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CH 008
CH 008
CH 008
FAST FACTS
Normal
TO CAD
Low Likelihood (absence of high- or
intermediate-likelihood features but may
have the following)
Probable ischemic symptoms in absence of
any of the intermediate-likelihood
characteristics
Recent cocaine use
Modified from Braunwald E, Mark DB, Jones RH et al: Unstable angina: diagnosis and management, Rockville, Md, 1994, Agency for Health Care Policy and Research and the
National Heart, Lung, and Blood Institute, U.S. Public Health Service, U.S. Department of Health and Human Services; AHCPR Publication No. 94-0602.
CAD, coronary artery disease.
TABLE 8-1
LIKELIHOOD THAT SIGNS AND SYMPTOMS REPRESENT ACUTE CORONARY SYNDROME SECONDARY
Intermediate Likelihood (absence of
high-likelihood features and presence
High Likelihood (any of the following)
of any of the following)
History
Chest or left arm pain or discomfort
Chest or left arm pain or discomfort
as chief symptom reproducing
as chief symptom
prior documented angina
Age <70 yr
Known history of CAD, including
Male sex
myocardial infarction
Diabetes mellitus
Examination
Transient mitral regurgitation,
Extracardiac vascular disease
hypotension, diaphoresis,
pulmonary edema, or rales
Electrocardiogram
New, or presumably new, transient ST
Fixed Q waves
segment deviation (>0.05 mV) or
Abnormal ST segments or T
T wave inversion (>0.2 mV) with
waves not documented to be new
symptoms
Cardiac markers
Elevated cardiac troponin I, troponin
Normal
T, or creatine kinase myocardial
band
88 Cardiology
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ACUTE CORONARY SYNDROMES
90 Cardiology
BOX 8-1
THROMBOLYSIS IN MYOCARDIAL INFARCTION RISK FACTOR SCORE
RISK FACTORS
Age >65 years
Three or more risk factors for coronary artery disease
Prior coronary stenosis 50%
Two or more anginal events in past 24 hr
Aspirin use in past 7 d
ST segment changes
Positive cardiac markers
30-DAY RISK OF ADVERSE CARDIAC EVENT*
Number of Risk Factors
Risk (%)
0-1
4.7
2
8.3
3
13.2
4
19.9
5
26.2
6-7
41.0
Data from Antman E et al: JAMA 284:835, 2000.
*Defined as myocardial infarction, cardiac-related death, or persistent ischemia. Low risk, score
0-2; intermediate risk, score 3-4; high risk, score 5-7.
Modified from Braunwald E, Mark DB, Jones RH et al: Unstable angina: diagnosis and management, Rockville, Md, 1994, Agency for Health Care Policy and Research and the
National Heart, Lung, and Blood Institute, U.S. Public Health Service, U.S. Department of Health and Human Services; AHCPR Publication No. 94-0602.
CAD, coronary artery disease; MI, myocardial infarction.
*Estimation of the short-term risks of death and nonfatal cardiac ischemic events in unstable angina is a complex multivariable problem that cannot be fully specified in a table
such as this; therefore this table is meant to offer general guidance and illustration rather than rigid algorithms.
