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Peak A is the early release of myoglobin or creatine kinase isoenzyme MB (CK-MB) after acute myocardial infarction (AMI). Peak B is the cardiac troponin level after
infarction. Peak C is the CK-MB level after infarction. Peak D is the cardiac troponin level after unstable angina. Data are plotted on a relative scale, where 1.0 is set at
the myocardial-infarction cutoff concentration. Courtesy of Wu et al (1999). ROC = receiver operating characteristic
o ECG:
Unstable angina: Normal, there may be ST Depression/T wave inversion
Non-STEMI: ST depression/T wave inversion
STEMI:
ST elevation for >1mm in 2 contiguous chest leads
New onset LBBB
o Imaging:
CXR: Cardiomegaly?
ECHO: assessment of valves and EF? (heart failure)
Cardiac perfusion scintiography(assessment of a perfusion of the
myocardium looking at areas that are under perfused
o Invasive:
Angiogram: the gold standard to diagnose coronary artery disease, can be
therapeutic as well.
Management
o Advice patient regarding losing weight, stopping smoking, low fat diet, exercise (30
minutes every day), good control of DM,
o Acute management: (MONA BAH)
Oxygen (2-4L) as 70% of ACS patients is hypoxemic.
Morphine 2.5-5 mg IV + Metoclopramide 10mg IV (analgesia and antiemetic)
GTN spray sublingual 2 puffs (vasodilator)
Aspirin 300mg PO chewable (anti-platelet) + Clopidogrel 300mg PO (inhibits
platelet aggregation)
Atenolol 5mg IV for 15 minutes (beta blocker)
Ramipril 2.5-10 mg PO (ACEI for thrombus remodelling)
Atorvastatin 80mg PO (HMG-CoA inhibitor for thrombus remodelling and
hyperlipidemia)
o If the patient has non-STEMI [Add] (since there is a thrombus that is incompletely
occluding; want to prevent further formation of thrombus):
Enoxaparin (antithrombin; LMWH) 1mg/kg SC BD
Tirofiban (GP IIIa/IIb antagonist, prevents aggragation) 0.4mg/kg/min IV for
30 mins then 0.1mg/kg/min IV for 48-108 hours
o If the patient has STEMI [treatment as above +] thrombolyse the patient
Indicated in:
Symptoms of ischemia
Symptoms are within the last 12 hours
New LBBB
ST elevation in 2 contiguous chest leads >1mm
Contraindications
History of intracranial haemorrhage
Known structural cerebral vascular lesion (AV Malformation)
Intracranial malignancy
Ischemic stroke within the last 3 months (but not within 3 hours)
Suspected aortic dissection
Active bleeding or bleeding diathesis
Significant head trauma within the last 3 months.
Relative contraindications:
Poorly controlled chronic severe hypertension
Severely uncontrolled hypertension on presentation (>180 SBP,
>110 DBP)
Recent internal bleeding (2-4 weeks)
Pregnancy
Active peptic ulcer
Use of anticoagulants (high INR high risk of bleed)
Major surgery within the last 3 weeks or trauma
Ischemic stroke more than 3 months ago/ dementia
Noncompressible vascular punctures
Allergy (more than 5 days ago) to altepase/streptokinase.
Altepase (tissue-Plasminogen activator) 15mg IV stat, then 50mg IV for 30
minutes, then 35mg IV for 1 hour
o PCI or Fibrinolysis:
Fibrinolysis preferred if:
<3 hours from onset
PCI not available/delayed
door to balloon > 90min
door to balloon minus door to needle > 1hr
Door to needle goal <30min
No contraindications
PCI preferred if:
PCI available
Door to balloon < 90min
Door to balloon minus door to needle < 1hr
Fibrinolysis contraindications
Late Presentation > 3 hr
High risk STEMI
Killup 3 or higher
STEMI dx in doubt
o Percutaneous intervention (PCI) (AKA cardiac catheterisation)
Indicated in:
Identification of the extent and severity of coronary artery disease
Assessment of valvular or cardiomyopathies
Confirming the diagnosis of ACS
Contraindicated:
Severe uncontrolled hypertension
Ventricular arrhythmias
Acute stroke
Severe anemia
Active gastrointestinal bleeding
Allergy to radiographic contrast
Acute renal failure
Uncompensated congestive failure (patient cannot lie flat)
Unexplained febrile illness and/or untreated active infection
Electrolyte abnormalities (eg, hypokalemia)
Severe coagulopathy
Method: done under local anaesthesia
Arterial access from the upper extremity (modified Sones method)
using sones catheter from the brachial, radial or axillary arteries
Lower extremity (femoral artery) using Judkins technique:
o Advantages: ease of access and safety of procedure
o Disadvantages: Vascular injury if puncture was done higher
or lower than the common femoral artery and the need for
extended bed rest after the procedure (2-6 hours)
Complications:
Intra-procedural: hypotension, heart failure, chest pain and
arrhythmias
Major complications: death 0.08%, MI less than 0.03%, stroke
0.06%, infection (0.06%, 0.6% in upper extremity approach), Renal
dysfunction (due to contrast; 5% 1% long term dialysis),
arrhythmias
Bleeding from vessels at puncture site, most common complication:
bleeding into the retroperitoneal space (unexplained hypotension
and decreasing haematocrit) do Abdominal USS and then CT to
confirm. Also pseudoaneurysm (connection between haematoma
and the lumen pulsatile mass with systolic bruit). AV formation.
o In summary:
o
o
o
Complications:
o Arrhythmias, Heart failure, papillary muscle rupture, valvular dysfunction,
myocardial rupture, mural thrombi, PE, Stroke, death
Prognosis:
o 38% die within a year of presentation