Beruflich Dokumente
Kultur Dokumente
Iftikhar Ul Haq
Consultant Cardiologist
Learning outcomes
Demonstrate ability to both describe and recognise
appropriate features in clinical presentation (including
relevant history, examination and investigation) found in
patients with ACS vs. other causes of chest pain.
Demonstrate ability to interpret investigations sufficient
to establish a differential diagnosis of acute coronary
syndrome: including non-ST elevation ECG changes
and biomarkers.
Demonstrate knowledge and understanding of the
pathophysiological processes contributing to the
development of acute coronary syndrome
The ECG
Vascular endothelial cell function
Shock
Muscle cell biology
Illness prevention and smoking
Universal Definition of MI
The term MI should be used when there is
evidence of myocardial necrosis in a clinical
setting consistent with myocardial ischaemia
Tn > 99th percentile of URL (Type 1 MI)
PLUS at least one of:
Symptoms of ischaemia
ECG changes indicating ischaemia
ECG evidence of necrosis: new pathological Q waves
Imaging - new loss of myocardium, or new RWMA
Universal Definition of MI
Type 1 usual MI
Type 2 - imbalance in myocardial O2 supply and
demand ischaemia without definite CAD
Type 3 - Sudden death: other evidence of AMI or
occlusive thrombus
Type 4 - PCI associated MI: Tn x3 URL
Type 5 - CABG associated: Tn x5 URL & new Q
waves/LBBB, or angiographic/imaging evidence
Definitions
ACUTE CORONARY SYNDROME
No ST Elevation
ST Elevation
NSTEMI
Unstable Angina
NQMI
QwMI
Myocardial Infarction
Plaque Rupture
Lipid
pool
Lipid-rich
plaque
Plaque
disruption
Fissure
Occlusive
thrombus
Acute MI,
Q-wave
Subocclusive
thrombus
Unstable
angina/
Non-Q-wave
MI
Mortality (%)
10
8
ST depression
8.9% (n=4,263)
ST elevation
6.8% (n=3,369)
T-wave inversion
3.4% (n=2,723)
20
40
Immediate assessments
First
Patient history
ECG
Physical examination
Then
Risk stratification
Blood marker tests
Diagnosis of ACS
Requires the presence of at least two of the following
criteria:1. Chest pain (clinical manifestation)
2. ECG changes consistent with ischaemia or
necrosis
3. Elevation of cardiac markers
Breathlessness
Tachycardia
Nausea or vomiting
Sweating and clamminess
Fixed
Patients sex
Age
Family history
Ethnicity
Previous angina/MI
CVA/PVD
CARDIAC
Anxiety
Angina
Myocardial Infarction
PULMONARY
Pericarditis
Pulmonary Embolus
Aortic dissection
Pleurisy
Pneumothorax
MUSCULOSKELETAL
Chostochondritis
Trauma
GASTRO
Ulcer or Reflux
Gallstones
Pancreatitis
Suspected ACS
Check immediately if chest pain is current, or when the last episode was, particularly if in the last
12 hours.
Check if the chest pain may be cardiac. Consider:
history of the pain
any cardiovascular risk factors
history of ischaemic heart disease and any previous treatment
previous investigations for chest pain.
Check if any of the following symptoms of ischaemia are present. These may indicate an ACS:
Pain in the chest and/or other areas (for example, the arms, back or jaw) lasting longer than15
minutes.
Chest pain with nausea and vomiting, marked sweating or breathlessness (or a combination of
these), or with haemodynamic instability.
New onset chest pain, or abrupt deterioration in stable angina, with recurrent pain occurring
frequently with little or no exertion and often lasting longer than 15 minutes.
Central chest pain may not be the main symptom.
Do not use response to glyceryl trinitrate (GTN) to make a diagnosis of ACS.
Do not assess symptoms of an ACS differently in men and women or among different ethnic
groups.
Advise people about seeking medical help if they have further chest pain.
If the chest pain is non-cardiac, explain this to the person and refer for further investigation if
appropriate.
