UHCW Cardiology Teaching
Dr Chris McAloon

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65 year old man
Playing golf
Sudden onset chest pain
Crushing, central, severe
Vomiting
No previous chest pain
HTN, Ex-Smoker
Otherwise well
GTN helped – not resolved

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◦ Character / Radiation / GTN spray effect
◦ Was this pain like your previous Angina/ MI pain?
◦ Smoker / Hypertension / Diabetes Hyperlipidaemia
/ Family history
◦ Previous MI / CABG / PCI / CVA
Differentials

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Central Crushing Chest Pain
Exertional chest pain
Occurs at rest
Radiation
◦ Neck, arms (classically left)
Levine’s Sign
◦ Clenched fist over chest
Breathless
Autonomic features

ECS ACS NTE Guidelines 2011

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Nicotine Stains
GTN spray
Xanthelasma
Scar’s
◦ Chest
◦ Legs
Evidence DM
BP/ Pulse/ Failure

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65 year old
◦ Ankles/shins for SVG scar
◦ Radial for graft scar
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CABG
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35 year old
◦ Metallic Click
◦ Look left lateral
◦ Cyanosis etc
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Valve/ Congenital surgery

ECS ACS Guidelines 2011

ECS ACS Guidelines 2011

©2003 by British Medical Journal Publishing Group
Grech E D , Ramsdale D R BMJ 2003;326:1259-1261

Grech E D , Ramsdale D R BMJ 2003;326:1259-1261
©2003 by British Medical Journal Publishing Group

©2003 by British Medical Journal Publishing Group
Grech E D , Ramsdale D R BMJ 2003;326:1379-1381

ECG Changes
V1-V3
Site of
Infarction
Anteroseptal
Vessel Occluded
LAD
V4, V5, AVL, I
Widespread
1, AVL, V1-V6
II, III, AVF
↓ ST V1-V2
↑ ST in post leads
Anterior Lateral LAD, diagonal
Large Anterior
Inferior
Posterior
Prox LAD (could be LMS
- Pump probs
RCA (or Cx)
- Bradyarrhythmia
RCA (or Cx)
NB remember Cx occlusion can be silent on the ECG

ST elevation V1-V6, reciprocal changes in
II, III, AVF

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STEMI
31,412 in 2009-10
Frequency falling
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NSTEMI
Estimated 100, 000 in 2009-10
Recorded frequency rising
50% not managed on ACU/ CCU
BCS Recommendations Acute Coronary Care Oct 2011

BCS Recommendations Acute Coronary Care Oct 2011

ECS ACS STE Guidelines 2011

THINK REPERFUSION STRATEGY:
■ Primary PCI if available (
CALL THE CATH LAB )
■ Thrombolysis if not, then refer to PCI centre
(GTN)
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High Flow Oxygen (15L)
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300mg Aspirin/ 600mg Clopidogrel
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Analgesia: Morphine + Metoclopramide
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Reperfusion: PCI / Fibrinolysis

Successful
Thrombolysis
ST segment resolution
50% at 90 minutes
ECS Revasculration Guidelines 2011

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Direct paramedic transfer to PPCI centre or timely inter-hospital transfer
PPCI with first medical contact-to-balloon time <120 minutes
Monitoring on CCU (including for repatriated patients)
Early initiation of secondary prevention and cardiac rehabilitation
ECS Revasculration Guidelines 2011

BCS Recommendations Acute Coronary Care Oct 2011

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95% England covered by PPCI networks
Thrombolysis remains in place in remote centres
◦ Geography impacts time to PPCI centre
30% Thrombolysis fail to reperfuse and need immediate rescue PCI

ECS ACS STE Guidelines 2011

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Disruption of occlusion using a balloon
Stent deployed to maintain anterograde blood flow
Types
Primary PCI – PCI within 2 hours
Rescue PCI – PCI after failed thrombolysis
Facilitated PCI – PCI bridged with lytic therapy
◦ Time delayed PPCI

