Acute Coronary Syndromes PDF

INTERNAL MEDICINE Acute Coronary Syndromes Acute Coronary The term acute coronary syndrome encompasses Syndrome the spectrum of symptoms and clinical findings with acute myocardial ischemia  Usually precipitated by acute thrombosis...

INTERNAL MEDICINE Acute Coronary Syndromes Acute Coronary The term acute coronary syndrome encompasses Syndrome the spectrum of symptoms and clinical findings with acute myocardial ischemia  Usually precipitated by acute thrombosis induced by a ruptured or eroded atherosclerotic coronary plaque (unstable plaque) and coronary thrombosis Spectrum of Acute Coronary Syndromes  ST Elevation MI (STEMI) o Complete blockage of a coronary artery o Specific ECG changes (significant ST-segment elevation in two contiguous leads o Often present with severe & prolonged chest pain (may radiate to arms/jaw/back), SOB, diaphoresis, N/V  Non ST Elevation MI (NSTEMI) o Partial blockage of a coronary artery o Nonspecific ECG changes (ST-segment depression, T-wave inversion, or no changes) o Symptoms similar to STEMI, may be less severe  Unstable angina (UA) o New onset angina, increasing angina, or angina at rest reflecting a significant disruption in coronary artery blood flow without evidence of myocardial necrosis Myocardial Myocardial Infarction is defined as a rise and/or fall of cardiac biomarkers PLUS one of: Infarction  Symptoms of ischemia  Development of pathologic Q waves on the ECG  New or presumed new ST changes on ECG or new LBBB  Identification of intracoronary thrombus by angiography or autopsy  Imaging evidence of new loss of viable myocardium or new regional wall motion abnormality Classification of Myocardial Infarction  Type 1 MI- pathologic process in the wall of the coronary artery (plaque rupture, fissuring, dissection)  Type 2 MI- results from a critical imbalance between myocardial oxygen supply and demand (coronary spasm, anemia, arrhythmias, hypotension, hypertension, respiratory failure)  Type 3 MI- MI resulting in death for which cardiac enzymes are not available  Type 4 MI- MI related to PCI/stent thrombosis  Type 5 MI- MI related to CABG Approach to Differential Diagnosis Acute Chest Pain Immediate Management  Vitals including blood pressure in BOTH arms  Oxygen if hypoxic (SpO2 < 90%)  IV access  ECG within 10 minutes of medical contact  History & physical  CBC, electrolytes, BUN, Cr, troponin, and CK  CXR  INTERNAL MEDICINE Acute Coronary Syndromes  Pain management (nitro, opioid) STEMI ST Elevation MI (STEMI)  Ischemic type chest pain  ECG compatible o ST elevation >2mm in 2+ contiguous leads (e.g., V2+V3, V5+V6, etc.) o New LBBB (left bundle branch block) STEMI Management  Primary goal is to open the infarct related artery as soon as possible to restore perfusion Revascularization  Mechanical  primary PCI  Pharmacological  fibrinolytic therapy  Surgical  CABG Primary PCI Fibrinolytic Therapy (e.g., Atleplase, Tenecteplase)  Better vessel patency  Risk of stroke (1.2%), intracranial hemorrhage (0.7%), with PCI (>90% major non-cerebral bleeding (1.8% severe bleeding, restoration of flow vs 55- 11.4% moderate bleeding) 60% with lytic)  Less recurrent Indications for Fibrinolysis ischemia/infarction with  Goal FMC to balloon time is not achievable PCI  Goal FMC to needle time