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Acute Coronary Syndromes

Acute Coronary Syndromes. 1. Case. A 55-year-old man presents with a chief complaint of severe (10 of 10) substernal chest pain. He has pain radiating down his left arm and up into his jaw, nausea, and a profound sense of impending doom. He is covered with small beads of sweat.

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Acute Coronary Syndromes

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  1. Acute CoronarySyndromes 1

  2. Case A 55-year-old man presents with a chief complaint of severe (10 of 10) substernal chest pain. He has pain radiating down his left arm and up into his jaw, nausea, and a profound sense of impending doom. He is covered with small beads of sweat. Vital signs: TEMP = 37.2°C; HR = 110 bpm; BP = 150/100 mm Hg; RESP = 12 Describe your immediate assessment.Describe your immediate general treatment.

  3. Items of Immediate Assessment (<10 min) • First ask the patient about symptoms • Immediately assess vital signs Then never forget three things • Oxygen • I/V Line • Monitor

  4. Immediate General Treatment • Oxygen at 4 L/min • Aspirin 160 to 325 mg • Nitroglycerin SL or spray • Morphine IV (if pain not relieved with nitroglycerin) • MONA PROTOCOL Review the Why? (actions), When? (indications), How? (dose), and Watch Out! (precautions) of these medications to consider in patients with ischemic chest pain.

  5. Oxygen Used in Acute Coronary Syndromes Why? • Increases supply of oxygen to ischemic tissue When? • Always when AMI is suspected How? • Start with nasal cannula at 4 L/min • Remember one word: oxygen-IV-monitor Watch Out! • Rarely COPD patients with hypoxic ventilatory drive will hypoventilate

  6. Nitroglycerin: Actions • Decreases pain of ischemia • Increases venous dilation • Decreases venous blood return to heart • Decreases preload and cardiac oxygen consumption • Dilates coronary arteries • Increases cardiac collateral flow

  7. Nitroglycerin: Precautions • Use extreme caution if systolic BP <90 mm Hg • Use extreme caution in RV infarction • Suspect RV infarction with inferior ST changes • Limit BP drop to 10% if patient is normotensive • Limit BP drop to 30% if patient is hypertensive • Watch for headache, drop in BP, syncope, tachycardia • Tell patient to sit or lie down during administration

  8. Morphine Sulfate: Actions, Indications • Why? (Actions) • To reduce pain of ischemia • To reduce anxiety • To reduce extension of ischemia by reducing oxygen demands • When? (Indications) • Continuing pain • Evidence of vascular congestion (acute pulmonary edema) • Systolic blood pressure >90 mm Hg • No hypovolemia

  9. Morphine Sulfate: Dose, Precautions • How? (Dose) • 2 to 4 mg titrated to effect • Goal: Eliminate pain • Watch out for (Precautions) • Drop in blood pressure, especially in patients with • Volume depletion • Increased systemic resistance • RV infarction • Depression of ventilation • Nausea and vomiting (common) • Bradycardia • Itching and bronchospasm (uncommon)

  10. Aspirin: Actions • Why? (Actions) • Blocks formation of thromboxane A2 (thromboxane A2 causes platelets to aggregate and arteries to constrict) • These actions will reduce • Overall mortality from AMI • Nonfatal reinfarction • Nonfatal stroke

  11. Aspirin: Indications, Dose, Precautions • When? (Indications) As soon as possible! • Standard therapy for all patients with new pain suggestive of AMI • Give within minutes of arrival • How? (Dose) 160- to 325-mg tablet taken as soon as possible • Watch Out! (Precautions) • Relatively contraindicated in patients with active peptic ulcer disease or asthma • Contraindicated in patients with known aspirin hypersensitivity • Bleeding disorders • Severe hepatic disease

  12. Assess Initial 12-Lead ECG Findings Classify patients with acute ischemic chest pain into 1 of the 3 groups above within 10 minutes of arrival. • ST elevation or new or presumably new LBBB: • strongly suspicious for injury • ST-elevation AMI • ST depression or dynamicT-wave inversion: • strongly suspicious for ischemia • High-risk unstable angina/non–ST-elevation AMI • Nondiagnostic ECG: • absence of changes in ST segment or T waves • Intermediate/low-riskunstable angina

  13. Recognition of AMI • Know what to look for— • ST elevation >1 mm • 3 contiguous leads • Know where to look • Refer to 2000 ECCHandbook J point plus 0.04 second PR baseline ST-segment deviation= 4.5 mm

  14. How to MeasureST-Segment Deviation J point plus 0.04 second PR baseline ST-segment deviation

  15. Baseline Ischemia—tall or inverted T wave (infarct),ST segment may be depressed (angina) Injury—elevated ST segment, T wave may invert Infarction (Acute)—abnormal Q wave,ST segment may be elevated and T wavemay be inverted Infarction (Age Unknown)—abnormal Q wave,ST segment and T wave returned to normal 12-Lead ECG Variations in AMI and Angina

  16. AMI Localization I lateral aVR V1 septal V4 anterior aVL lateral II inferior V2 septal V5 lateral III inferior aVF inferior V3 anterior V6 lateral

  17. ß-Blockers • Mechanism of action • Blocks catecholamines from binding to ß-adrenergic receptors • Reduces HR, BP, myocardial contractility • Decreases AV nodal conduction • Decreases incidence of primary VF

  18. Severe CHF/PE SBP <100 mm Hg Acute asthma (bronchospasm) 2nd- or 3rd-degree AV block Mild/moderate CHF HR <60 bpm History of asthma IDDM Severe peripheral vascular disease ß-Blockers AbsoluteContraindications Cautions

  19. Heparin • Mechanism of action • Indirect thrombin inhibitor (with AT III) • Indications • PTCA or CABG • With fibrin-specific lytics • High risk for systemic emboli • Conditions with high risk for systemic emboli, such as large anterior MI, atrial fibrillation, or LV thrombus

  20. Fibrinolytic Therapy • Breaks up the fibrin network that binds clots together • Indications: ST elevation >1 mm in 2 or more contiguous leads or new LBBB or new BBB that obscures ST • Time of symptom onset must be <12 hours • Caution: fibrinolytics can cause death from brain hemorrhage • Agents differ in their mechanism of action, ease of preparation and administration; cost; need for heparin • 5 agents currently available: alteplase (tPA, Activase), anistreplase (Eminase), reteplase (Retavase), streptokinase (Streptase), tenecteplase (TNKase)

  21. Antiplatelet Agents • Blocks glycoprotein IIb/IIIa receptors on platelets • Blocked receptors cannot attach to fibrinogen • Fibrinogen cannot aggregate platelets to platelets • Indications: ACS with NO ST-segment elevation: • Non–Q-wave MI • Unstable angina managed medically • UA undergoing PCI • Examples: abciximab (ReoPro), eptifibitide (Integrilin), tirofiban (Aggrastat)

  22. 2. PTCA + stent placement 1. PTCA: Percutaneous Transluminal Coronary Angioplasty 3. Atherectomy: “grinds away” the plaque Three Percutaneous Coronary Interventions (PCIs)

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