Acute Coronary Syndromes & Practice Ecg: Brsud Tabanan

Acute Coronary Syndromes & Practice ECG Wayan Sutarmawan

BRSUD Tabanan

Acute Coronary Syndrome Definition: a constellation of symptoms related to obstruction of coronary arteries with chest pain being the most common symptom in addition to nausea, vomiting, diaphoresis etc. Chest pain concerned for ACS is often radiating to the left arm or angle of the jaw, pressure-like in character, and associated with nausea and sweating. Chest pain is often categorized into typical and atypical angina.

Acute Coronary Syndrome Definition: Simptom yang diakibatkan oleh menyempitbuntunya arteri coroner.

Chest pain/chest discomfort: • Substernal • Menyebar • Tumpul • Panas • Tertindih benda berat • Sehabis exercise

Faktor risiko

ATHEROSCLEROSIS

START

END

Acute Coronary Syndrome UAP

NSTEMI

STEMI

Acute Coronary Syndrome UAP Klinis

ECG

Laboratorium / Cardiac Marker

NSTEMI

STEMI

Acute Coronary Syndrome UAP

NSTEMI

STEMI

Klinis

Positive

Positive

Positive

ECG

N / Ischemic sign ST depresi/T inversi

N / Ischemic sign ST depresi/T inversi

Negative

Positive

Laboratorium / Cardiac Marker

ST Elevasi

Positive

Symptoms Pain

– Pressure – Burning (hot) – Chest/arms/jaw/back

Sympathetic response

– – – – – –

Parasympathetic response Inflammatory response Other

Sweats Tachycardia Cool, clammy skin Nausea Vomiting Weak

– Mild fever – Dyspnea – Asymptomatic

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

Acute Coronary Syndrome UAP

NSTEMI

STEMI

Klinis

Positive

Positive

Positive

ECG

N / Ischemic sign ST depresi/T inversi

N / Ischemic sign ST depresi/T inversi

Negative

Positive

Laboratorium / Cardiac Marker

ST Elevasi

Positive

Acute Coronary Syndrome: Risk Factors Risk factors: Medical – Diabetes mellitus (DM) – Hypertension – Hyperlipidemia: Includes fats, oils, waxes, sterols, nucleic acids, triglycerides – Hypercholesterolemia: Cholesterol is a lipid – Prior cerebrovascular accident: Over 7% of patients with ACS had prior stroke

American College of Cardiology (ACC) 2002 Guidelines for UA/NSTEMI Medications with Class I indication

First 24 hours •Aspirin •Clopidogrel •Nitroglycerin •Beta Blocker •ACE Inhibitor •Heparin •IIB/IIIA Inhibitors •Morphin/Mo

Discharge •Aspirin •Beta Blocker •Clopidogrel •ACE Inhibitor •Statin

Acute Treatment: STEMI • Reperfusion: Thrombolysis vs. PTCA • O2 • ASA • Clopidogrel • Beta blockers • Nitrates

• ACE inhibitors • Morphine • Anticoagulants

Electrocardiogram  STEMI:

 Q waves , ST elevations, hyper acute T waves; followed by T wave inversions.  Clinically significant ST segment elevations:  > than 1 mm (0.1 mV) in at least two anatomical contiguous leads  or 2 mm (0.2 mV) in two contiguous precordial leads (V2 and V3)

 Note: LBBB and pacemakers can interfere with diagnosis of MI on EKG

ST-Elevation MI

The ECG shows: • Sinus rhythm • Normal axis • Small Q waves in lead III but not elsewhere • Elevated ST segments in leads II, III, VF, with upright T waves • T wave inversion in lead VL

Summary Acute inferior 18 myocardial infarction

The ECG shows: Summary • Sinus rhythm Acute anterolateral myocardial • One ventricular extrasystole infarction. • Normal axis • Q waves in leads V2-V3; small Q waves in leads VL, V4 19 • Raised ST segments in leads I, VL, V3-V5

The ECG shows: • Sinus rhythm • Normal axis • Q waves in leads II, III, VF • Normal QRS complexes in the anterior leads • Marked ST segment elevation in leads V1-V6

Summary Old inferior and acute anterior myocardial infarctions. 20

Sinus Tachycardia 110 x /mnt, First degree AV Block, IMA inferior 21

Lilly. Pathophysiology of Heart Disease, 4th Ed. Lippincott Williams, 2007. Page 182

Fibrilasi atrial A. Gelombang fibrilasi B. Fibrilasi atrial dengan respon ventrikuler cepat C. Fibrilasi atrial dengan respon ventrikuler lambat

Cardiac Marker

Deferential Diagnosis Chest Pain

Complications of MI CHF Dysrhythmias Pericarditis Thromboembolic Complications Rupture of Ventricular Free Wall Rupture of Interventricular septum Mitral Valve Insuffisiency

TIMI RISK SCORE –increase in mortality with increasing score ~40% all cause mortality at 14 days for patients requiring urgent revascularisation

Classification of Recommendations and Levels of Evidence A recommendation with Level of Evidence B or C does not imply that the recommendation is weak. Many important clinical questions addressed in the guidelines do not lend themselves to clinical trials. Although randomized trials are unavailable, there may be a very clear clinical consensus that a particular test or therapy is useful or effective. *Data available from clinical trials or registries about the usefulness/ efficacy in different subpopulations, such as sex, age, history of diabetes, history of prior myocardial infarction, history of heart failure, and prior aspirin use. †For comparative effectiveness recommendations (Class I and IIa; Level of Evidence A and B only), studies that support the use of comparator verbs should involve direct comparisons of the treatments or strategies being evaluated.