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
(life-threating but
not medical emergency)

STEMI
(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
Aortic Dissection
Pulmonary Embolism
Acute choleycystitis
Pericarditis
Costocondritis
Esophogeal spasm
Many others

The
Cant
Misses

ST-Elevation MI

ST-Elevation MI

ST-Elevation MI

ST-Elevation MI
Coronary Stenosis: Progression to STEMI
Serial Angiogrpahy in 239 Patients
Stenosis
Pre-MI
0%
25%
50%
75%
90-99%
Nobuyoshi M et al., JACC 1991;18:904-10

Culprit
For MI
8
10
29
5
6
10
39

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
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.

8.0%

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 cant 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
No ST
Possible
UA/NSTEMI
MSO4
NTG
ASA
Beta Blockers

Definite/Likely
UA/NSTEMI
MSO4
NTG
ASA
Beta Blockers
Heparin
Plavix

ST

Follow ST
Protocols
Definite/Likely
UA/NSTEMI with cath
or PCI planned
MSO4
NTG
ASA
Beta Blockers
Heparin
Plavix
IIB/IIIA Inhibitor

American College of Cardiology (ACC)

2002 Guidelines for UA/NSTEMI
Medications with Class I indication
First 24 hours
Morphine
Nitroglycerin
Aspirin
Beta Blocker
Plavix
Heparin
IIB/IIIA
Inhibitors

Discharge
Aspirin
Beta Blocker
Plavix
ACE Inhibitor
Statin

ACC 2002 Guidelines for UA/NSTEMI

How well do we do?

NRMI-4 NSTE MI Acute Care:

3rd Quarter 2001

ACC 2002 Guidelines for UA/NSTEMI

How well do we do?

NRMI-4 NSTE MI Discharge Care:

3rd
Quarter
2001
100%
84%
75%

80%

71%
56%

60%
40%

21%
20%
0%
ASA

Beta Blocker

* LVEF < 40%

# Known hyperlipidemia

ACE
Inhibitor *

Statins #

Cardiac
Rehab

ACC 2002 Guidelines for UA/NSTEMI

How well do we do?
Gap between Leading and Lagging US Hospitals

Performance
Quality Indicator
ASA use < 24 h
blocker use < 24 h
Heparin use <24 h
GP IIb-IIIa < 24 h
D/C ASA use
D/C blocker use
D/C ACE-I use
D/C lipid lowering

Bottom 10%
54%
33%
50%
0%
54%
44%
21%
33%

Top 10%
99%
98%
92%
51%
99%
96%
83%
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?
Cant 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