dr. Rahmad Isnanta, SpPD, KKV
Acute Coronary
Syndrome
there are a lot of importment data of the pain:
localisation radiation onset of the pain
the type (press, smart,cutting)
dinamic of the pain (continouosly, ongoing, undulaiting) answer to the medical therapy
CHEST PAIN
48 yo Man, Chest pain after lunch
while
walking to
car.
Non Cardiac Cardiac
D DIAGNOSIS F
Pulmonary Pneumonia
Pleuritis Pneumothorax Pulmonary Embolism
Tumor
Gastrointestinal GERD
Esophageal spasm Mallory-Weiss Tear Peptic Ulcer disease Biliary/Gallbladder Disease
Pancreatitis
Musculoskeletal
Costochondritis Cervical Disk Disease
Rib Fracture
Intercostal Muscle Cramp
Other
Herpes Zoster Disorders of the Breast
Splenic Infarct
Panic Attacks/Anxiety Disorder Fibromyalgia
DKA
NON CARDIAC CHEST PAIN
Aortic Dissection Pulmonary Embolism Pulmonary Hypertension
Pericardial Diseases Aortic Stenosis
Heart Failure Cocaine Abuse
Acute Coronary Syndromes
Stable Angina Unstable Angina Myocardial Infarction
Cardiogenic Shock
Cardiac Chest Pain
Chest Pain
Non Cardiac
Cardiac
PE
PTX
Oesophageal disaster
Aortic disease
Myo/pericardium
Coronary disease
Coronary spasm
Obstructive CAD
ACS
Stable angina
current complaint:
pain
there are a lot of importment data of the pain:
localisation radiation onset of the pain
the type (press, smart,cutting)
dinamic of the pain (continouosly, ongoing, undulaiting) answer to the medical therapy
ACUTE CORONARY
SYNDROME: DIAGNOSIS
PATHOGENESIS: ACS
> 90% - plaque disruption with platelet aggregation
intracoronary thrombus Concepts of clot formation
Continuum of ACS from unstable
angina to STE MI
Acute Coronary Syndromes
Unstable angina ST-Elevation MI
(Q-wave MI) Non-ST Elevation MI
(Non-Q-wave MI)
Stable CAD
The continuum of acute coronary syndromes ranges from unstable
angina, through non-ST-elevation myocardial infarction (also referred
to as “non-Q-wave” myocardial infarction [MI]), to ST-elevation MI
(also referred to as “Q-wave” MI).
TRIGGERS TO PLAQUE RUPTURE
Inflammatory cytokines
Plaque Rupture
Physical Stress Vulnerable
Plaque
Emotional
Stress
ACC/AHA 2007 Guidelines for the Management of Patients with Unstable Angina/Non-ST Elevation Myocardial Infarction
Unstable Angina / NSTEMI
Definition
“… ST-segment depression or prominent T-wave inversion and/or positive biomarkers of necrosis…
in the absence of ST-
segment elevation and in an appropriate clinical
setting..."
ACC/AHA 2007 Guidelines for the Management of Patients with Unstable Angina/Non-ST Elevation Myocardial Infarction
Unstable Angina / NSTEMI
(Unstable Angina)
STEMI
LBBB
CAD is a diffuse process with focal atherosclerotic material (plaque).
Some plaques are obstructive but not thrombotic.
Others are potentially thrombotic but not obstructive.
Myocardial Infartion=
Death of myocardial cells.
Clinical MI = symptoms,
ECG and Biomarkers
Normal Atherosclerotic Plaque
CAD as a cause of Myocardial Ischemia and Infarction
Angiography vs. Pathology
ACS 179
LAD
Angiography vs CTA for CAD
Motoyama et al. JACC 2007
Fibrous plaque
Positive remodeling
Soft plaque
Natural History of CAD : A story of remodeling
• Acute Coronary Syndrome
• 72 year-old Man
• Plaque crater, erosion
• Thrombus
• Calcific nodule
Braunwald’s Heart Disease, 7
thEdition
Beta blockers CA blockers ACEI
NTG NTG
ASA
Heparin GPB’s Statins
Ranolazine
Perfusion Abnormalities
Systolic Dysfunction
Δ ECG
Angina
Diastolic Dysfunction
Duration and severity of ischemia Nuclear Imaging
Stress Echo/MRI
Stress ECG
Ischemic Cascade
SPECTRUM OF ACS PRESENTATIONS
Definition Ischemia without
necrosis Necrosis
(nontransmural) Transmural necrosis
Diagnosis
Negative Biomarkers Positive biomarkers Positive biomarkers
No ECG ST-segment elevation ECG ST-segment elevation
Treatment Invasive or conservative depending on risk Immediate reperfusion
UA NSTEMI STEMI
Roger VL, Go AS, Lloyd-Jones DM, et al.. Circulation. 2011;123:e18-e209
.
