Acute Coronary Syndromes Or heart attacks for the

Acute Coronary Syndromes Or, heart attacks for the would-be dumb ass Brendan Munn Emergency Residents’ Academic Day August 27 2009 CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

Objectives 1. 2. 3. 4. 5. review terminology and pathophys approach to risk stratification discuss ACS management with cases review the literature on management prevent and manage complications CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

Definitions and Pathophys CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

Chest pain suggestive of ischemia Immediate assessment within 10 Minutes Initial labs and tests 12 lead ECG labs initial cardiac enzymes electrolytes, cbc, bun/cr, glucose, coags CXR 9/25/2020 Emergent care History & Physical IV access cardiac monitors MONA BHCG SA assess reperfusion manage complications 4

case 1 HPI : 52 F with 0. 5 h central chest pain no associated sx or radiation CRF: +FHx, smoker, HTN, T 2 DM BMI 35 CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

Are Risk Factors Helpful? CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

Are Risk Factors Helpful? >17, 000 post hoc with suspected ACS compared with outcome of ACS “limited clinical value in diagnosing acute coronary syndromes, especially in patients over 40 years” “useful < 40 if no risk factors (LR 0. 17) or if 4 or more (LR 7. 39) Han J. Ann Emerg Med 2007 CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

case 2 HPI : 73 yo. M w hx exertional chest pain and SOB. crescendo use of NTG spray over last 3 weeks. CP in ED. CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

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is this a NORMAL ecg? what ABNORMAL findings would you expect in ACS? CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

NSSTT changes : STE/STD < 1 mm +/T wave morphology changes without inv or peak CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

Are ECG Changes Helpful? CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

Are ECG Changes Helpful? 1% of patients with normal ECG had AMI and 4% had a final diagnosis of UA in another study, w classic angina and normal ECG 3% had final diagnosis of AMI 3 -4% of patients with AMI and over 20% of patients with UA have NSSTT findings Lee TH. JAMA 1999; Zimetbaum P. NEJM 2003. CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

case 3 HPI : 64 F with 2 h chest pain radiating to both arms. O/E : Diaphoretic, HR 120, BP 142/75 CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

ECG ? STEMI CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

Is this ST Elevation? CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

Is this ST Elevation? ACS Definition > 1. 0 mm in 2 contiguous precordial > 2. 0 mm in 2 contiguous limb method of calculation baseline, j point other causes of ST segment elevation Wang K. NEJM 2003 CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

ST Elevation CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

Causes of ST Elevation CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

Causes of ST Elevation (in 175 patients) Brady J. Am J Emerg Med 2001 CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

ECG Pearls in ACS 50% of patients with AMI will have a clearly diagnostic ECG at presentation (STE or STD) ST segment elevation identifies those who benefit from reperfusion therapy (lytics) Mortality increases with the number of leads showing STE, presence of LBBB and anterior location Reciprocal changes are seen in 70% of inferior and 30% of anterior MIs, which demonstrates over 90% specificity and PPV for AMI RV infarcts complicate 40% of inferior AMIs Lee TH. JAMA 1999 CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

ECG is an important tool! guidelines say: get one within 10 minutes repeat every 15 mins prn CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

Are Cardiac Markers Helpful? CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

Are Cardiac Markers Helpful? Troponin (Tn. T, Tn. I) very specific, >CK good sensitivity, >CK guidelines draw 8 -12 h prognostic value risk stratification false positives CK-MB less specific, earlier CK or CK-MB peak predicts mortality and LVEF for both STEMI and UA/NSTEMI post infarct and post PCI Hamm C. Circulation 2002, Aviles RJ. NEJM 2002, Alexander JH. JAMA 2000, Savonitto S. J Am Coll Cardiol 2002 CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

Chest pain suggestive of ischemia Immediate assessment within 10 Minutes Initial labs and tests 12 lead ECG labs initial cardiac enzymes electrolytes, cbc, bun/cr, glucose, coags CXR 9/25/2020 Emergent care History & Physical IV access cardiac monitors MONA BHCG SA assess reperfusion manage complications 25

case 4 HPI : 59 F w 3 h pleuritic CP, rad neck CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

Are Clinical Features Helpful? CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

Are Clinical Features Helpful? Goodacre S. Acad Emerg Med 2002 CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

How Good Are We in ACS? CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

How Good Are We in ACS? Analyzed clinical data from a multicentre prospective trial of over 10, 000 patients with chest pain suggestive of ACS 17% ultimately met the criteria for ACS (8% had AMI and 9% had UA) 2. 1% of those with AMI and 2. 3% of those with UA were mistakenly discharged from the ED Pope J. NEJM 2000 EMRAP Jan 2008 CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