TABLE 8-2
SHORT-TERM RISK OF DEATH OR NONFATAL MYOCARDIAL INFARCTION IN PATIENTS WITH UNSTABLE ANGINA*
Low Risk (no high- or intermediate-risk
High Risk (at least 1 of the following
Intermediate Risk (no high-risk feature
feature but may have any of the
features must be present)
but must have 1 of the following)
following features)
History
Accelerating tempo of ischemic
Prior MI, peripheral or cerebrovascular
symptoms in preceding 48 hr
disease, or coronary artery bypass
graft; prior aspirin use
Character of pain
Prolonged (>20 min) rest pain
Prolonged (>20 min) rest angina, now
New-onset Canadian Cardiovascular
resolved, with moderate or high
Society Class III or IV angina in
likelihood of CAD; rest angina
the past 2 wk without prolonged
(<20 min) or relieved with rest or
(<20 min) rest pain but with moderate
sublingual nitroglycerin
or high likelihood of CAD
Clinical findings
Pulmonary edema, probably due to
Age >70 years
ischemia; new or worsening mitral
regurgitation murmur; S3; or new or
worsening rales
Hypotension
Bradycardia or tachycardia
Age >75 years
Electrocardiogram
Angina at rest with transient ST
T wave inversions > 0.2 mV
Normal or unchanged electrocardiogram
segment changes >0.05 mV
Pathological Q waves
during an episode of chest discomfort
Bundle branch block, new or
presumed new
Sustained ventricular tachycardia
Cardiac markers
Markedly elevated (e.g., troponin T or
Slightly elevated (e.g., troponin T
Normal
troponin I > 0.1 ng/ml)
> 0.01 but < 0.1 ng/ml)
92 Cardiology
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ACUTE CORONARY SYNDROMES
94 Cardiology
8
ACUTE CORONARY SYNDROMES
BOX 8-2
CLASS I RECOMMENDATIONS FOR AN EARLY INVASIVE STRATEGY
FOR UNSTABLE ANGINA AND NONST SEGMENT ELEVATION
MYOCARDIAL INFARCTION
Recurrent angina or ischemia at rest or with low-level activities despite intensive
antiischemic therapy
Elevated troponin T or troponin I
New or presumably new ST segment depression
Recurrent angina or ischemia with congestive heart failure symptoms, S3 gallop,
pulmonary edema, worsening rales, or new mitral regurgitation
High-risk findings on noninvasive stress testing
Depressed left ventricular systolic function (e.g., ejection fraction < 0.4 on
noninvasive testing)
Hemodynamic instability
Sustained ventricular tachycardia
Percutaneous coronary intervention within 6 mo
Prior coronary artery bypass graft
96 Cardiology
TABLE 8-3
RISK STRATIFICATION BASED ON KILLIP CLASS IN THE GISSI-1 TRIAL OF
STREPTOKINASE AND PLACEBO IN ACUTE MYOCARDIAL INFARCTION
GISSI-1 (% of patients)
Killip Class
Definition
Incidence
Control Mortality
Lytic Mortality
I
No congestive
71
7.3
5.9
heart failure
II
S3 gallop or
23
19.9
16.1
basilar rales
III
Pulmonary edema
4
39
33
(rales more than
halfway up)
IV
Cardiogenic shock
2
70.1
69.9
(systolic blood
pressure <90)
TABLE 8-4
THROMBOLYSIS IN MYOCARDIAL INFARCTION RISK SCORE FOR ST SEGMENT
ELEVATION MYOCARDIAL INFARCTION
Clinical Risk Indicators
Points
HISTORY
Age 75 yr
3
Age 65-74 yr
2
History of diabetes, hypertension, or angina
1
EXAMINATION
Systolic blood pressure < 100 mmHg
3
Heart rate >100 beats/min
2
Killip class II-IV
2
Weight < 67 kg
1
PRESENTATION
Anterior ST elevation or left bundle branch block
1
Time to reperfusion > 4 hr
1
Total possible points
14
Data from Morrow DA et al: JAMA 286:1356, 2001.
TABLE 8-5
TIMI ANGIOGRAPHIC GRADING SYSTEM: ANGIOGRAPHIC ASSESSMENT OF
RESTORATION OF FLOW TO THE IRA
TIMI Grade
Definition
0
Complete occlusion of the IRA
1
Some flow beyond the obstruction but none distally (e.g., penetration
of blood without perfusion)
2
Reperfusion of the entire IRA but flow is delayed and slower than
normal
3
Normal flow in the IRA
Modified from TIMI Study Group: N Engl J Med 312:932, 1985.
IRA, infarct-related artery; TIMI, Thrombolysis in Myocardial Infarction.
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ACUTE CORONARY SYNDROMES
98 Cardiology
TABLE 8-6
SELECT THROMBOLYTIC STUDIES
Study
Year
Findings
ISIS-2
1988
This placebo-controlled, randomized trial of 17,187 patients
demonstrated lower 30-day mortality with streptokinase
(9.2%) or aspirin (9.4%) treatment than placebo (13.2%)
(p < .00001) and lowest mortality when aspirin and
streptokinase were combined (8%) (p < .00001).23
GUSTO-1
1993
GUSTO-3
1997
ASSENT-2
1999
BOX 8-4
RECOMMENDATIONS OF THE AMERICAN COLLEGE OF CARDIOLOGY AND
AMERICAN HEART ASSOCIATION FOR THROMBOLYTIC THERAPY
CLASS I
ST elevation (>0.1 mm in 2 or more contiguous leads), time to therapy 12 hr
New or presumably new left bundle branch block within past 12 hr
CLASS IIA
12-lead electrocardiographic findings consistent with a true posterior MI within
12 hr of symptom onset
Patients with symptoms beginning within the past 12 to 24 hr with continued ST
elevation (>0.1 mm in 2 or more contiguous leads) and ischemic symptoms
CLASS III
ST elevation with time to therapy >24 hr
ST segment depression unless true posterior MI suspected
Data from Antman EM et al: Circulation 110:588-636, 2004. Available at www.acc.org.