KEY FEATURES OF AN ECG
Marieb EN, Hoehn K. Human Anatomy and Physiology. 8th ed. San Francisco, CA: Pearson Benjamin Cummings; 2010.
EXAMPLE OF ST-SEGMENT ELEVATION (STEMI)
J point
STE
EXAMPLE OF ST-SEGMENT DEPRESSION (UA/STEMI)
J point
STD
EXAMPLE OF T-WAVE INVERSION (UA/STEMI)
T wave changes
NORMAL 12-LEAD ECG
http://www.uptodate.com/contents/image?imageKey=CARD%2F1617.
Accessed Aug 6. 2011.
INFERIOR
ANTERIOR LATERAL
LATERAL
EARLY-STAGE ACUTE MI (STEMI)
ST-segment elevation
ST-segment depression
T-wave inversion
3-DAY-OLD MI (STEMI)
ST-segment elevation
T-wave inversion
UA - NSTEMI
T-wave inversion
Early Invasive Initial Conserva tive
Braunwald E et al. Available at: www.acc.org.
Bowen WE, McKay RG. N Engl J Med.
2001;344:1939-1942.
* Also known as Q-wave MI
†
Also known as non-Q- wave MI
TREATMENT OF ACUTE CORONARY SYNDROME
Thygesen K et al. Circulation 2007; available at:
http://circ.ahajournals.org.
NEW CLINICAL CLASSIFICATION OF MI
Classification Description
1 Spontaneous MI due to coronary event, i.e. plaque erosion and/or rupture, fissuring, or dissection
2 MI secondary to ischemia due to an imbalance of O
2supply and demand, as from coronary spasm or embolism, anemia, arrhythmias, hypertension, or hypotension
3 Sudden unexpected cardiac death, including cardiac arrest, with new ST-segment elevation; new LBBB; or pathologic or angiographic evidence of fresh coronary thrombus--in the absence of reliable biomarker findings 4a MI associated with PCI
4b MI associated with documented in-stent thrombosis
5 MI associated with CABG surgery
Thygesen, K. et al. Circulation 2007;116:2634-2653
0 1 2 3 4 5 6 7 8
Cardiac troponin-no reperfusion
Days After Onset of STEMI
M u lt ip le s o f t h e U R L
Upper reference limit 1
2 5 10 20 50
URL = 99th %tile of Reference Control Group
100
Cardiac troponin- reperfusion
CKMB-no reperfusion CKMB-reperfusion
CARDIAC BIOMARKERS IN STEMI
Alpert et al. J Am Coll Cardiol 2000;36:959.
Wu et al. Clin Chem 1999;45:1104.
TIMING OF RELEASE OF VARIOUS BIOMARKERS AFTER ACUTE MYOCARDIAL INFARCTION
Shapiro BP, Jaffe AS. Cardiac biomarkers. In: Murphy JG, Lloyd MA, editors. Mayo Clinic Cardiology: Concise Textbook. 3rd ed. Rochester, MN: Mayo Clinic Scientific Press and New York: Informa Healthcare USA, 2007:773–
80.
Anderson JL, et al. J Am Coll Cardiol 2007;50:e1–e157, Figure 5.
Cardiac-specific troponins are optimum biomarkers
(Level IC)
For STEMI, reperfusion therapy should be initiated as
soon as possible and is not contingent on a biomarker
assay (Level IC)
Non-MI Causes of Troponin Elevation
J Am Coll Cardiol. 2014;63(3):201-214
54 YO M W 2H SEVERE SUBSTERNAL CP - ECG
Early Invasive Initial Conserva tive
Braunwald E et al. Available at: www.acc.org.
Bowen WE, McKay RG. N Engl J Med.
2001;344:1939-1942.
* Also known as Q-wave MI
†
Also known as non-Q- wave MI
TREATMENT OF ACUTE CORONARY SYNDROME
Left Coronary System has mild CAD. RCA is
100%
FINAL POST STENT
MEDICAL THERAPY FOR STEMI MANAGED BY PRIMARY PCI
ASA
Anticoagula nt
UF H
(Biva l)
P2Y12 inhibitor
Clopidogrel
600 Prasugrel 60, or Ticagrelor 180
Beta Blocker
IV prn
Oral within 24h
GP IIb/IIIa
Eptifibati de Abcixim ab
Stati n
Presentation Access—Wire—
Balloon
ED CCL
IMPORTANCE OF RAPID REPERFUSION IN STEMI
30-minute delay = 8% increase in 1-year mortality 30-minute delay = 8% increase in 1-year mortality
Rathore SS, Curtis JP, Chen J, et al. BMJ. 2009;338:b1807.
