontig"o"% lead% orpre%en!e o# /a&e%
Intermediate pro+a+ility ST
depre%%ion T /a&e in&er%ion% are le%% %pe!i'!
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Ischemia & Infarction
• Indications of an acute infarction• Usually no ECG changes are seen in the first few minutes after occlusion
• Appearance of tall narrow T-waves or ST-segment elevation• 5 to 3 minutes post occlusion
• A few hours later! the T-waves invert "ischemia#
• in an $%! the T-wave inversion is symmetrical an may persist for years
• inverte& T-waves without other in&ications are not &iagnostic of an $%
• ST-segment elevation ' in&ication of in(ury "although it may )e reversi)le#
• ST-elevation may also in&icate transmural ischemia• usually the first &efinite sign of an infarction
• may or may not )e accompanie& )y T-wave inversion
• *mm or more in lim) lea&s or +mm or more in precor&ial lea&s
• &ifferentiate )etween early repolari,ation or .-point elevation/
• the larger the ischemic area! the greater the ST &isplacement
• ST elevation persisting for more than a few hours may in&icate ventricular aneurysm
• ST &epression may )e seen in reciprocal lea&s0
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ST %egment Ele&ation
http122www0eme&u0org2
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ST %egment Ele&ation
http122www0eme&u0org2
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ST SEGMENT E4E3ATION
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ST %egment depre%%ion
http122www0eme&u0org2
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Cardia! @iomarker% Cardia! +iomarker% are protein
mole!"le% relea%ed into t1e +lood
%tream #rom damaged 1eart m"%!le Sin!e ECG !an +e in!on!l"%i&e
+iomarker% are #re"ently "%ed to
e&al"ate #or myo!ardial in:"ry T1e%e +iomarker% 1a&e a
!1ara!teri%ti! ri%e and #all pattern
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Troponin T and I T1e%e i%o#orm% are &ery %pe!i'!
#or !ardia! in:"ry
Pre#erred marker% #or dete!ting
myo!ardial !ell in:"ry
Ri%e -( 1o"r% a#ter in:"ry
Peak in 8-(8 1o"r%
Stay ele&ated #or (8 day%
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Creatine =ina%e )M@*
Time %e"en!e a#ter myo!ardialin#ar!tion
@egin% to ri%e ( 1o"r% Peak% - 1o"r%
ret"rn% to normal in - day%
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Ischemia & Infarction
• Biomarkers in an MI:
ays after $% 4nset
$ u l t i p l e s o f t h e A $ % c
u t o f f 5 i m i t
* + 3 6 5 7 8 9
$yoglo)in
Car&iac Troponin
C:-$;
Car&iac Troponin after unsta)le angina
*
+
5
*
+
5
A$% &ecision limitUpper normal limit
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Determining MI !ont<
E!1o!ardiograp1y May %1o/ dy%kine%ia o# m"%!le
m"ral t1rom+"% per#oration%ane"ry%m% papillary m"%!le r"pt"reand &al&e le%ion%
N"!lear %!an%
Te!1neti"m pyrop1o%p1ate Con!entrate% in area o# damage
T1alli"m %!an% S1o/ !old %pot% in non(per#"%ed
myo!ardi"m and demon%trate area% o#
re&er%i+le i%!1emia
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E!1o!ardiograp1y
U%e -(dimentional and M modee!1o!ardiograp1y /1en e&al"ating
o&erall &entri!"lar #"n!tion and/all motion a+normalitie%
E!1o!ardiograp1y !an al%o identi#y
!ompli!ation% o# MI ) eg5 3al&"lar orperi!ardial e"%ion 3SD*
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Coronary Angiography
a&<hah
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