Acute Chest Pain Syndromes
2014
Morton J. Kern MD
Chief of Medicine LBVAH
Professor of Medicine
Associate Chief Cardiology
University California Irvine
History
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48 y.o M smoker with hyperlipidemia presents to ER
with sudden onset chest discomfort x 2 hours ago.
Chest pain radiating to jaw and associated with N/V
and SOB.
BP 110/60 HR 98
RRR normal S1/S2, Grade II/VI HSM apex. + S3
Lungs with bibasilar rales
ED Evaluation of
Patients With CP
Differential Diagnosis: Life-Threatening
 Acute Coronary Syndrome
 Pulmonary embolus
 Aortic dissection
 Perforating ulcer
 Tension pneumothorax
 Boerhaave syndrome (esophageal rupture with
mediastinitis)
Spectrum of ACS Presentations
UA
Definition
NSTEMI
Ischemia without
necrosis
Negative Biomarkers
Necrosis
(nontransmural)
Positive biomarkers
STEMI
Transmural necrosis
Positive biomarkers
Diagnosis
ECG ST-segment
elevation
No ECG ST-segment elevation
Treatment
Invasive or conservative depending on risk
Immediate reperfusion
Roger VL, Go AS, Lloyd-Jones DM, et al.. Circulation. 2011;123:e18-e209.
CAD is a diffuse process with
focal accumulation of
atherosclerotic material in
epicardial vessels.
Some lesions are obstructive
but not thrombotic and others
are potentially thrombotic but
not obstructive.
Myocardial Infartion=
Death of myocardial cells.
Clinical MI = symptoms, ECG
and Biomarkers
CAD as a cause of Myocardial Ischemia and Infarction
Normal
Atherosclerotic Plaque
Typical Morphological Traits Associated With Rupture-Prone Plaques
Vancraeynest, D. et al. J Am Coll Cardiol 2011;57:1961-1979
Myocardial Oxygen Demand = Supply
BB
Statins
ACEI/ARB
CA++B
=
NTG
ASA, Heparin, GPBs
Na-K channel blker
Ranolazine
Acute Myocardial Infarction

Myocardial infarction: myocardial cell death or necrosis.

Occurs when myocardial ischemia exceeds myocardial
cellular repair in the setting of :





Thrombus superimposed on atherosclerotic plaque
High grade fixed coronary stenosis
Dynamic stenosis (coronary vasospasm)
Metabolic demands ( HTN, AS, anemia, HOCM)
Low output states ( low aortic DP- coronary perfusion)
Symptoms of Myocardial Infarction
• Chest discomfort
– Pressure
– Squeezing
– Fullness
– Pain
• Discomfort in other areas of the upper body
– Arms
– Jaw
– Neck
– Back
– Stomach
• Shortness of Breath
• Cold sweat, nausea or lightheadedness
• **Women have atypical presentations!! Be more wary
Physical Exam of Acute Ischemia/Infarction
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Examination findings can vary:
Low-grade fever, pale and with cool, clammy skin
Hypotension or hypertension depending on the extent of the MI
Dyskinetic cardiac impulse (in anterior wall MI) occasionally can be
palpated
S3 and S4 heart sounds +
Systolic murmur if mitral regurgitation or ventricular septal defect
develop, pericardial rub
Possibly have signs of congestive heart failure, including pulmonary
rales, peripheral edema, elevated or absent jugular venous pressure
Normal
STEMI
NSTEMI
NSTEMI
S
S
T
S
Q
T
Q
T
T
54 yo M w 2h severe substernal CP
ECG after onset of CP
New clinical classification of MI
Classification
Description
1
Spontaneous MI due to coronary event, i.e. plaque erosion
and/or rupture, fissuring, or dissection
2
MI secondary to ischemia due to an imbalance of O2 supply
and demand, as from coronary spasm or embolism, anemia,
arrhythmias, hypertension, or hypotension
3
Sudden unexpected cardiac death, including cardiac arrest,
with new ST-segment elevation; new LBBB; or pathologic or
angiographic evidence of fresh coronary thrombus--in the
absence of reliable biomarker findings
4a
MI associated with PCI
4b
MI associated with documented in-stent thrombosis
5
MI associated with CABG surgery
Thygesen K et al. Circulation 2007; available at:
http://circ.ahajournals.org.
Thygesen, K. et al. Circulation 2007;116:2634-2653
Biomarkers of Myocardial Damage
Timing of Release of Various Biomarkers After
Acute Myocardial Infarction
Cardiac-specific troponins are
optimum biomarkers (Level IC)
For STEMI, reperfusion therapy
should be initiated as soon as
possible and is not contingent on
a biomarker assay (Level IC)
Shapiro BP, Jaffe AS. Cardiac biomarkers. In: Murphy JG, Lloyd
MA, editors. Mayo Clinic Cardiology: Concise Textbook. 3rd ed.
