ACS and the 12 ACS and the 12 Lead ECGLead ECG

• The The 12 Lead ECG12 Lead ECG is at the center is at the center of the decision pathway in the of the decision pathway in the management of patients with management of patients with ischemic chest pain.ischemic chest pain.

AHA Guidelines 2000AHA Guidelines 2000

Scenario #1Scenario #1

• 55 y/o male c/o sub-sternal chest 55 y/o male c/o sub-sternal chest pressure that started while exerting pressure that started while exerting himself. Pain radiates to his himself. Pain radiates to his neck/jaw. Pain unrelieved with rest or neck/jaw. Pain unrelieved with rest or patients own NTG.patients own NTG.

• Patient is cool, and pale.Patient is cool, and pale.• DX?DX?

Scenario #2Scenario #2

• 60 y/o female c/o dull, aching, pain in her 60 y/o female c/o dull, aching, pain in her chest that radiates to her left breast. Sts chest that radiates to her left breast. Sts pain has been constant for past hour, pain has been constant for past hour, getting increasingly worse. Hx of HTN, getting increasingly worse. Hx of HTN, NIDDM, Angina. Sts pain is like previous NIDDM, Angina. Sts pain is like previous angina attack, just worse.angina attack, just worse.

• Patient is cool, pale, diaphoretic.Patient is cool, pale, diaphoretic.• DX?DX?

• What similarities do these two What similarities do these two scenarios share? scenarios share?

• How can their treatment both be How can their treatment both be different.different.

• How will the How will the 12 lead12 lead guide our guide our treatment of these patients?treatment of these patients?

IntroductionIntroduction

• Acute Coronary Syndrome is a group Acute Coronary Syndrome is a group of disease process’s that signs and of disease process’s that signs and symptoms mimic each other.symptoms mimic each other.

• Although similar, they are not the Although similar, they are not the same.same.

• The treatment for ACS is based on The treatment for ACS is based on the patient’s current “stage” in the the patient’s current “stage” in the disease processdisease process

A

C

S

S

T

A

G

E

S

Stable AnginaStable Angina

• A flow/demand A flow/demand imbalance between imbalance between reduced blood flow reduced blood flow through a through a narrowed artery, narrowed artery, and increased and increased demand. demand.

Unstable Angina/Non-Q Wave Unstable Angina/Non-Q Wave InfarctionInfarction

• Symptoms of angina that are new or Symptoms of angina that are new or increasing or that occur at rest. increasing or that occur at rest. Seldom relieved with rest, O2, or Seldom relieved with rest, O2, or NTG.NTG.

• Symptoms are usually due to platelet Symptoms are usually due to platelet aggregation in narrowed arteries aggregation in narrowed arteries with chronic atherosclerotic with chronic atherosclerotic occlusions.occlusions.

Unstable Angina/Non-Q Wave Unstable Angina/Non-Q Wave InfarctionInfarction

Unstable Angina can be complicated by the release of micro-emboli that occlude distal micro-vasculature.

Q-Wave InfarctionQ-Wave Infarction

• Complete Complete formation of formation of thrombus in an thrombus in an artery.artery.

• Spontaneous lysis Spontaneous lysis of the clot can of the clot can occur, but often occur, but often too late to salvage too late to salvage the heart muscle.the heart muscle.

Indicative ChangesIndicative Changes

• IschemiaIschemia:: Symmetrically inverted T Symmetrically inverted T waves or down sloping ST segment waves or down sloping ST segment depression greater then 1mmdepression greater then 1mm

• InjuryInjury:: ST segment elevation greater ST segment elevation greater then 1mmthen 1mm

• InfarctInfarct:: Pathological Q wave Pathological Q wave formationformation

IschemiaIschemia

Injury/InfarctionInjury/Infarction

Indicative ChangesIndicative Changes

• Based on the patients 12 lead ECG, Based on the patients 12 lead ECG, they will be placed into 1 of 3 they will be placed into 1 of 3 treatment categories that are aimed treatment categories that are aimed at correcting the specific Acute at correcting the specific Acute Coronary Syndrome present. Coronary Syndrome present.

Treatment CategoriesTreatment Categories

Why Do We Care?Why Do We Care?

• The only ACS disease process that The only ACS disease process that benefits from Thrombolytic therapy benefits from Thrombolytic therapy are those that are caused by are those that are caused by complete occlusion of an artery.complete occlusion of an artery.

• Recognition of Recognition of ST SegmentST Segment ElevationElevation ACS is the first step in a race against ACS is the first step in a race against the clock.the clock.

Treatment StrategiesTreatment Strategies

Treatment StrategiesTreatment Strategies

Treatment StrategiesTreatment Strategies

Treatment StrategiesTreatment Strategies

YES

NO

Scenario ReviewScenario Review

Scenario #1Scenario #1

• 55 y/o male c/o sub-sternal chest 55 y/o male c/o sub-sternal chest pressure that started while exerting pressure that started while exerting himself. Pain radiates to his himself. Pain radiates to his neck/jaw. Pain unrelieved with rest or neck/jaw. Pain unrelieved with rest or patients own NTG.patients own NTG.

• Patient is cool, and pale.Patient is cool, and pale.

Scenario #1Scenario #1

• Does this patient meet ECG Does this patient meet ECG requirements for thrombolysis?requirements for thrombolysis?

• What stage of ACS can you predict What stage of ACS can you predict from the presenting 12 lead?from the presenting 12 lead?

• What complications can you expect What complications can you expect to see if the patient’s condition to see if the patient’s condition worsens?worsens?

Scenario #2Scenario #2

• 60 y/o female c/o dull, aching, pain in her 60 y/o female c/o dull, aching, pain in her chest that radiates to her left breast. Sts chest that radiates to her left breast. Sts pain has been constant for past hour, pain has been constant for past hour, getting increasingly worse. Hx of HTN, getting increasingly worse. Hx of HTN, NIDDM, Angina. Sts pain is like previous NIDDM, Angina. Sts pain is like previous angina attack, just worse.angina attack, just worse.

• Patient is cool, pale, diaphoretic.Patient is cool, pale, diaphoretic.

Scenario #2Scenario #2

• Does this patient meet ECG Does this patient meet ECG requirements for thrombolysis?requirements for thrombolysis?

• What significance do the tall T waves What significance do the tall T waves suggest?suggest?

• What complications can you expect What complications can you expect to see if the patient’s condition to see if the patient’s condition worsens?worsens?

Exceptions to the RulesExceptions to the Rules

• Some subsets of patients may be Some subsets of patients may be eligible for Fibrinolytic therapy even eligible for Fibrinolytic therapy even though they do not present with ST though they do not present with ST segment elevation.segment elevation.– Posterior current of injuryPosterior current of injury– Tall, hyperacute t wavesTall, hyperacute t waves