DIAGNOSTICS OF

Acute Coronary Syndromes

At the end of this self study the participant will:
Verbalize meanings of specific ECG changes:
ST Elevation
ST Depression

Describe common tests used for patients with

suspected Acute Coronary Syndromes

Abbreviations:
ACS = Acute Coronary Syndrome
STEMI = ST Elevation Myocardial Infarction
AMI = Acute Myocardial Infarction
PCI = Percutaneous Coronary Intervention (e.g.,
angioplasty, stents)

Time is Still Muscle!

4 Ds of Timely Reperfusion

Door to Data (ECG)

Door to Decision
Door to Drug
Door to Dilatation

Goal < 10 min.

Goal < 20 min.
Goal < 30 min.
Goal < 90 min.

Door can be time of patient arrival, or time the

patient tells nursing staff of possible ACS signs
and symptoms
3

Door to Data: 10 minutes

INITIAL DIAGNOSIS
12-LEAD ECG
ST Elevation
ST elevation MI (STEMI) All High
Risk
No ST elevation
Acute Coronary Syndrome OR Non ST
elevation MI (Non STEMI)
High, Intermediate or Low Risk
4

Lead
Placement to
obtain a 12lead.
V lead
(chest lead)
placement
must be
exact.
5

Normal 12 Lead EKG Configurations

In order to more easily recognize abnormalities in
the 12 lead ECG one must first be able to recognize
the normal 12 lead ECG
Look for:
Flat baseline
Little to no
artifact
(waveforms are
clear)
6

12-lead changes seen in ACS

~ 2.0 MM patients admitted
to CCU or telemetry annually

ST Elevation

0.6 MM
ST-elevation MI

ST depression

1.4 MM
Non-ST elevation ACS

T wave inversion

Ischemia

Injury

ECG Progression
in AMI

ST-segment elevation may occur

within the first few hours of
infarction.
ST-segment elevation is indicative of
injury that is leading to infarction.
When ST-segment elevation is seen,
time is limited and the healthcare
provider must act quickly to initiate a
reperfusion strategy in order to
salvage the most myocardium.
10

From Garcia, et.al. (2001). 12 Lead ECG. The Art of interpretation, pg. 408. Used by permission.

Non-diagnostic ECGs
According to the National Registry of Myocardial
Infarction, only 39% of Acute MI patients have
STEMI on admit
Subsequent STEMI occurs within 12 hrs of symptoms
Acute MI patients who present & maintain normal or
nonspecific ECGs have lower mortality rates;
Increased mortality risk associated with development
of STEMI

11

Fesmire, FM, et al. Ann Emerg Med. 1998: 31: 3-11.

Littrell, KA, et al. JACC. 2001: 37 Suppl A p. 1282-101.
French, WJ, et al. NRMI 4 Special Report, June 2001

Door to decision: 20 minutes

Based on ECG and patient presentation
Does not require lab data nor advanced assessments
such as angiography (cardiac catheterization)
If decision is AMI, treatment planned
Door to Drug 30 minutes
Door to Dilatation (PCI) 90 minutes
If decision is not AMI, further evaluation is required

12

ACS
DIAGNOSIS
CARDIAC
ENZYMES
Negative
Unstable
Angina
Non-cardiac?
Positive
MI
13

Serum Enzyme Changes

Onset

Peak Time

CPK-MB

4-6 hours

12-24 hours 2-3 days

Troponin-I

4-6 hours

12-24 hours Up to 10
days

Myoglobin

1-2 hours

4-6 hours

14

Duration

24 hours

Diagnostic Tests
Echocardiogram evaluates:
Wall motion and valve function
Ejection fraction (EF)
% of blood pumped out of

ventricle with each beat

normal = 60-70%;
failure = < 40%
The greater the damage,

15

the greater the muscle loss, the lower the EF

Diagnostic Tests
Stress Testing: only performed if
enzymes are negative.
ECG
Perfusion Studies (indicate capillary
perfusion = better predictor)
Exercise Thallium
Dobutamine Stress Echo
Adenosine Thallium

16

Cardiac Catheterization
(Angiography)
Access: radial, brachial or
femoral arteries
If we can upload from YouTube,
theres a terrific video (no audio)
of a cath
http://www.youtube.com/watch?
v=yzxSrLa1d0g
17

Photo under fluoroscopy

18

Possible Post-Cath Complications

19

Hypotension
Active Bleeding
Limb Ischemia
Recurrent Ischemia/MI
Arrhythmias: Ventricular
and Bradycardia

Contrast Reaction
Contrast Nephropathy
Congestive Heart
Failure
Neuro Deficits

Post Cath Care

Sheaths are used with all PCIs
Assess for bleeding at site, and under the site;
outline ecchymotic areas
Note any perfusion changes around site
Palpate abdomen for firmness or distention
Be alert to changes in oxygenation assessment and
hemodynamic status
If bleeding is seen at site, place immediate manual
pressure
Monitor peripheral pulses
20

Next: ACS Treatments

21