Symptoms of Ischemic Heart Disease Chest discomfort with variable characteristics -pain, pressure,...
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Transcript of Symptoms of Ischemic Heart Disease Chest discomfort with variable characteristics -pain, pressure,...
Symptoms of Ischemic Heart Disease
• Chest discomfort with variable characteristics -pain, pressure, tightness, crushing, squeezing, stabbing, choking sensations -substernal origin with variable radiation to arm, neck, or jaw -especially when associated with exertion -duration in minutes (5-30), not seconds or hours • Associated symptoms or anginal equivalents (dyspnea,
nausea/vomiting, indigestion, diaphoresis, syncope)
Patient history is often diagnostic.
Physical Findings in Ischemic Heart Disease
• Diaphoresis or other sign of hypoperfusion• Congestive signs: JVD, rales, S3• Abnormal heart sounds: S3, new murmur• Hypoxia• Arrhythmias, especially ventricular, although must
rule out MI with new onset afib
Physical exam is most useful to rule out differential diagnoses and often is normal in
ischemic heart disease.
Etiologies of Ischemia
• Atherosclerosis
• Congenital coronary anomalies
• Coronary arteritis
• Radiation therapy
• Cocaine
• Aortic stenosis
• Hypertrophic cardiomyopathy
Differential Diagnosis of Chest PainAcute coronary syndromes
Other cardiovascular causes• Aortic dissection• Aortic stenosis• Pericarditis• Myocarditis• Hypertrophic cardiomyopathy• Aortic regurgitation• Mitral valve prolapse• Severe anemiaPulmonary causes• Pulmonary embolus• Pneumothorax• Pleurisy
Gastrointestinal causes• Esophageal spasm or reflux• Esophageal rupture• Peptic ulcer disease• Biliary or pancreatic diseaseMusculoskeletal causes• Costochondritis• Muscle strain• Thoracic outlet syndrome• Degenerative spine diseasePsychogenic causes• Anxiety/depression/panic attack• Psychosis• Secondary gain
IT IS IMPERATIVE TO ASSESS FOR POSSIBLE LIFE-THREATENING ALTERNATIVE DIAGNOSES, SUCH AS AORTIC DISSECTION, PE,
TENSION PNEUMOTHORAX, OR RUPTURED VISCUS..
Patient Education for Early Recognition and Response to Chest Pain
Healthcare providers should instruct patients previously
prescribed nitroglycerin (NTG) on use for chest
discomfort or pain and to call 9-1-1 if symptoms do not
improve or worsen 5 minutes after ONE sublingual
NTG dose*.
(* Nitroglycerin Dose: 0.4 mg sublingually)
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STEMI: ACC/AHA guidelines at www.acc.org
Prehospital Chest Pain Evaluation and Treatment
Prehospital EMS providers should administer 162 to 325 mg of
aspirin (chewed) to chest pain patients suspected of having
STEMI unless contraindicated or already taken by the patient.
Although some trials have used enteric-coated aspirin for initial
dosing, more rapid buccal absorption occurs with non–enteric-
coated formulations.
It is reasonable for all 9-1-1 dispatchers to advise patients without
a history of aspirin allergy who have symptoms of STEMI to
chew aspirin (162 to 325 mg) while awaiting arrival of
prehospital EMS providers. Although some trials have used
enteric-coated aspirin for initial dosing, more rapid buccal absorption
occurs with non–enteric-coated formulations.
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III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
STEMI: ACC/AHA guidelines at www.acc.org
Options for Transport of Patients With STEMI and Initial Reperfusion Treatment
EMS Transport
Onset of symptoms of
STEMI
9-1-1EMS
Dispatch
EMS on-scene• Encourage 12-lead ECGs.• Consider prehospital fibrinolytic if
capable and EMS-to-needle within 30 min.
GOALS
PCIcapable
Not PCIcapable
Hospital fibrinolysis:
Door-to-Needle
within 30 min.
EMS Triage Plan
Inter-HospitalTransfer
Patient EMS Prehospital fibrinolysisEMS-to-needlewithin 30 min.