Rochester, MN: Mayo Clinic Scientific Press and New York:
Informa Healthcare USA, 2007:773–80.
Anderson JL, et al. J Am Coll Cardiol 2007;50:e1–e157, Figure 5.
Troponin Elevation and Likelihood for
Mortality
% mortality at
42 days
8
Antman EMl. N Engl J Med. 1996; 335: 1342-1349.
6
4
2
0
<0.4
<1.0
<2.0
<5.0
Troponin levels
<9.0
9.0
Thygesen, K. et al. Circulation 2007;116:26342653
Treatment of Acute Coronary Syndrome
Early Invasive
Braunwald E et al. Available at: www.acc.org.
Bowen WE, McKay RG. N Engl J Med. 2001;344:1939-1942.
Initial
Conservative
* Also known as Q-wave MI
† Also known as non-Q-wave MI
54 yo M w 2h severe substernal CP
ECG after onset of CP
Left Coronary System has mild CAD
RCA is 100% occluded.
Final post Stent
PCI vs Fibrinolysis in STEMI
Systematic Overview
(23 RCTs, n=7,739)
Short term (4-6 weeks)
25 .0
Percent (%)
20 .0
15 .0
10 .0
22.0
L ysis
PCI
P=0.0002
8.5
7.2
5.0
P=0.0003
P<0.0001
7.3
7 .2
4.9
P<0.0001
6.8
2.8
P=0.0004
2.0 1.0
0.0
D eath
Keeley EC et al. Lancet. 2003;361:13-20.
D eath
SH OC K
exc l.
R e in farctio n
R ecu rren t
isch em ia
S tro ke
Medical Therapy for STEMI Managed
by Primary PCI
ED
CCL
Presentation
Access—Wire—Balloon
ASA
Anticoagulant
P2Y12 inhibitor
UFH
Clopidogrel 600
Prasugrel 60, or Ticagrelor 180
Eptifibatide
Abciximab
GP IIb/IIIa
Beta Blocker
Statin
(Bival)
IV prn
Oral within 24h
Importance of Rapid Reperfusion in STEMI
30-minute delay = 8% increase in 1-year mortality
Rathore SS, Curtis JP, Chen J, et al. BMJ. 2009;338:b1807.
Antman E. ST-segment elevation myocardial infarction: Management. In: Bonow RO, Mann DL, Zipes P, et al,
eds. Braunwald's Heart Disease. 9th ed. Philadelphia, PA: Elsevier Saunders; 2011a:1087-1110.
48 yo Man,
Chest pain
after lunch
while walking
to car.
48 yo M, HBP with Chest pain while walking
TIMI Risk Score
TIMI Risk Score Calculator
Age ≥65 years?
Yes (+1)
≥3 Risk Factors for CAD?
Yes (+1)
Known CAD (stenosis ≥50%)?
Yes (+1)
ASA Use in Past 7d
Yes (+1)
Severe angina (≥2 episodes w/in 24 hrs)?
Yes (+1)
ST changes ≥0.5 mm?
Yes (+1)
+ Cardiac Marker?
Yes (+1)
Total Score
pts
Antman EM, Cohen M, Bernink PJ, et al. JAMA. 2000;284:835-842.
TIMI Study Group. TIMI Risk Score Calculator. http://www.timi.org/?page_id=294. Updated 2011.
Accessed July 7, 2011.
What does TIMI RISK mean?
Increasing TIMI RISK 0/1 to 5/7
increases risk of death, MI,
urgent revascularization within
14 days 5% to 41%.
Antman EM et al. TIMI 11B, JAMA 2000;284:835-842
GRACE Risk Score
Find Points for Each Predictive Factor, Total Points, Look up Risk
Killip
Class
I
II
III
IV
Points
0
20
39
59
Cardiac Arrest
at Admission
Absent
Present
SBP,
mm Hg
≤80
80-99
100-119
120-139
140-159
160-199
≥200
Points
0
39
Points
58
53
43
34
24
10
0
Heart Rate,
Beats/min
≤50
50-69
70-89
90-109
110-149
150-199
≥200
ST-Segment
Deviation
Absent
Present
Points
0
3
9
15
24
38
46
Age,
y
≤30
30-39
40-49
50-59
60-69
70-79
80-89
≥90
Points
0
39
Points
0
8
25
41
58
75
91
100
Creatinine,
mg/dL
0-0.39
0.40-0.79
0.80-1.19
1.20-1.59
1.60-1.99
2.00-3.99
>4.0
Points
1
4
7
10
13
21
28
Elevated Cardiac
Enzyme Levels
Absent
Present
Points
0
14
Online calculator at http://www.outcomes-umassmed.org/grace/
Granger CB, Goldberg RJ, Dabbous O, et al. Arch Intern Med. 2003;163:2345-2353.