Pope J. NEJM 2000 CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

Chest pain suggestive of ischemia Immediate assessment within 10 Minutes Initial labs and tests 12 lead ECG labs initial cardiac enzymes electrolytes, cbc, bun/cr, glucose, coags CXR 9/25/2020 Emergent care IV access cardiac monitors oxygen aspirin nitrates History & Physical read ECG establish diagnosis assess for reperfusion identify complications 32

Approach UA/NSTEMI risk assessment ACC, TIMI choose invasive vs conservative reperfusion strategy lysis vs PCI medical therapy CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

case 5 HPI : 68 M 3 h chest pressure diaphoresis, N/V, SOB hx anterior MI, stent 2001 O/E : HR 110, BP 120/80, sat 94 RA CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

ecg ST depression use b williams, incl V 4 R CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

Risk Stratification likelihood of ACS adverse outcome missed diagnosis ECG Clinical Hx Physical Exam Markers CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

Stratify Risk : ACC Guidelines Low Moderate <10 minutes rest pain moderate to high likelihood CAD non-diagnostic ECG no elevation cardiac markers >10 minutes rest pain now resolved T inv > 2 mm age < 70 slight elevation cardiac markers High elevated markers ST depression treatment failure CHF failed noninv stress poor LV function hemodynamic instability sustained VT PCI within 6 mos prior CABG clinic conservative invasive CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

HIGH history INTERMEDIATE Chest or left arm pain or discomfort as chief symptom Reproduction of previous documented angina Age LOW Probable ischemic symptoms Recent cocaine use Known history of CAD/MI physical exam Diaphoresis, hypotension, pulmonary edema, new mitral regurgitation Extracardiac vascular disease Chest discomfort reproduced by palpation ECG New transient ST-segment deviation (> 0. 05 m. V) or Twave inversion (> 0. 2 m. V) with symptoms Fixed Q waves T-wave flattening or inversion in leads with dominant R waves Abnormal ST Old abnormal T waves Normal ECG cardiac markers 9/25/2020 Elevated cardiac troponin T or I, or elevated CK-MB Normal 38

TIMI score CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

routine invasive inc mortality early invasive <24 h beneficial in TIMI >= 3 unstable, refractory, CHF for early invasive 9/25/2020 TIMI 3 b TACTICS 40

TIMI score CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

GRACE score CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

using scores BAD NEWS all scores for short term prognosis (TIMI 14 d, GRACE 30 d) GOOD NEWS in the ED we live in the short term! CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

Medical Treatment CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

Medical Treatment M O N A orphine xygen itrates SA Statin B H C G eta Blocker eparin lopidogrel P IIb/IIIa ACEi / ARB CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

Morphine LOE STEMI/NSTEMI class I/IIa, level C dose 2 -4 mg IV then 2 -8 mg q 5 -15 mins mech analgesia, dec adrenergic tone, dec SVR, dec oxygen demand care hypotension, hypovolemia, respiratory depression CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

Oxygen LOE class I, level C dose 2 -4 L/min mech may limit ischemia by inc O 2 delivery care mouth breathers, smokers CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

Nitrates LOE class I, level B dose 0. 4 mg SLx 3, infusion 0 -640 mcg/min mech analgesia, dilates coronary vessels, dec SVR, dec preload careful with PDE 5 inhibitors, hypotension, RV infarction CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

ASA LOE class I, level A dose 160 -325 mg chewed and swallowed mech irreversible inhibition of platelet aggregation care hypersensitivity, bleeding d/o, PUD CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

ASA ISIS 2 Lancet 1988 17, 200 pt DBRCT strepto. K vs ASA vs both in MI aspirin benefit = strepto (NNT 20) without increased bleed META-ANALYSIS BMJ 2002 287 studies low daily dose of 75 -150 mg effective secondary prevention minimum 150 mg loading dose in acute setting CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

Beta Blockers LOE class I, level A dose metoprolol 5 mg IV q 5, 50 po q 6 h mech negative inotrope and chronotrope, dec demand/inc perfusion, dec arrythmias, improved diastolic relaxation careful with CHF, brady/blocks, hypotension, asthma CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

Beta Blockers ISIS 1 Lancet 1986 16, 000 pt IV atenolol vs usual. benefit. COMMIT/CCS 2 Lancet 2005 45, 000 pt DBRCT IV/po metoprolol vs none in MI. no benefit, inc cardiogenic shock Guidelines 5 mg IV q 5 and 50 mg q 6 h po in first 24 h if no contraindications or risk cardio shock CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

Heparin LOE class I-IIa, level C dose depends mech direct thrombin inhibitor bleeding d/o, PUD, low risk patients care LMWH less HIT, easier but not better renal dosing CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

META-ANALYSIS JAMA 1996 33% reduction MI/death heparin vs placebo w ASA in UA ESSENCE J Am Coll Card 1999 3, 200 pt DBRCT ASA + enox vs UFH in UA/NSTEMI SYNERGY JAMA 2004 10, 000 pt DBRCT enox vs UFH in NSTEMI w PCI, GPI Ex. TRACT - TIMI 25 J Am Coll Card 2007 20, 000 pt DBRCT enox vs UFH in STEMI w lysis META-ANALYSIS Eur Heart J 2007 49, 000 pt enox vs UFH in all ACS CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

