Acute Coronary
Syndromes
Jason Ryan, M.D.
Acute Coronary Syndromes
Unstable Angina +
Non-ST-Elevation MI +
ST-Elevation MI
Acute Coronary Syndromes (ACS)
UA + NSTEMI
(life-threating but
not medical emergency)
STEMI
(medical emergency)
Acute Coronary Syndromes
Generally, same symptoms for all
– Squeezing, pressure-like, substernal chest
pain
– Often associated with shortness of breath and
diaphoresis
– Pearl: If nausea and vomitting think inferior
wall MI
– With UA/NSTEMI, often preceding history of
exertional symptoms
Remember the DDx for Chest Pain
ACS
Aortic Dissection
Pulmonary Embolism
Acute choleycystitis
Pericarditis
Costocondritis
Esophogeal spasm
Many others
The
Can’t
Misses
ST-Elevation MI
ST-Elevation MI
ST-Elevation MI
ST-Elevation MI
Coronary Stenosis: Progression to STEMI
Serial Angiogrpahy in 239 Patients
Stenosis
Pre-MI
0%
25%
50%
75%
90-99%
Nobuyoshi M et al., JACC 1991;18:904-10
Culprit
For MI
8
10
29
5
6
10
39
ST-Elevation MI
If you suspect STEMI:
– OMI: Oxygen, monitor, IV access
– ABC: Ensure patient is stable
– Call cardiology
– Pre-cath medication:
Aspirin 325mg PO
Lopressor 25mg PO (if BP and Pulse will tolerate)
– Beware cardiogenic shock
Heprin 5000U bolus (if no active bleeding issues)
Discuss IIB/IIIA and Clopidogrel with cardiology
Unstable Angina (UA) and
Non ST Elevation Myocardial Infarction
(NSTEMI)
• 5,315,000 annual ER presentations for chest pain
• 1,433,000 annual U.S. hospital admissions for
UA/NSTEMI
• 50 patients per month at BIDMC coded as:
AMI, SUBENDOCARDIAL ISCHEMIA
UA and NSTEMI
Placebo Event Rates in Recent Trials of UA and NSTEMI
Death/MI
at 30 days
PRISM1
7.1%
PRISM-PLUS2
11.9%
PURSUIT3
15.7%
GUSTO-IV ACS4
PARAGON A5
1. PRISM Study Investigators. N Engl J Med 1998;338:1498-1505.
2. PRISM-PLUS Study Investigators. N Engl J Med 1998;338:1488-1497.
3. Harrington RA. Am J Cardiol 1997;80:34B-38B.
4. The GUSTO IV-ACS Investigators. Lancet 2001;357:1915-1924.
5. The PARGON Investigators. Circulation 1998;97:2386-2395.
8.0%
11.7%
UA and NSTEMI
Definitions
– Unstable angina
New onset angina
Angina that occurs at rest
Angina that occurs with accelerating frequency
(crescendo angina)
May have EKG changes (ST depression)
Biomarkers will be negative
UA and NSTEMI
Definitions
– NSTEMI
Typical rise and fall of cardiac biomarkers plus at
least one of the following:
–
–
–
–
Anginal chest pain
Ischemic EKG changes (ST-depression)
Development of Q waves on EKG
Coronary intervention
Often can’t tell UA from NSTEMI at
presentation
Joint European Society of Cardiology/American College of Cardiology committee
NSTEMI
The Biomarkers:
– CK
Rises 4-6 hours after MI
Peaks and falls by 36-48 hours after MI
Total CK is non-specific
CK-MB is more specific for cardiac tissue
– (but there is still some in skeletal muscle!!)
– Remember this is one component in the diagnosis of
NSTEMI
– CK alone cannot be used to diagnose NSTEMI
NSTEMI
The Biomarkers:
– Troponin
Rises 4-6 hours after MI
Can remain elevated for up to two weeks!
Very specific for cardiac damage
Elevated in many other conditions than ACS
–
–
–
–
Hypotension of any cause (~80% patients)
Renal failure
Congestive heart failure
Many others
Always predicts worse outcomes
NSTEMI
Four pieces to NSTEMI:
– Symptoms
– EKG changes
– CK
– Troponin
ACC Guidelines for Management of UA/NSTEMI
Chest Pain
EKG
No ST
Possible
UA/NSTEMI
MSO4
NTG
ASA
Beta Blockers
Definite/Likely
UA/NSTEMI
MSO4
NTG
ASA
Beta Blockers
Heparin
Plavix
ST
Follow ST
Protocols
Definite/Likely
UA/NSTEMI with cath
or PCI planned
MSO4
NTG
ASA
Beta Blockers
Heparin
Plavix
IIB/IIIA Inhibitor
American College of Cardiology (ACC)
2002 Guidelines for UA/NSTEMI
Medications with Class I indication
First 24 hours
•Morphine
•Nitroglycerin
•Aspirin
•Beta Blocker
•Plavix
•Heparin
•IIB/IIIA
Inhibitors
Discharge
•Aspirin
•Beta Blocker
•Plavix
•ACE Inhibitor
•Statin
ACC 2002 Guidelines for UA/NSTEMI
How well do we do?