Diagnosis of ACS
Requires the presence of at least two of the following
criteria:1. Chest pain (clinical manifestation)
2. ECG changes consistent with ischaemia or
necrosis
3. Elevation of cardiac markers
ECG
Perform an ECG immediately - especially if the
patient is still in pain
If ECG is normal or non diagnostic in a patient with
continuing symptoms repeat after 30mins
If symptoms resolve repeat ECG after 2 hours changes
can occur late
Repeat ECG if pain persists
Normal ECG
Anterolateral ST depression
Relative concentration
Myoglobin
Troponin
CK, AST
LDH
Normal
0 6 12 18 24 2 3 4 5 6 7 8 9 10
Hours
Days
Time after infarct
8
6
4
2
0
0 - <0.4
0.4 - <1.0
2.0 - <5.0
5.0 - <9.0
>9.0
Troponin I Level
Antman EA, Tanasijevic MJ, Thompson B, et al. Cardiac-specific troponin I levels to predict the risk of mortality
in patients with acute coronary syndromes. N Engl J Med. 1996;335:1342-1349
Troponin Pitfalls
Troponin can be elevated in
PE
Sepsis
Post-op
AF
LVF
15.4%
16
13.7%
14
12.8%
12.5%
12
10.0%
10
9.6%
8
6
6.0%
3.1%
4.1%
ST dev 0.05-0.09 mV
0
>0.10
ECG
None
0.01-0.10
Troponin T (ng/ml)
<0.01
POINTS
Age 65
RISK
SCORE
DEATH OR
MI
DEATH, MI OR URGENT
REVASC
0/1
13
PRESENTATION
Recent (24H) severe angina
20
Cardiac markers
12
26
6/7
19
41
(0-7)
*Entry criteria: UA or NSTEMII defined as ischemic pain at rest within past 24H, with
evidence of CAD (ST segment deviation or positive marker)
Antman et al JAMA 2000; 284: 835-842
Pathogenesis of ACS:
Platelet
Adhesion
Platelet
Activation
Platelet
Aggregation
Thrombotic
Occlusion
Epinephrine
Collagen
ADP
Arachidonic
Acid
Aspirin
Thrombin
Ticlopidine
Clopidogrel
Heparin
LMW Heparin
Direct Thrombin
Inhibitors
The
Platelet
IIb/IIIa
receptors
GP IIb/IIIa inhibitors
fibrin
Aspirin
Clopidogrel
LMWH
GPIIb/IIIa receptor antagonists
Beta blockers
Nitrates (if ongoing pain/LVD)
Statins
Offer a single loading dose of 300 mg aspirin and continue aspirin indefinitely
Offer fondaparinux to patients without a high bleeding risk unless angiography is planned
within 24 hours
Offer unfractionated heparin if angiography is likely within 24 hours
Carefully consider choice and dose of antithrombin for patients with a high bleeding risk
Consider unfractionated heparin, with dose adjusted to clotting function, if creatinine > 265
micromoles per litre
13
Unstable angina/NSTEMI
Use established scoring system such as GRACE to predict 6-month mortality and assess risk
of future adverse cardiovascular events1. Assess bleeding risk and pertinent comorbidity
before considering treatments and at each stage of management
Unstable angina/NSTEMI
Low risk
(> 1.53.0%)1
Yes
No
Coronary angiography
Ischaemia demonstrated?
No
Conservative
management
Discuss
management with
interventional
cardiologist and
cardiac surgeon
Unstable angina/NSTEMI
Intermediate risk
(> 3.06.0%)1
High risk
(> 6.09.0%)1
Highest risk
(> 9.0%)1
Offer a single 300-mg loading dose of clopidogrel2 and continue clopidogrel for 12 months
Balance potential reduction in ischaemic risk with risk of bleeding and consider:
adding a GPI (eptifibatide or tirofiban), or
bivalirudin as an alternative to the combination of a heparin plus a GPI if the patient is not
on fondaparinux or a GPI and angiography is scheduled within 24 hours of admission
19
Unstable angina/NSTEMI
Management of intermediate risk, high risk
and highest risk continued
Offer coronary angiography (with follow-on PCI if indicated) within 96 hours of first
admission unless contraindicated. Perform as soon as possible if patient is clinically
unstable or at high ischaemic risk
Coronary angiogram
RCA stenosis
Learning outcomes
Clinical presentation of ACS
History, Examination
Investigations
ECG, biomarkers
Pathophysiology
Risk assessment in ACS