EMS transportEMS-to-balloon within 90 min.
Patient self-transport Hospital door-to-balloon
within 90 min.Dispatch
1 min.
5 min.
8 min.
STEMI: ACC/AHA guidelines at www.acc.org
Emergent Diagnostic Testing
• 12-lead EKG
• Cardiac enzymes (CPK, CKMB, Troponin)
• CBC
• Basic or comprehensive chemistry panel
• Coagulation studies
• D-Dimer
• PA and lateral CXR
Cardiac Biomarkers in ACSCPK (creatine phosphokinase) – enzyme common in skeletal, smooth, and
cardiac muscle as well as brain and kidney; three isoenzymes:
MB – cardiac and some skeletal muscle
MM – primarily in skeletal muscle
BB – primarily in brain and kidney
Troponin – protein that regulates interaction of actin and myosin
Troponin C – common to skeletal and cardiac muscle
Troponin T and I – diagnostic & prognostic value in myocardial injury
Cardiac biomarkers provide the most accurate diagnosis of acute myocardial injury and are the reference standard for the diagnosis of MI.
Other Biomarkers
Nonspecific serum markers – elevated in MI but non-specific
• AST (aspartate aminotransferase)
• LDH (lactate dehyrogenase)
• Myoglobin – rapid release and return to baseline but
elevated with muscle infarct and renal failure
Newer biomarkers – predictive of risk in ACS but not commonly used for this purpose
• BNP (B-type natriuretic peptide)
• CRP (C-reactive protein)
00 11 22 33 44 55 66 7788
Cardiac troponin-no reperfusion Cardiac troponin-no reperfusion
Days After Onset of STEMIDays After Onset of STEMI
Mu
ltip
les
of
the
UR
LM
ult
iple
s o
f th
e U
RL
Upper reference limitUpper reference limit11
22
55
1010
2020
5050
URL = 99th %tile of URL = 99th %tile of Reference Control GroupReference Control Group
100100
Cardiac troponin-Cardiac troponin-reperfusion reperfusion
CKMB-no reperfusion CKMB-no reperfusion
CKMB-CKMB-reperfusion reperfusion
Cardiac Biomarkers in ACS
Alpert et al. J Am Coll Cardiol 2000;36:959.Wu et al. Clin Chem 1999;45:1104. STEMI: ACC/AHA guidelines at www.acc.org
Cardiac Biomarkers in STEMI
Troponins- Now the Gold Standard!
Rise after 3-6 hoursNegative Troponin within 6 hours of onset of S&S rules out the MIPeaks at about 20 hoursMay be raised for 14 days
Cardiac Biomarkers: Troponin T & I
Troponin TLevels may help to stratify risk
Less specific than Troponin I
Increased in angina
Increased in chronic renal failure
Highly sensitive for detecting myocardial ischemia
Troponin I90% sensitivity for MI 8 hours after onset of S&S and 95% specificity
Negative rules out MI
Obtain two negative troponin values 4-6-8 hours apart
Normally exceedingly low
Even a small elevation indicates myocardial damage
Troponin I Levels and Mortality in Patients with
NSTEMI
0
2
4
6
8
0- <0.4
0.4-<1.0
1.0-<2.0
2.0-<5.0
5.0-<9.0
>9.0
% M
orta
lity
at 4
2 D
ays
Adapted with permission from Antman EA, Tanasijevic MJ, Thompson B, et al. Cardiac-specific troponin I levels to predict the risk of mortality in patients with acute coronary syndromes. N Engl J Med. 1996;335:1342-1349. Copyright © 1996, Massachusetts Medical Society. All rights reserved.
Troponin I Level
EKG Changes in STEMI
ST elevation of 1mm or more in the limb leads or of 2mm or more in precordial leads is significant.
The pattern of ST elevation indicates the location of infarct and the involved coronary artery.
Dynamic changes in the ST segment or the T wave represent an evolving infarct.
A new left bundle branch block is significant.