Anderson JL, Adams CD, Antman EM, et al. Circulation. 2007;116:e148-e304.
GRACE Risk Score
60
50
In-hospital Mortality
≥52
6 Month Mortality
In-Hospital Death, %
44
40
36
29
30
23
18
20
13
9.8
10
2.9 3.9
2.1
1.6
≤0.2 0.3 0.4 0.6 0.8 1.1
5.4
7.3
0
GRACE Risk Score
Granger CB, Goldberg RJ, Dabbous O, et al. Arch Intern Med. 2003;163:2345-2353.
Summary of Treatment Strategies for ACS
Prehospital
Symptoms suggestive of ACS
EMS transport and care
ED
ED assessment and general treatment
ECG
Normal or nondiagnostic
ST elevation
Suspicious
STEMI
Early hospital
care
High-risk UA/NSTEMI
Adjunctive medical therapy
Consider early invasive
strategy
Lower-risk UA/NSTEMI
High risk
Continued observation and
testing
ECG
Reperfusion
(fibrinolytics or PCI)
Adjunctive medical therapy
Late hospital care
Continue medical therapy and monitoring
Troponins
Low risk
Stress test
No evidence of ACS
Postdischarge
Secondary
prevention
Discharge with follow-up
Secondary prevention
Discharge with follow-up
Adapted from O'Connor RE, Brady W, Brooks SC, et al. Circulation. 2010;122:S787-S817.
Summary of Treatment Strategies for ACS: Prehospital
Management
Prehospital
Symptoms suggestive of ACS
EMS transport and care
ED
ED assessment and general treatment
ECG
Normal or nondiagnostic
ST elevation
STEMI
Early hospital
care
Suspicious
High-risk UA/NSTEMI
Adjunctive medical therapy
Reperfusion
(fibrinolytics or PCI)
Consider early invasive
strategy
Adjunctive medical therapy
Late hospital
care
Postdischarge
Secondary
prevention
Continue medical therapy and monitoring
Discharge with follow-up
Secondary prevention
Lower-risk UA/NSTEMI
High risk
Low risk
Continued observation
and testing
ECG
Troponins
Stress test
No evidence of ACS
Symptoms suggestive of ACS
EMS transport and care
Discharge with follow-up
Adapted from O'Connor RE, Brady W, Brooks SC, et al. Circulation. 2010;122:S787-S817.
Summary of Treatment Strategies for
ACS: ED Management
Prehospital
Symptoms suggestive of ACS
EMS transport and care
ED
ED assessment and general treatment
ECG
Normal or nondiagnostic
ST elevation
STEMI
Early hospital
care
Suspicious
High-risk UA/NSTEMI
Adjunctive medical therapy
Reperfusion
(fibrinolytics or PCI)
Lower-risk UA/NSTEMI
Consider early invasive
strategy
High risk
Adjunctive medical therapy
Late hospital
care
Postdischarge
Secondary
prevention
Low risk
Continued observation
and testing
ECG
Troponins
Stress test
ED assessment and general treatment
No evidence of ACS
Continue medical therapy and monitoring
Discharge with follow-up
Secondary prevention
Discharge with follow-up
ECG
ST elevation
Suspicious
STEMI
High-risk
UA/NSTEMI
Normal or
nondiagnostic
Lower-risk
UA/NSTEMI
Adapted from O'Connor RE, Brady W, Brooks SC, et al. Circulation. 2010;122:S787-S817.
Summary of Treatment Strategies for
ACS: Early Hospital Management
Prehospital
Symptoms suggestive of ACS
EMS transport and care
ED
STEMI
ECG
STEMI
Suspicious
High-risk UA/NSTEMI
Adjunctive medical therapy
Reperfusion
(fibrinolytics or PCI)
Consider early invasive
strategy
Adjunctive medical therapy
Late hospital
care
Postdischarge
Secondary
prevention
Lower-risk
UA/NSTEMI
Normal or nondiagnostic
ST elevation
Early hospital
care
High-risk
UA/NSTEMI
ED assessment and general treatment
Adjunctive medical
therapy
Reperfusion
(fibrinolytics or PCI)
Continue medical therapy and monitoring
Discharge with follow-up
Secondary prevention
Lower-risk UA/NSTEMI
High risk
Continued observation
and testing
ECG
Troponins
Stress test
Continued
Consider early
High risk
observation and
invasive strategy
testing
ECG
Troponins
Adjunctive medical
Low
Stress test
therapy
Low risk
No evidence of ACS
Discharge with follow-up
risk
No evidence
of ACS
Adapted from O'Connor RE, Brady W, Brooks SC, et al. Circulation. 2010;122:S787-S817.