100%
NRMI-4 NSTE MI Acute Care:
3rd
Quarter
2001
85%
80%
71%
72%
60%
40%
24%
20%
0%
ASA
Beta Blocker
Heparin (all)
GP IIb/IIIa
ACC 2002 Guidelines for UA/NSTEMI
How well do we do?
NRMI-4 NSTE MI Discharge Care:
3rd Quarter 2001
100%
84%
75%
80%
71%
56%
60%
40%
21%
20%
0%
ASA
Beta Blocker
* LVEF < 40%
# Known hyperlipidemia
ACE
Inhibitor *
Statins #
Cardiac
Rehab
ACC 2002 Guidelines for UA/NSTEMI
How well do we do?
Gap between ‘Leading and Lagging’ US Hospitals
Performance
Quality Indicator
ASA use < 24 h
 blocker use < 24 h
Heparin use <24 h
GP IIb-IIIa < 24 h
D/C ASA use
D/C  blocker use
D/C ACE-I use
D/C lipid lowering
Bottom 10%
54%
33%
50%
0%
54%
44%
21%
33%
Top 10%
99%
98%
92%
51%
99%
96%
83%
99%
ACC 2002 Guidelines for UA/NSTEMI
Does doing well matter?
Benefits of Using Evidence-Based Therapies
(Non-ST  ACS Patients from GUSTO IIb)
Additional Lives
Discharge
Saved per 1,000
Therapy
Current Use (ideal use)
Aspirin
86%
9
Beta blockers
59%
11
ACE inhibitors
52%
23
Alexander K, JACC, 1998
Case 1
A 54 year old man with DM, HTN, and high cholesterol
presents to the ER complaining of substernal chest pain.
The pain feels like his chest is being squeezed. He first
noted it two months ago when carrying packages up a
flight of stairs. Last week he noticed it when walking to
work. The past two days, the pain has occurred
whenever he climbs the stairs in his house. This morning
it occurred while driving to work.
His initial EKG shows sinus tachycardia with anterior ST
depressions.
His initial cardiac biomarkers are negative.
He becomes pain free during his first few minutes in the
ER and his EKG changes resolve.
Case 1
Is this an ACS?
– YES!!!
How should this patient be managed?
– Morphine and NTG to make him pain free
– Aspirin, Beta blocker, Heparin, Integrillin
– Plan for catheterization with 24-48 hours
Case 2
A 75 yom with HTN presents to the ER
complaining of squeezing, substernal
chest pain. The pain began this morning
while taking a shower and has waxed and
waned all day (~10 hours time).
Initial EKG shows sinus tachycardia
without ST changes
Initial biomarkers:
– CK 300, MB 20, Trop T 0.5
Case 2
Is this an ACS?
– YES!!!
How should this patient be managed?
– Morphine and NTG to make him pain free
– Aspirin, Beta blocker, Heparin, Integrillin
– Plan for catheterization within 24-48 hours
Case 3
A 82 yof is transferred to the ED from her
nursing home where she was noted to be
lethargic. For the past two days, she has had
decreased POs and one episode of vomiting.
The patient is unable to give a history.
On initial ED eval, her blood pressure is 72/45
and her temp is 101.4
Initial EKG shows sinus tachycardia
Initial biomarkers show CK 110, MB 6, Trop 0.5
Case 3
In this an ACS?
– Unlikely
How should this patient be managed
– ASA if no contraindication
– No BB given hypotension
– No heparin or IIB/IIIA as this is not likely ACS
– Work up fever and hypotension
– Cycle biomarkers
– Repeat EKG in 6-12 hours
Case 4
A 62 yom with a history of ESRD on HD,
Ischemic CM with EF 20% presents with
lethargy and altered mental status for two days
Initial vitals are remarkable for a room air O2 sat
of 88%
EKG shows sinus rhythm with old anterior Q
waves (see on EKG 1 year prior). No new ST
changes.
Initial cardiac markers:
– CK 200 MB 9 Trop 0.8
Case 4
In this an ACS?
– Unlikely
– Troponin is his only marker of ACS and he has at
least two reasons for false positive (CRF, CHF)
How should this patient be managed
– ASA if no contraindication
– BB if not in CHF
– No heparin or IIB/IIIA unless further evidence of ACS
develops
– Work up lethargy and altered mental status
– Cycle biomarkers
– Repeat EKG in 6-12 hours
Case 5
A 55 yom presents to the ED c/o episodic chest
pain for one week. The pain is sharp, left sided,
and lasts 10-15 minutes. The pain occurs when
walking and never at rest, although sometimes
he can walk without symptoms. He is pain free
now.
EKG shows sinus rhythm without ST changes.
Initial biomarkers
– CK 90, MB not done, Trop <0.01
Case 5
In this an ACS?
– Can’t tell
– Some features consistent, some not
How should this patient be managed
– ASA and BB
– No heparin or IIB/IIIA unless biomarkers become
elevated
– Cycle biomarkers
– Repeat EKG in 6-12 hours
– If rules out, consider exercise stress test