Acute Coronary Syndrome




OVERVIEW
Duration:
10-20 min
Quality:
Pressure
Dull
Heaviness
Squeezing
Tight
Location:
Sub-sternal
Worse w/ Exersion

Relieved w/ rest = ANGINA

Pain @ rest =
UNSTABLE ANGINA

EKG
ABNORMAL NORMAL
ST-Depression
(NSTEMI)
ST-Elevation
(STEMI)
  Risk Factors:
Non-Modifiable:

       - (+) FHx
      - Male, > 55 y
      - Female (post menopausal)

Modifiable:

 - HTN (MC Risk factor)
 - DM (worst risk factor)
 - HL                         
 - Smoker (greatest immediate imporvement)
 - Cocaine/Amphetamine Use
Ischemia Infarct

Unstable Angina

MI
β-MONAH: CATH in < 1 hr   YES
NO
CP onset
< 12h
> 12h
β-Blocker
Morphine
O2
NTG
Aspirin
Heparin

-Statin

TNK (prefer < 1-3 hr)
-or-
Angioplasty within 90 min or ED arrival

[Stents]
Elective CABG ?
Cardiology Consult

STRESS TEST

DC
NORMAL ABNORMAL
(ST-Depression)
  Next Step?
Contraindication:
- Melena
- Recent Surgery
- BP > 180/110
- Brain bleed (anytime in life)
- Aortic Dissection
To Dx? To Manage?
ANGIOGRAM

β-MONAH
β-Blocker
Morphine
O2
NTG
Aspirin/ACEI
Heparin
-Statin

1-2 vessel 3 vessel
-or-
LMA

Angioplasty

CABG

 

ECG by Anatomy







 

Work-up

  1. EKG, CXR, CBC, BMP, PT/INR, STAT TROPONIN I or T, CK, CK-MB.
  2. Digoxin level (If pt on digoxin)

Risk factors assessment:

  • Stress Test:
    • Pt with LBBB = Dobutamine Echo OR Adenosine MPI.  NO EXERCISE EKG.
What stress test to use?

IMAGING

 Exercise EKG
Dipyridamol OR Adenosine thallium stress test OR Dobutamine echo Stress thallium OR Stress echo? - Your pts who can tolerate exercise.
Pts who cannot exercise to target HR or > 85% of maximum:
- COPD/Asthma (Dobutamine stress test)
- Amputation
- Deconditioning
- Weakness/Previous Stroke
- Lower-extremity ulcer
- Dementia
- Obesity (Sestamibi nuclear stress test)

Baseline Abnormal EKG
- LBBB

EKG is unreliable for ischemia:
- Digoxin use
- LBBB
- Wolf-Parkinson white
- Pacemaker in place
- Left ventricular hypertrophy
- > 1 mm of ST-depression at rest (any baseline anomaly of ST segment on EKG)
Contraindications to EXERCISE stress test:
Absolute contraindications to exercise testing include:
  • an acute MI within the previous 2 days,
  • unstable angina,
  • cardiac arrhythmias causing symptoms or hemodynamic compromise,
  • severe aortic stenosis (Severe aortic stenosis typically is associated with an aortic valve area (AVA) of < 0.8 cm)
  • symptomatic decompensated heart failure,
  • acute pulmonary embolism or infarct,
  • acute pericarditis or myocarditis,
  • acute aortic dissection, and
  • Lack of ACLS equipment or signed consent.
Contraindications to Dipyridamole & Adenosine stress test:
  • Asthma
  • COPD
  • HypOtension
  • Bradycardia, or
  • Heart block


 
High-Risk Findings on Stress Test:
The provocation of ischemia at a workload of 6.5 METs or less, or a high-risk exercise treadmill score (> –11), implies severe limitation of the ability to increase coronary blood flow, and indicates a high risk for adverse cardiac outcome (>3% annual mortality). Other high-risk findings include:
  • severe resting left ventricular dysfunction (<35%)
  • severe left ventricular dysfunction with exercise (≤35%)
  • a stress-induced large perfusion defect, particularly if anterior
  • stress-induced multiple perfusion defects of moderate size
  • a large, fixed perfusion defect with left ventricular dilation or increased lung uptake (thallium-201)
  • a stress-induced moderate perfusion defect with left ventricular dilation or increased lung uptake (thallium-201)
  • echocardiographic wall-motion abnormalities involving two or more segments developing with a low dose of dopamine or at a heart rate <120 beats/min
  • evidence of extensive ischemia on stress echocardiography

 

Recommends initial invasive strategy in patients with the following characteristics:
  • Recurrent angina or ischemia at rest or with low-level activities despite intensive medical therapy.
  • Elevated cardiac biomarkers (TnT or TnI)
  • New or presumably new ST-segment depression
  • Signs or symptoms of HF or new or worsening mitral regurgitation
  • High-risk findings from noninvasive testing
  • Hemodynamic instability
  • Sustained ventricular tachycardia
  • PCI within 6 months
  • Prior CABG
  • High-risk score (eg, TIMI, GRACE)
  • Reduced left ventricular function (LVEF < 40%)

 