Summary of Treatment Strategies for
ACS: Medical Management
Prehospital
Symptoms suggestive of ACS
EMS transport and care
ED
ED assessment and general treatment
ECG
Normal or nondiagnostic
ST elevation
STEMI
Early hospital
care
Suspicious
High-risk UA/NSTEMI
Adjunctive medical therapy
Reperfusion
(fibrinolytics or PCI)
Consider early invasive
strategy
Adjunctive medical therapy
Late hospital
care
Postdischarge
Secondary
prevention
Continue medical therapy and monitoring
Discharge with follow-up
Secondary prevention
Lower-risk UA/NSTEMI
Agents Used in Adjunctive Medical Therapy/ Medical
Management
High risk
Low risk
Continued observation
and testing
ECG
Troponins
Stress test
Antiplatelet agents and
anticoagulants
No evidence of ACS
Discharge with follow-up
Other agents
• Nitroglycerin
• Heparin (UFH and LMWH)
• Analgesics
• Direct thrombin inhibitors
• Aspirin
• RAAS inhibitors
(ACE inhibitors, ARBs)
• Thienopyridines
• Glucose control
• Gp IIb/IIIa inhibitors
• Risk factor management
• Warfarin
• Magnesium
• CCBs
Adapted from O'Connor RE, Brady W, Brooks SC, et al. Circulation. 2010;122:S787-S817.
Summary of Treatment Strategies for
ACS: Reperfusion
Prehospital
Symptoms suggestive of ACS
EMS transport and care
ED
Reperfusion
ED assessment and general treatment
 Restoration of blood flow to the infarct area
ECG
Normal or nondiagnostic
ST elevation
STEMI
Early hospital
care
Suspicious
High-risk UA/NSTEMI
Adjunctive medical therapy
Reperfusion
(fibrinolytics or PCI)
Consider early invasive
strategy
Adjunctive medical therapy
Late hospital
care
Postdischarge
Secondary
prevention
Continue medical therapy and monitoring
Discharge with follow-up
Secondary prevention
 STEMI: faster reperfusion = better outcomes
Lower-risk UA/NSTEMI
Continued observation
and testing
ECG
Troponins
Stress test
Percutaneous coronary intervention (PCI)
High risk
Low risk
 Also known as percutaneous transluminal
coronary angioplasty (PTCA)
No evidence of ACS
 Invasive technique: a catheter is used to
mechanically open the occluded artery
Discharge with follow-up
 Preferred if available promptly
Fibrinolysis
 IV agents that dissolve thrombi by attacking fibrin
 Increases bleeding risk
 Used when prompt PCI is not available
Adapted from O'Connor RE, Brady W, Brooks SC, et al. Circulation. 2010;122:S787-S817.
Summary of Treatment Strategies for
ACS: Late Hospital Care
Prehospital
Symptoms suggestive of ACS
EMS transport and care
ED
ED assessment and general treatment
ECG
Normal or nondiagnostic
ST elevation
STEMI
Early hospital
care
Suspicious
High-risk UA/NSTEMI
Adjunctive medical therapy
Reperfusion
(fibrinolytics or PCI)
Consider early invasive
strategy
Adjunctive medical therapy
Late hospital
care
Postdischarge
Secondary
prevention
Continue medical therapy and monitoring
Discharge with follow-up
Secondary prevention
Lower-risk UA/NSTEMI
High risk
Low risk
Continued observation
and testing
ECG
Troponins
Stress test
No evidence of ACS
Discharge with follow-up
Continue medical therapy
and monitoring
Adapted from O'Connor RE, Brady W, Brooks SC, et al. Circulation. 2010;122:S787-S817.
Summary of Treatment Strategies for
ACS: Postdischarge Care
Prehospital
Symptoms suggestive of ACS
EMS transport and care
ED
ED assessment and general treatment
ECG
Normal or nondiagnostic
ST elevation
STEMI
Early hospital
care
Suspicious
High-risk UA/NSTEMI
Adjunctive medical therapy
Reperfusion
(fibrinolytics or PCI)
Consider early invasive
strategy
Adjunctive medical therapy
Late hospital
care
Postdischarge
Secondary
prevention
Continue medical therapy and monitoring
Discharge with follow-up
Secondary prevention
Lower-risk UA/NSTEMI
High risk
Low risk
Continued observation
and testing
ECG
Troponins
Stress test
No evidence of ACS
Discharge with follow-up
Discharge with follow-up
Secondary prevention
Adapted from O'Connor RE, Brady W, Brooks SC, et al. Circulation. 2010;122:S787-S817.
Additional Differential Dx for ACS Chest
Pain Syndromes
• Perforating ulcer
• Pericarditis
• GERD (Gastroesophageal reflux disease)
• Heart failure, Pneumonia, Pneumothorax
Name the 3 most common
causes of life threatening
chest pain
AMI
aortic dissection
pulmonary embolus