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SYNDROMES
R MAHARAJ
EMERGENCY MEDICINE
LECTURE OUTLINE
INTRODUCTION
EPIDEMIOLOGY/PREVALENCE/DEFINITION
PATHOPHYSIOLOGY OF ACUTE CORONARY
SYNDROMES
APPROACH TO SUSPECTED ACUTE
CORONARY SYNDROME GUIDELINE
UPDATE
TREATMENT/MANAGEMENT UPDATE
INTRODUCTION
DEFINITIONS
CAD is a continuum of disease.
Angina -> unstable angina -> AMI -> sudden cardiac death
Acute coronary syndrome encompasses unstable angina, NSTEMI,
STEMI
Stable angina transient episodic chest pain d/t myocardial
ischaemia, reproducible, frequency constant over time.usually
relieved with rest/NTG.
Classification of angina Canadian Cardiovascular Society
classification.
CLASS 2
CLASS 3
CLASS 4
UNSTABLE ANGINA
Pain occurring at rest duration > 20min, within one week of first
visit
New onset angina ~ Class 2 severity, onset with last 2 months
Worsening of chest pain increase by at least 1 class, increases in
frequency, duration
Angina becoming resistance to drugs that previously gave good
control.
ACS PATHOPHYSIOLOGY
APPROACH
SUGGESTIVE OF ANGINA
LESS SUGGESTIVE OF
ANGINA
TYPE OF PAIN
DULL
PRESSURE/CRUSHING
PAIN
SHARP/STABBING
DURATION
SECONDSTO
HOURS/CONTINUOUS
ONSET
GRADUAL
RAPID
LOCATION/CHEST WALL
TENDERNESS
SUBSTERNAL, NOT
TENDER TO PALP.
LATERAL CHEST
WALL/TENDER TO PALP.
REPRODUCIBALITY
WITH
EXERTION/ACTIVITY
WITH
BREATHING/MOVING
AUTONOMIC SYMPTOMS
PRESENT USUALLY
ABSENT
ATYPICAL PAIN
Reasons :
Provides prognostic information
HISTORY
ECG
BIOCHEMICAL MARKERS
ECG
Abnormal or normal
Normal ECG does not exclude ACS 1-6% proven to have AMI, 4%
unstable angina
GUIDELINES:
Initial 12 lead ECG goal door to ECG time 10min, read by
experienced doctor (Class 1 B)
If ECG not diagnostic/high suspicion of ACS serial ECGs initially
15 -30 min intervals (Class 1 B)
BIOCHEMICAL MARKERS
IDEAL MARKER:
High concentration in myocardium
Myocardium specific
Released early in injury
Proportionate to injury
Non expensive testing
Troponins
CKMB
Myoglobin
Other markers
TROPONINS T/I
Troponin T vs I
both equivalent in diagnostic and prognostic abilities ( except in
renal failure Trop T less sensitive)
MYOGLOBIN
CKMB
Used in conjunction with troponins
Useful in diagnosing re-infarction
OTHER MARKERS
Lack specificity
IMAGING MODALITIES
Cardiac MRI
Multidetector CT for coronary calcification
Coronary CT angiography
Undergoing clinical evaluation
MANAGEMENT ALGORITHM
MANAGEMENT UPDATE
2007ACS/AHA GUIDELINES:
Rapid catergorisation of patient (Class 1 C)
Possible ACS, non diagnostic ECG/biomarkers observed in facility
with cardiac monitoring (Class 1 C)
Alternative to in patient treatment: for those with 12hr ECG/markers
negative stress ECG in 72hrs (Class 1 C)
Giving precautionary treatment for those for OPD stress (Class 1 B)
INITIAL INVASIVE
VS
INITIAL CONSERVATIVE STRATEGY
CLASS 1 RECOMMENDATIONS:
Early invasive strategy for refractory angina, hemodynamic
instability (LOE B)
Early invasive strategy for stabilised patients with elevated risk for
clinical events.
