Acute Coronary

Syndromes

Jason Ryan, M.D.

 Acute Coronary Syndromes
Unstable Angina +
Non-ST-Elevation MI +
ST-Elevation MI

Acute Coronary Syndromes (ACS)

UA + NSTEMI STEMI
(life-threating but (medical emergency)
not medical emergency)
 Acute Coronary Syndromes
Generally, same symptoms for all
– Squeezing, pressure-like, substernal chest
pain
– Often associated with shortness of breath and
diaphoresis
– Pearl: If nausea and vomitting think inferior
wall MI
– With UA/NSTEMI, often preceding history of
exertional symptoms
Remember the DDx for Chest Pain
ACS The
Aortic Dissection Can’t
Misses
Pulmonary Embolism
Acute choleycystitis
Pericarditis
Costocondritis
Esophogeal spasm
Many others
ST-Elevation MI
ST-Elevation MI
ST-Elevation MI
 ST-Elevation MI
Coronary Stenosis: Progression to STEMI
Serial Angiogrpahy in 239 Patients
Stenosis Culprit
Pre-MI For MI
0% 8
25% 10 29
50% 5
75% 6
90-99% 10
39
Nobuyoshi M et al., JACC 1991;18:904-10
 ST-Elevation MI
If you suspect STEMI:
– OMI: Oxygen, monitor, IV access
– ABC: Ensure patient is stable
– Call cardiology
– Pre-cath medication:
Aspirin 325mg PO
Lopressor 25mg PO (if BP and Pulse will tolerate)
– Beware cardiogenic shock
Heprin 5000U bolus (if no active bleeding issues)
Discuss IIB/IIIA and Clopidogrel with cardiology
 Unstable Angina (UA) and
Non ST Elevation Myocardial Infarction
(NSTEMI)
• 5,315,000 annual ER presentations for chest pain

• 1,433,000 annual U.S. hospital admissions for

UA/NSTEMI

• 50 patients per month at BIDMC coded as:

AMI, SUBENDOCARDIAL ISCHEMIA
 UA and NSTEMI

Placebo Event Rates in Recent Trials of UA and NSTEMI

Death/MI
at 30 days
PRISM1 7.1%
PRISM-PLUS2 11.9%
PURSUIT3 15.7%
GUSTO-IV ACS4 8.0%

PARAGON A5 11.7%

1. PRISM Study Investigators. N Engl J Med 1998;338:1498-1505.

2. PRISM-PLUS Study Investigators. N Engl J Med 1998;338:1488-1497.
3. Harrington RA. Am J Cardiol 1997;80:34B-38B.
4. The GUSTO IV-ACS Investigators. Lancet 2001;357:1915-1924.
5. The PARGON Investigators. Circulation 1998;97:2386-2395.
 UA and NSTEMI
Definitions
– Unstable angina
New onset angina
Angina that occurs at rest
Angina that occurs with accelerating frequency
(crescendo angina)
May have EKG changes (ST depression)
Biomarkers will be negative
 UA and NSTEMI
Definitions
– NSTEMI
Typical rise and fall of cardiac biomarkers plus at
least one of the following:
– Anginal chest pain
– Ischemic EKG changes (ST-depression)
– Development of Q waves on EKG
– Coronary intervention

Often can’t tell UA from NSTEMI at

presentation

Joint European Society of Cardiology/American College of Cardiology committee

 NSTEMI
The Biomarkers:
– CK
Rises 4-6 hours after MI
Peaks and falls by 36-48 hours after MI
Total CK is non-specific
CK-MB is more specific for cardiac tissue
– (but there is still some in skeletal muscle!!)
– Remember this is one component in the diagnosis of
NSTEMI
– CK alone cannot be used to diagnose NSTEMI
 NSTEMI
The Biomarkers:
– Troponin
Rises 4-6 hours after MI
Can remain elevated for up to two weeks!
Very specific for cardiac damage
Elevated in many other conditions than ACS
– Hypotension of any cause (~80% patients)
– Renal failure
– Congestive heart failure
– Many others
Always predicts worse outcomes
 NSTEMI
Four pieces to NSTEMI:
– Symptoms
– EKG changes
– CK
– Troponin
 ACC Guidelines for Management of UA/NSTEMI

Chest Pain

EKG
Follow ST
No ST ST Protocols

Possible Definite/Likely Definite/Likely

UA/NSTEMI UA/NSTEMI UA/NSTEMI with cath
MSO4 or PCI planned
MSO4 NTG MSO4
NTG ASA NTG
ASA Beta Blockers ASA
Beta Blockers Heparin Beta Blockers
Plavix Heparin
Plavix
IIB/IIIA Inhibitor
 American College of Cardiology (ACC)
2002 Guidelines for UA/NSTEMI

Medications with Class I indication

First 24 hours Discharge

•Morphine •Aspirin
•Nitroglycerin •Beta Blocker
•Aspirin •Plavix
•Beta Blocker •ACE Inhibitor
•Plavix •Statin
•Heparin
•IIB/IIIA
Inhibitors
 ACC 2002 Guidelines for UA/NSTEMI
How well do we do?