EKG Changes: Ischemia
• T-wave inversion (flipped T)
• ST segment depression
• T wave flattening
• Biphasic T-waves
EKG Changes: Injury• ST segment elevation of greater than 1mm in at least 2
contiguous leads
• Heightened or peaked T waves
• Directly related to portions of myocardium rendered electrically inactive
EKG Changes: Infarct
Significant Q-wave where none previously existed
• Impulse traveling away from the positive lead
• Necrotic tissue is electrically dead
Criteria for Q-wave significance
• Depth of Q wave should be 25% the
height of the R wave
• Width of Q wave is 0.04 secs
• Diminished height of the R wave
Dynamic EKG Changes
1 Year
Baseline
Hyperacute T wave
ST elevation
Inverted T wave
Q wave
EKG Changes: Anterior/Septal MI
ST changes: V1,V2, V3, V4 Culprit Vessel: LAD
EKG Changes: Inferior MI
ST Changes: II, III, aVF Culprit Vessel: RCA
EKG Changes: Lateral MI
ST Changes: I, aVL, V5, V6 Culprit Vessel: Circumflex
EKG Changes: Posterior MI
ST Changes: Reciprocal in V1, V2 Culprit Vessels: RCA or Cx
Summary of EKG Changes
Lat: I, aVL, V5, V6 Ant/Septal: V1, V2, V3, V4
Inf: II, III, aVF Post: Rec V1, V2
EKG Changes: Summary
Non-invasive Diagnostic Testing
• Echocardiography• Exercise stress testing• Pharmacologic stress testing -Adenosine -Persantine• Nuclear stress testing• Echocardiography• CTA• Cardiac MRI
May be considered only after acute MI or other emergent process has been ruled out.
Acute Pharmacologic Interventions in STEMI
• Oxygen
• Nitroglycerin
• Analgesia (Morphine)
• Aspirin
• Beta Blockers
MONA MONAB
Supplemental oxygen should be administered to
patients with arterial oxygen desaturation (SaO2
< 90%).
It is reasonable to administer supplemental oxygen to all patients with uncomplicated STEMI during the first 6 hours.
Oxygen
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STEMI: ACC/AHA guidelines at www.acc.org
Patients with ongoing ischemic discomfort should receive sublingual NTG (0.4 mg) every 5 minutes for a total of 3 doses, after which an assessment should be made about the need for intravenous NTG.
Intravenous NTG is indicated for relief of ongoing
ischemic discomfort that responds to nitrate therapy,
control of hypertension, or management of pulmonary
congestion.
Nitroglycerin
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STEMI: ACC/AHA guidelines at www.acc.org
Nitrates should not be administered to patients with:
Nitrates should not be administered to patients who have received a phosphodiesterase inhibitor for erectile dysfunction within the last 24 hours (48 hours for tadalafil/Cialis©).
• systolic pressure < 90 mm Hg or ≥ to 30 mm Hg below baseline
• severe bradycardia (< 50 bpm)• tachycardia (> 100 bpm) or• suspected RV infarction.
Nitroglycerin
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STEMI: ACC/AHA guidelines at www.acc.org
Analgesia
Morphine sulfate (2 to 4 mg intravenously with
increments of 2 to 8 mg intravenously repeated at
5 to 15 minute intervals) is the analgesic of choice
for management of pain associated with STEMI.
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STEMI: ACC/AHA guidelines at www.acc.org
Aspirin
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Aspirin should be chewed by patients who have
not taken aspirin before presentation with STEMI.
The initial dose should be 162 mg (Level of
Evidence: A) to 325 mg (Level of Evidence: C)
Although some trials have used enteric-coated aspirin for initial dosing, more rapid buccal absorption occurs with non–enteric-coated formulations.
III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
STEMI: ACC/AHA guidelines at www.acc.org
NSAIDs
NSAIDS (except ASA) should not be given during the acute hospitalization due to increased risk of mortality, reinfarction, HTN, heart failure, and myocardial rupture.
This restriction includes both nonselective as well as COX-II forms of NSAIDs.