Management

STEMI Management

  1. Cardiac monitor, IV Access, Supplemental O2.
Recommended Doses of Drugs Used in the Emergency Treatment of ST-Segment Elevation Myocardial Infarction
Antiplatelet Agents
Aspirin 160-325 mg PO CHEW
Contraindication:
- aspirin intolerance and allergy
- Active bleeding
- Active retinal bleeding
- Hemophilia
- Severe untreated hypertension, or
- Active peptic ulcer.
Clopidogrel Loading dose of 300 mg PO (consider 600 mg if percutaneous coronary intervention anticipated) followed by 75 mg/d. No loading dose is administered in patients >75 y old receiving fibrinolytics.
Antithrombins
Unfractionated heparin Bolus of 60 units/kg (maximum, 4000 units) followed by infusion of 12 units/kg/h (maximum, 1000 units/h) titrated to a partial thromboplastin time 1.5–2.5 x control.
Enoxaparin 30 mg IV bolus followed by 1 mg/kg SC every 12 h.
Regardless of age, if CrCl < 30 mL/min: 1 mg/kg subcutaneously q24h
Fondaparinux 2.5 mg SC.
Contraindicated if CrCl < 30 mL/min
Fibrinolytic Agents
Streptokinase 1.5 million units over 60 min.
Anistreplase 30 units IV over 2-5 min.
Alteplase Body weight >67 kg: 15 mg initial IV bolus; 50 mg infused over next 30 min; 35 mg infused over next 60 min.
Body weight <67 kg: 15 mg initial IV bolus; 0.75 mg/kg infused over next 30 min; 0.5 mg/kg infused over next 60 min.
Reteplase 10 units IV over 2 min followed by 10 units IV bolus 30 min later.
Tenecteplase Weight Dose (total dose not to exceed 50 milligrams)
<60 kg 30 mg
60 but <70 kg 35 mg
70 but <80 kg 40 mg
80 but <90 45 mg
90 50 mg
Glycoprotein IIb/IIIa Inhibitors*
Abciximab 0.25 mg/kg bolus followed by infusion of 0.125 mcg/kg/min (maximum, 10 mcg/min) for 12-24 h.
Eptifibatide 180 mcg/kg bolus followed by infusion of 2.0 mcg/kg/min for 72-96 h.
Tirofiban 0.4 mcg/kg/min for 30 min followed by infusion of 0.1 mcg/kg/min for 48-96 h.
Other Anti-Ischemic Therapies
Nitroglycerin Sublingual: 0.4 mg q 5 min x 3 PRN pain.
IV: Start at 10 mcg/min, titrate to 10% reduction in MAP if normotensive, 30% reduction in MAP if hypertensive.
Contraindications:
• Recent use of erectile dysfunction drugs
• Severe hypotension or RV injury
• Severe AS
Morphine 2-5 mg IV q 5-15 min PRN pain.
Bradycardia: Atropine 0.5 mg IV q3-5min prn
Respiratory depression: Narcan 0.4 mg IV q2-3min prn
Metoprolol 50 mg PO q 12 hours first day, unless significant hypertension, may consider 5 mg IV over 2 min every 5 min up to 15 mg; withhold β-blockers initially if the patient is at risk for cardiogenic shock/adverse effects.
Contraindications:
• CHF
• Hypotension
• Bradycardia
• Asthma, COPD, PVD
• Cocaine use
• Heart block
Atenolol 25–50 mg PO, unless significant hypertension, may consider 5 mg IV over 5 min, repeat once 10 min later; withhold β-blockers initially if the patient is at risk for cardiogenic shock/adverse effects.
 
 

NSTEMI Management

Recommended Doses of Drugs Used in the Emergency Treatment of Unstable Angina/Non-ST-Segment Elevation Myocardial Infarction
Antiplatelet Agents
Aspirin 160-325 mg PO
Clopidogrel Loading dose of 300-600 mg PO followed by 75 mg/d
Antithrombins
Heparin Bolus of 60 units/kg (maximum, 4000 units) followed by infusion of 12 units/kg/h (maximum, 1000 units/h) titrated to a partial thromboplastin time 1.5-2.5 x control
Enoxaparin 1 mg/kg SC q12h
Regardless of age, if CrCl < 30 mL/min: 1 mg/kg subcutaneously q24h
Fondaparinux 2.5 mg SC
Contraindicated if CrCl < 30 mL/min
Direct Thrombin Inhibitor
Bivalirudin 0.75 mg/kg IV bolus followed by 1.75 mg/kg/h infusion for duration of procedure
Glycoprotein IIb/IIIa Inhibitors
Abciximab 0.25 mg/kg bolus followed by infusion of 0.125 mcg/kg/min (maximum, 10 mcg/min) for 12-24 h
Eptifibatide 180 mcg/kg bolus followed by infusion of 2.0 micrograms/kg/min for 72-96 h
Tirofiban 0.4 mcg/kg/min for 30 min followed by infusion of 0.1 microgram/kg/min for 48-96 h
Other Anti-Ischemic Therapies
Nitroglycerin Sublingual: 0.4 mg every 5 min x 3 PRN pain
IV: Start at 10 mcg/min, titrate to 10% reduction in MAP if normotensive, 30% reduction in MAP if hypertensive
Contraindications:
• Recent use of erectile dysfunction drugs
• Severe hypotension or RV injury
• Severe AS
Metoprolol 50 mg PO every 12 h first day, unless significant hypertension, may consider 5 mg IV over 2 min every 5 min up to 15 mg; withhold β-blockers initially if the patient is at risk for cardiogenic shock/adverse effects*
Contraindications:
• CHF
• Hypotension
• Bradycardia
• Asthma, COPD, PVD
• Cocaine use
• Heart block
Atenolol 25-50 mg PO, unless significant hypertension, may consider 5 mg IV over 5 min, repeat once 10 min later; withhold β-blockers initially if the patient is at risk for cardiogenic shock/adverse effects*