©2003 by British Medical Journal Publishing Group
Grech E D , Ramsdale D R BMJ 2003;326:1259-1261

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48 year old lady
Shopping
Central dull Pain on walking
Not relieved GTN spray
Gets on exertion normally
Recently distant decreasing to onset pain
Pain last night in bed

©2003 by British Medical Journal Publishing Group
Grech E D , Ramsdale D R BMJ 2003;326:1259-1261

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Stable Angina
◦ pattern of frequency, intensity, ease of provocation, or duration does not change over several weeks
Accelerating Angina
◦ change in the pattern of stable angina
◦ greater ease of provocation, more prolonged episodes, and episodes of greater severity or more frequent use of sublingual GTN
Unstable Angina
◦ pattern of chest pain changes abruptly

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Angina at rest—Also prolonged, usually > 20 minutes
Angina of new onset—At least CCS class III in severity
Angina increasing—Previously diagnosed angina that has become more frequent, longer in duration, or lower in threshold
(change in severity by > 1 CCS class to at least CCS class III)

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Class I – Pain strenuous exertion
Class II – Slight limitation ordinary exertion
Class III – Marked limitation physical exertion
Class IV – Pain on any exertion
CCS = Canadian Cardiology Society

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≥3 risk factors for coronary artery disease
≥50% coronary stenosis on angiography
ST segment change >0.5 mm
≥2 anginal episodes in 24 hours before presentation
Elevated serum concentration of cardiac markers
Use of aspirin in 7 days before presentation

©2003 by British Medical Journal Publishing Group
Grech E D , Ramsdale D R BMJ 2003;326:1259-1261

ECS ACS Guidelines 2011

BCS Recommendations Acute Coronary Care Oct 2011

Simplified management pathway for patients with unstable angina or non-ST segment elevation myocardial infarction.
Grech E D , Ramsdale D R BMJ 2003;326:1259-1261
©2003 by British Medical Journal Publishing Group

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Aspirin 300mg
Clopidogrel 300mg (600mg if going to the lab)
LMWH
Bisoprolol / Atorvastatin 80mg ON/
ACE/ARB (can be next day)
GTN Spray/ Infusion
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HIGH RISK patients: GPIIbIIIa
Cath Lab within 48-96hrs

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High risk (GRACE >140) within 24 hours
◦ At Stafford discuss with Stoke
Intermediate risk (GRACE < 140) and high risk criterion within 72 hours
Low risk with recurrent symptoms
◦ Stress Test

ECS ACS Guidelines 2011

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Thienopyridine related to Clopidogrel
Active metabolite irreversible inhibitor of ADP receptor
Effective when Clopidogrel Resistance
More rapid/ greater/ more consistent platelet inhibition
No drug interactions
Licensed used STEMI going PPCI

Wiviott SD et al. N Engl J Med 2007;357:2001-2015

Wiviott SD et al. N Engl J Med 2007;357:2001-2015

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Cyclopentyl-triazolo-pyrimidine
Reversible inhibitor of ADP receptor
Rapid/ Predictable action
CYP450 interaction
NICE approval October 2011 ACS

Wallentin L et al. N Engl J Med 2009;361:1045-1057

Wallentin L et al. N Engl J Med 2009;361:1045-1057

ECS ACS Guidelines 2011

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Immediately
Aspirin ± PPI (Bleeding risk)
Clopidogrel (12 months)
B Blocker
ACEi- if intolerant give ARB
Atorvastatin 80mg
GTN Spray PRN
◦ 15 minute rule
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Lifestyle
Diet
Physical Activity
Stop Smoking
Cardiac Rehab

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Definitions ACS
Incidence and Prevalence
Pathophysiology
Differential Diagnoses
STEMI Intervention – current evidence
NSTEMI intervention – current evidence
Antithrombotic therapy use
New anti-thrombotics