MI, myocardial infarction.
8
ACUTE CORONARY SYNDROMES
BOX 8-3
ABSOLUTE AND RELATIVE CONTRAINDICATIONS TO THROMBOLYTIC
THERAPY FOR MYOCARDIAL INFARCTION
ABSOLUTE CONTRAINDICATIONS
Any prior intracranial hemorrhage
Known structural cerebral vascular lesion (e.g., arteriovenous malformation)
Known malignant intracranial neoplasm (primary or metastatic)
Ischemic stroke within 3 mo except acute ischemic stroke within 3 hr
Suspected aortic dissection
Active bleeding or bleeding diathesis (excluding menses)
Significant closed head or facial trauma within 3 mo
RELATIVE CONTRAINDICATIONS
History of chronic, severe, poorly controlled hypertension
Severe uncontrolled hypertension on presentation (>180/110 mmHg)
History of prior ischemic stroke > 3 mo before, dementia, or known intracranial
disorder not covered in contraindications
Traumatic or prolonged (> 10 min) cardiopulmonary resuscitation or major surgery
(within 3 wk)
Noncompressible vascular punctures
Internal bleeding within 4 weeks
For streptokinase or anistreplase, prior exposure (especially within 2 yr) or prior
allergic reaction
Pregnancy
Active peptic ulcer
Current use of anticoagulants (the higher the international normalized ratio, the
higher the risk of bleeding)
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ACUTE CORONARY SYNDROMES
BOX 8-5
RECOMMENDATIONS FOR PRIMARY PCI
CLASS I
As an alternative to thrombolytic therapy in patients with acute MI and ST segment
elevation or new or presumed new LBBB who can undergo angioplasty of the
infarct-related artery within 12 hr of onset of symptoms if performed in a timely
fashion (balloon inflation within 90 min of presentation) by people skilled in the
procedure and supported by experienced personnel in an appropriate laboratory
environment.
Specific Considerations
PCI should be performed as quickly as possible, with a DTBT goal <90 min.
If symptom duration is <3 hr and the expected DTBT minus door-to-needle time is
<1 hr, PCI is preferred; if DTBT minus door-to-needle time is >1 hr, fibrinolytic
therapy is preferred.
If symptom duration is >3 hr, PCI is preferred, with goal DTBT <90 min.
PCI should be considered, if clinically suitable, for patients <75 yr old with STEMI
or LBBB who develop shock within 36 hr of MI and can be revascularized
within 18 hr of shock.
PCI should be performed in patients with severe CHF or pulmonary edema (Killip
class III) and onset of symptoms within 12 hr, with DTBT as short as possible
(i.e., goal <90 min).
CLASS IIA
PCI is reasonable for patients with good functional status who are 75 yr or older
with STEMI or LBBB or who develop shock within 36 hr of MI and are suitable
for revascularization that can be performed within 18 hr of shock.
It is reasonable to perform PCI with symptom onset in the past 12-24 hours when
CHF or hemodynamic or electrical instability is present.
CLASS IIB
The benefit of primary PCI for patients with STEMI who are eligible for fibrinolysis
is not well established when performed by operators with fewer than 75 PCI
procedures per year.
CLASS III
PCI should not be performed in a noninfarcted artery at the time of primary PCI in
patients without hemodynamic compromise.
Primary PCI should not be performed in asymptomatic patients more than 12 hr
after onset of STEMI if they are hemodynamically and electrically stable.
102 Cardiology
TABLE 8-7
COMPLICATIONS OF MI
Incidence (%)
Time to Onset
After MI
Percentage of
MI-Associated
Mortality
<1
2
7
2-7 d
5-14 d
Any time
5
10
5
Any time
80
REFERENCES
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ACUTE CORONARY SYNDROMES
104 Cardiology
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106 Cardiology