STEMI: ACC/AHA guidelines at www.acc.org
Oral beta-blocker therapy should be administered
promptly to those patients without a contraindication,
irrespective of concomitant fibrinolytic therapy or
performance of primary PCI.
It is reasonable to administer intravenous beta-
blockers promptly to STEMI patients without
contraindications, especially if a tachyarrhythmia or
hypertension is present.
Beta-Blockers
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STEMI: ACC/AHA guidelines at www.acc.org
Primary PCI for STEMI:General Considerations
Patient with STEMI (including posterior MI) or MI with new or presumably new LBBB
PCI of infarct artery within 12 hours of symptom onset
Balloon inflation within 90 minutes of presentation
Skilled personnel available (individual performs > 75 procedures per year)
Appropriate lab environment (lab performs > 200 PCIs/year of which at least 36 are primary PCI for STEMI)
Cardiac surgical backup available
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STEMI: ACC/AHA guidelines at www.acc.org
Primary PCI for STEMI:Specific Considerations
Medical contact–to-balloon or door-to-balloon should be within 90 minutes.
PCI preferred if > 3 hours from symptom onset.
Primary PCI should be performed in patients with severe congestive heart failure (CHF) and/or pulmonary edema (Killip class 3) and onset of symptoms within 12 hours.
III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
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STEMI: ACC/AHA guidelines at www.acc.org
Times to remember
• 10 minutes time for ED eval• 30 minutes door to needle• 90 minutes door to balloon• 3 hours (symptom onset) Fibrinolytic
vs. PCI therapy• 12 hours (symptom onset) Time limit for
revascularization therapies as supported by data
•Given the current literature, it is not possible to say definitively that a particular reperfusion approach is superior for all pts, in all clinical settings, at all times of day.
•The main point is that some type of reperfusion therapy should be selected for all appropriate pts with suspected STEMI.
• The appropriate & timely use of some reperfusion therapy is likely more important than the choice of therapy.
Caveat on Reperfusion
STEMI: ACC/AHA guidelines at www.acc.org
Caveat on Reperfusion
The medical system goal is rapid recognition and treatment of patients with STEMI such that either:
1. Door-to-needle time for initiation of fibinolytic therapy
can be achieved within 30 miutes
OR
2. Door-to-balloon time for PCI can be kept within 90
minutes.
STEMI: ACC/AHA guidelines at www.acc.org
Maintenance Management of the Patient after MI
• Aspirin
• Plavix
• Beta Blocker
• ACE inhibitor/ARB
• Statin therapy
Aspirin
A daily dose of aspirin (initial dose of 162 to
325 mg orally; maintenance dose of 75 to 162
mg) should be given indefinitely after STEMI to
all patients without a true aspirin allergy.
III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
STEMI: ACC/AHA guidelines at www.acc.org
Thienopyridines (Plavix)
In patients for whom PCI is planned, clopidogrel
(Plavix) should be started and continued:
• ≥ 1 month after bare-metal stent
• ≥ 3 months after sirolimus-eluting stent
• ≥ 6 months after paclitaxel-eluting stent
• Up to 12 months in absence of high risk for bleeding.
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STEMI: ACC/AHA guidelines www.acc.org
Duration of Plavix use varies among interventional cardiologists.
Use of generic Plavix was strongly discouraged, but the generic form is no longer available.
Thienopyridines (Plavix)
2007 STEMI guidelines now include long-term use of Plavix regardless of reperfusion therapy (ie-fibrinolysis, PCI, or neither):
• Plavix 75mg po daily (LOE A) for at least 14 days (LOE B) or one year if patients under 75 years of age (LOE C).
• Plavix should be held for 5-7 days prior to to CABG.
STEMI: ACC/AHA guidelines www.acc.org
Maintenance Management
Beta blockers should be continued indefinitely in all patients who have no known contra- indications.
ACE inhibitor (or ARB) if necessary should be continued indefinitely in all patients post MI.
Aggressive lipid management with a statin should be initiated promptly and continued.