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Acute Coronary Syndrome

MINI LECTURE

KELVI N NGUYEN
OBJECTIVES
Definition of ACS
UA, NSTEMI, and STEMI
Risk stratification in NSTEMI
Management

Acute Coronary Syndrome
Definition: a constellation of symptoms related to
obstruction of coronary arteries with chest pain being the
most common symptom in addition to nausea, vomiting,
diaphoresis etc.

Chest pain concerned for ACS is often radiating to the left
arm or angle of the jaw, pressure-like in character, and
associated with nausea and sweating. Chest pain is often
categorized into typical and atypical angina.
Acute coronary syndrome
Based on ECG and cardiac enzymes, ACS is classified
into:
STEMI: ST elevation, elevated cardiac enzymes
NSTEMI: ST depression, T-wave inversion, elevated cardiac
enzymes
Unstable Angina: Non specific EKG changes, normal
cardiac enzymes

Unstable Angina
Occurs at rest and prolonged, usually lasting >20
minutes
New onset angina that limits activity
Increasing angina: Pain that occurs more frequently,
lasts longer periods or is increasingly limiting the
patients activity

EKG
STEMI:
Q waves , ST elevations, hyper acute T waves; followed by T wave
inversions.
Clinically significant ST segment elevations:
> than 1 mm (0.1 mV) in at least two anatomical contiguous leads
or 2 mm (0.2 mV) in two contiguous precordial leads (V2 and V3)







Note: LBBB and pacemakers can interfere with diagnosis of MI on
EKG



EKG
NSTEMI:
ST depressions (0.5 mm at least) or T wave inversions ( 1.0
mm at least) without Q waves in 2 contiguous leads with
prominent R wave or R/S ratio >1.
Isolated T wave inversions:
can correlate with increased risk for MI
may represent Wellens syndrome:
critical LAD stenosis
>2mm inversions in anterior precordial leads
Unstable Angina:
May present with nonspecific or transient ST segment
depressions or elevations
Cardiac Enzymes
Troponin is primarily used for diagnosing MI
because it has good sensitivity and specificity.
CK-MB is more useful in certain situations such as post
reperfusion MI or if troponin test is not available
Other conditions can cause elevation in troponin
such as renal failure or heart failure
The increasing troponin trend is the important thing
to look for in diagnosing MI. Order Troponin
together with ECG when doing serial testing to rule
out ACS.
Risk Stratification: TIMI score
NSTEMI or unstable angina are risk stratified:
Age>=65
>= 3 CAD risk factors:
HTN, hyperlipidemia, diabetes, smoker, family hx of early MI
Documented CAD with >=50% stenosis
ST segment deviation
2 aginal episodes in past 24 hours
Aspirin use in the past week (marker for more severe case)
Elevation of cardiac enzymes
Stratify risk based on number of variables
Risk:
0-2: Low 3-4: Intermediate 5-7: High risk
NSTEMI & Unstable Angina Management
NSTEMI or EKG changes suggest ischemia with high risk:
Telemetry
Aspirin
Beta blocker
Nitrates
Heparin (UFH or LMWH)
ACE-I/ARB
Statin
Consider GP IIb/IIIa inhibitor and clopidogrel
EKG normal or non-specific changes with intermediate or low
risk:
Telemetry
Rule out ACS with 3 sets of troponin, EKG
Consider pre-discharge stress test
STEMI Management
STEMI patients usually go straight to the cath lab from
the ED. Goal: door to balloon 90 minutes.
Initial management for STEMI:
Cardiac monitor
Supplemental O2
Nitrates*
Beta blocker
Morphine
Clopidogrel
Aspirin
Good IV access
Call cardiology fellow!

Case
60 year old male with history of DM2 for 20 years,
HTN, HLD who presented to the ED with 4 hour
onset of chest pain which was described as in the
anterior chest without radiation. The pain seemed to
improve when he sits down and worsening when he
walked upstairs.
VS: T 36.9, HR: 95, BP: 84/56, RR 22, O2 sat. 99%
RA.
ECGs are shown as followed
What will you do?
Whats your diagnosis?
What should be done now?
References
2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency
Cardiovascular Care. Circulation 2005;112:IV-89-IV-110
2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction : A Report of
the American College of Cardiology Foundation/American Heart Association Task Force on Practice
Guidelines. Circulation 2013, epublished April 29
th
2013 and print published june 4
th
2013.
Herman LK, et al. Comparison of frequency of inducible myocardial ischemia in patients presenting to
emergency department with typical versus atypical or nonanginal chest pain. Am J Cardiol. 2010
105:1561-4.

www.uptodate.com:
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Initial evaluation and management of suspected acute coronary syndrome in the emergency department
Criteria for the diagnosis of acute myocardial infarction