Murphy S. Eur Heart J 2007 CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

Fondaparinux 2. 5 mg mech Anti-Xa OASIS 5 NEJM 2006 20, 000 PT DBRCT enox vs fonda for ACS cheaper, equivalent, lower bleed rate irrespective of switching antithrombotics, PCI Guidelines use in UA/NSTEMI if non invasive or if undecided in invasive/STEMI needs UFH to reduce cath thrombus CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

Clopidogrel LOE class I, level B dose 300 - 600 mg then 75 mg daily mech irreversible inhibition of platelet aggregation via ADP care CABG evidence for use in support of cath, PCI or if unable to take aspirin CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

CAPRIE Lancet 1996 19, 500 pt DBRCT clopidogrel vs ASA in prevention CURE NEJM 2001 12, 500 pt DBRCT clopidogrel vs placebo in UA/NSTEMI CLARITY - TIMI 28 NEJM 2005 3500 pt DBRCT clopidogrel vs placebo in STEMI w lysis COMMIT Lancet 2005 45, 500 pt DBRCT clopidogrel vs placebo in STEMI w ASA +/- lytics, no PCI CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

Clopidogrel - Guidelines UA/NSTEMI/STEMI loading dose + 75 mg daily for min 14 d no loading dose in > 75 y CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

Glycoprotein IIb/IIIa Inhibitors LOE class IIa, level B dose depends mech competitive binding of GP receptor on platelets, preventing fibrin crosslinkage care with the healthcare budget few indications unless for cath CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

Statin LOE class X, level X dose atorvastatin 80 mg mech unknown acutely (pleiotropic? ), long term HMG-Co. A reductase inhibition and dec plaque care liver disease CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

Statin PROVEIT - TIMI 22 NEJM 2004 4000 pt RCT prava 40 vs atorva 80 in MI MIRACL JAMA 2001 3000 pt RCT early atorvastatin 80 vs placebo in NSTEMI ARMYDA-ACS J Am Coll Card 2007 171 pt RCT atorvastatin 80 vs placebo in PCI CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

ACE Inhibitor / ARB LOE class I, level A dose as low as 1. 25 mech decreases afterload, helps ventricular remodeling use in HF, DM, LV dysfunction, HTN care elevated Cr CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

case 6 paramedics call enroute ? STEMI direct to cath HPI : 30 mins CP CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

Ecg 1 CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

repeat Ecg 2 CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

Reperfusion Strategy? CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

Contraindications to Thrombolysis CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

Contraindications to Thrombolysis absolute prior ICH ischemic CVA < 3 mos AVM/neoplasm suspected dissection bleeding diathesis relative bleeding disorder anticoagulated severe hypertension ischemic CVA > 3 mos prolonged CPR recent surg, trauma, PUD CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

23 trials. CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

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Lytics vs PCI Fibrinolysis preferred if: – <3 hours from onset – PCI not available/delayed • door to balloon > 90 min • door to balloon minus door to needle > 1 hr – Door to needle goal <30 min – No contraindications PCI preferred if: – PCI available – Door to balloon < 90 min – Door to balloon minus door to needle < 1 hr – Fibrinolysis contraindications – Late Presentation > 3 hr – High Risk STEMI • Killip 3 or cardiogenic shock – STEMI dx in doubt CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

case 7 You are working in Lethbridge ED HPI : 64 yo. M crushing chest pain for 6 h CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

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lysis? follow up of lysis? transfer for PCI? CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

other indications for cath cardiogenic shock killip >= 3 rescue PCI new - any lysed patient within 6 h CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

Rescue PCI repeat ECG at 90 mins < 50% ST resolution persist/worsen chest pain cardiogenic shock heart failure CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

TRANSFER AMI 1000 patients randomized to lysis plus PCI vs conservative / rescue PCI within 6 h 46% RRR in death/MI at 30 days Cantor W. NEJM 2009 CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

Review 1. is this a STEMI? check ECG < 10 mins, repeat q 15 prn 2. rapid reperfusion for STEMI thrombolytics vs direct PCI rescue / transfer in lysis 3. risk stratification for UA/NSTEMI conservative vs invasive strategy TIMI score helpful CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

Review 4. medical therapy MONA BHCG SA heparin for high risk fondaparinux 2. 5 mg if UA/NSTEMI UFH if STEMI or early invasive beta blocker and statin early if possible CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

References 1. 2. 3. 4. 5. Tintinalli Up To Date EMRAP ACC Guidelines 2004/2007 Selected megatrials CALGARY EMERGENCY MEDICINE TEACHING ROUNDS