Antman E. ST-segment elevation myocardial infarction: Management. In: Bonow RO, Mann DL, Zipes P, et al, eds. Braunwald's Heart Disease. 9th ed. Philadelphia, PA:
Elsevier Saunders; 2011a:1087-1110.
48 yo M, HBP with Chest pain while walking
TIMI Risk Score Calculator
Age ≥65 years? Yes (+1)
≥3 Risk Factors for CAD? Yes (+1)
Known CAD (stenosis ≥50%)? Yes (+1)
ASA Use in Past 7d Yes (+1)
Severe angina (≥2 episodes w/in 24 hrs)? Yes (+1)
ST changes ≥0.5 mm? Yes (+1)
+ Cardiac Marker? Yes (+1)
Total Score pts
TIMI RISK SCORE (N=7)
Antman EM, Cohen M, Bernink PJ, et al. JAMA. 2000;284:835-842.
TIMI Study Group. TIMI Risk Score Calculator.
http://www.timi.org/?page_id=294. Updated 2011. Accessed July 7, 2011.
What does TIMI RISK mean?
Increasing TIMI RISK 0/1 to 5/7 increases risk of death, MI, urgent revascularization within 14 days 5% to 41%.
Antman EM et al. TIMI 11B, JAMA 2000;284:835-842
Early Invasive Initial Conserva tive
Braunwald E et al. Available at: www.acc.org.
Bowen WE, McKay RG. N Engl J Med.
2001;344:1939-1942.
* Also known as Q-wave MI
†
Also known as non-Q- wave MI
TREATMENT OF ACUTE CORONARY SYNDROME
STEMI?
Aortic dissection Pulmonary embolus
Perforating ulcer Pericarditis
GERD (Gastroesophageal reflux disease) Heart failure, Pneumonia, Pneumothorax
DIFFERENTIAL DX FOR ACS CHEST PAIN SYNDROMES (BEYOND STEMI,
NSTEMI, UA)
ACS PATHOPHYSIOLOGY
Distruption of coronary artery plaque -> platelet
activation/aggregation /activation of coagulation
cascade -> endothelial vasoconstriction
->intraluminal
thrombus/embolisation ->
obstruction -> ACS
Severity of coronary vessel obstruction & extent of
myocardium involved determines characteristics
of clinical presentation
Mary L. Dohrmann, MD Professor of Clinical Medicine Division of Cardiovascular Medicine
ECGS (AGAIN!)
Practice!
Practice!
Practice!
ECG INTERPRETATION
Rhythm
Sinus Not sinus
Ventricular Supravent.
Morphology
WPW > LBBB > LVH > MI
MORPHOLOGY HIERARCHY
THE NORMAL ECG
51 Y/O MALE WITH CHEST PAIN 100% OCCLUSION OF A DIAGONAL
(ALSO HAD 3 VESSEL DISEASE, NORMAL LVEF)
29 Y/O WITH CHEST PAIN
DIFFUSE ST ELEVATION C/W PERICARDITIS,
?PR SEGMENT DEPRESSION
47 Y/O MALE WITH CHEST PAIN
ACUTE INFERIOR MI – CULPRIT VESSEL RCA
41 Y/O MALE WITH SEVERE SOB
EXTENSIVE ANTERIOR/ANTEROLATERAL MI
54 Y/O MALE WITH EXERTIONAL CHEST PAIN AMI, INDETERMINATE AGE; RBBB AND LEFT
AXIS
60 Y/O COMATOSE S/P MVA LOW VOLTAGE
Simple cifferential of low voltage: air, fat, fluid, no muscle
60 Y/O WITH CHEST PAIN
LVH WITH LAD, ST-T ABN, & LAE
In patient with angina and LVH, always think of aortic stenosis and
hypertrophic cardiomyopathy in differential diagnosis
40 Y/O WITH CHEST PAIN & PALPITATIONS SHORT PR/DELTA WAVE C/W PREEXCITATION
(WPW) – NOTE PSEUDO-QS INFERIORLY
70 Y/O WITH EXERTIONAL CHEST PAIN LBBB
If need stress test in this patient, use pharmacologic stress with adenosine combined