High risk factors include:
CLASS 2b
May opt for initial conservative strategy in stabilised high risk
patients dependent on patient/physician preference (LOE B)
CLASS 3
Invasive strategy -not recommended in patients with multiple co
morbidities, low risk patients, patients not consenting.(LOE C)
GENERAL:
Oral B Blockers in first 24hrs still Class 1 but not used in signs of
heart failure, cardiogenic shock and reactive airway disease.(LOE
B)
ANTIPLATELET THERAPY:
CLASS 1 RECOMMENDATION
Aspirin to all patients as soon as possible and continued (if no C/I) (LOE A)
Initial dose 162 -325mg
Maintenance 75 -162mg
No added benefit from higher doses except post stenting
CLASS 2a
In patients managed conservatively who develop recurrent
ischaemia on clopidogrel/ASA/Anticoagulant can add
glycoprotein inhibitor. (LOE C)
CLASS 2b
In patients managed conservatively can add glycoprotein inhibitor
therapy, in addition to aspirin & anticoagulant (LOE B)
CLASS 3
ABCIXIMAB should not be given if PCI not planned (LOE A)
ANTICOAGULANT THERAPY
CLASS 1
Anticoagulant therapy should be added as soon as possible
For patients undergoing angiography/PCI enoxaparin/UFH (LOE
A) of Bivalirudin/ fondaparinux (LOE B)
CLASS 2a
Enoxaparin /fondaparinux vs UFH
ADDITIONAL MANAGEMENT
STEMI
PHARMACOLOGICAL UPDATE:
ANALGESIA changes from 2004 guidelines
BETA BLOCKERS
Modified recommendation
Oral Beta Blockers should be initiated in first24rs, if no contraindications (heart failure, risk of cardiogenic shock) Class 1 B
Patients with early contraindications -> re- evaluated later for
possible use
Role of IV B blockers used in hypertensive patients with STEMI
Class 2a B
Class 3 LOE A IV B blockers should not be administrated to
patients with heart failure, risk of cardiogenic shock
REPERFUSION STRATEGY
FIBRINOLYTICS
AVAILABLE FIBRINOLYTICS:
STREPTOKINASE 1.5mu infusion over 30min (1hour ACLS)
rtPA accelerated infusion over 1.5hrs
- 15mg IV bolus, 0.75mg/kg over 30 min, 0.5mg/kg over 1hr
ANISTREPLASE 30 U IV over 5 min
TENECTEPLASE 30 TO 50 MG
RETEPLASE 10 U IV bolus, ffd. 10U IV after 30 min
RESCUE PCI:
CLASS 1 LOE B angiography with +/- PCI in patients (<75 yrs)with
cardiogenic shock, severe heart failure, ventricular
dysrythmias
ANTICOAGULANT ADJUNCTS
NEW RECOMMENDATIONS:
CLASS 1
Patients undergoing fibrinolysis should be kept on anticoagulants for
atleast 48 hrs and preferably the duration of hospital stay. LOE A
ANTICOAGULANTS
THIENOPYRIDINES
CLASS I
CLOPIDOGREL now recommended in all STEMI patients in
addition to aspirin, whether undergoing reperfusion or not. Dosage
75mg daily(LOE A)
Duration -14 days (LOE B)
CLASS 2 A
In patients < 75yrs Clopidogrel 300mg loading dose
recommended(LOE C)
Long term maintenance therapy should be considered, 75mg dly for 1
year (LOE C)
SECONDARY PREVENTION
INCREASED FOCUS ON SECONDARY PREVENTION:
SMOKING CESSATION
DIET MODIFICATION/WT CONTROL
BP CONTROL
LIPID MANAGEMENT
EXERCISE
DIABETES MANAGEMENT
CONCLUSION
REFERENCES
PAUL PD ET AL, KEY ARTICLES IN MANAGEMENT OF ACS & PCI -2007 UPDATE,
PHARMACOTHERAPY 2007:27(12), 1722 -1750
WHITE HD, DEFINING THE LIMITS OF ACS, CARDIOLOGY AT THE LIMITS IV, EDITORS:
OPIE LH, YELLON DM
SIX AJ ET AL, CHEST PAIN IN THE ER: VALUE OF THE HEART SCORE, NETH. HEART J.
2008 JUNE,16(6):191 -196
ANTMAN EM ET AL, 2007 FOCUSSED UPDATE OF ACC/AHA 2004 GUIDELINES FOR MAXN
OF PATIENTS WITH STEMI, DOWNLOADED http://circ.ahajournals.org