NRMI-4 NSTE MI Acute Care:

100%
85%
3rd Quarter 2001
80% 71% 72%

60%

40%
24%
20%

0%
ASA Beta Blocker Heparin (all) GP IIb/IIIa
 ACC 2002 Guidelines for UA/NSTEMI
How well do we do?
NRMI-4 NSTE MI Discharge Care:
100% 3rd Quarter 2001
84%
80% 75% 71%
56%
60%

40%
21%
20%

0%
ASA Beta Blocker ACE Statins # Cardiac
Inhibitor * Rehab
* LVEF < 40%
# Known hyperlipidemia
ACC 2002 Guidelines for UA/NSTEMI
How well do we do?

Gap between ‘Leading and Lagging’ US Hospitals

Performance
Quality Indicator Bottom 10% Top 10%
ASA use < 24 h 54% 99%
 blocker use < 24 h 33% 98%
Heparin use <24 h 50% 92%
GP IIb-IIIa < 24 h 0% 51%
D/C ASA use 54% 99%
D/C  blocker use 44% 96%
D/C ACE-I use 21% 83%
D/C lipid lowering 33% 99%
 ACC 2002 Guidelines for UA/NSTEMI
Does doing well matter?
Benefits of Using Evidence-Based Therapies
(Non-ST  ACS Patients from GUSTO IIb)
Additional Lives
Discharge Saved per 1,000
Therapy Current Use (ideal use)
Aspirin 86% 9
Beta blockers 59% 11
ACE inhibitors 52% 23

Alexander K, JACC, 1998

 Case 1
A 54 year old man with DM, HTN, and high cholesterol
presents to the ER complaining of substernal chest pain.
The pain feels like his chest is being squeezed. He first
noted it two months ago when carrying packages up a
flight of stairs. Last week he noticed it when walking to
work. The past two days, the pain has occurred
whenever he climbs the stairs in his house. This morning
it occurred while driving to work.
His initial EKG shows sinus tachycardia with anterior ST
depressions.
His initial cardiac biomarkers are negative.
He becomes pain free during his first few minutes in the
ER and his EKG changes resolve.
 Case 1
Is this an ACS?
– YES!!!
How should this patient be managed?
– Morphine and NTG to make him pain free
– Aspirin, Beta blocker, Heparin, Integrillin
– Plan for catheterization with 24-48 hours
 Case 2
A 75 yom with HTN presents to the ER
complaining of squeezing, substernal
chest pain. The pain began this morning
while taking a shower and has waxed and
waned all day (~10 hours time).
Initial EKG shows sinus tachycardia
without ST changes
Initial biomarkers:
– CK 300, MB 20, Trop T 0.5
 Case 2
Is this an ACS?
– YES!!!
How should this patient be managed?
– Morphine and NTG to make him pain free
– Aspirin, Beta blocker, Heparin, Integrillin
– Plan for catheterization within 24-48 hours
 Case 3
A 82 yof is transferred to the ED from her
nursing home where she was noted to be
lethargic. For the past two days, she has had
decreased POs and one episode of vomiting.
The patient is unable to give a history.
On initial ED eval, her blood pressure is 72/45
and her temp is 101.4
Initial EKG shows sinus tachycardia
Initial biomarkers show CK 110, MB 6, Trop 0.5
 Case 3
In this an ACS?
– Unlikely
How should this patient be managed
– ASA if no contraindication
– No BB given hypotension
– No heparin or IIB/IIIA as this is not likely ACS
– Work up fever and hypotension
– Cycle biomarkers
– Repeat EKG in 6-12 hours
 Case 4
A 62 yom with a history of ESRD on HD,
Ischemic CM with EF 20% presents with
lethargy and altered mental status for two days
Initial vitals are remarkable for a room air O2 sat
of 88%
EKG shows sinus rhythm with old anterior Q
waves (see on EKG 1 year prior). No new ST
changes.
Initial cardiac markers:
– CK 200 MB 9 Trop 0.8
 Case 4
In this an ACS?
– Unlikely
– Troponin is his only marker of ACS and he has at
least two reasons for false positive (CRF, CHF)
How should this patient be managed
– ASA if no contraindication
– BB if not in CHF
– No heparin or IIB/IIIA unless further evidence of ACS
develops
– Work up lethargy and altered mental status
– Cycle biomarkers
– Repeat EKG in 6-12 hours
 Case 5
A 55 yom presents to the ED c/o episodic chest
pain for one week. The pain is sharp, left sided,
and lasts 10-15 minutes. The pain occurs when
walking and never at rest, although sometimes
he can walk without symptoms. He is pain free
now.
EKG shows sinus rhythm without ST changes.
Initial biomarkers
– CK 90, MB not done, Trop <0.01
 Case 5
In this an ACS?
– Can’t tell
– Some features consistent, some not
How should this patient be managed
– ASA and BB
– No heparin or IIB/IIIA unless biomarkers become
elevated
– Cycle biomarkers
– Repeat EKG in 6-12 hours
– If rules out, consider exercise stress test