Acute Coronary Syndrome and Chest Pain of Recent Onset
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Short summary of challenges and issues regarding diagnosing and management of Acute Coronary Syndrome and Chest Pain of Recent onset.
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Acute Coronary Syndrome and Chest Pain of Recent Onset
- 1. Chest pain of recent onset and ACS few highlights GP - meeting at NNUH 13 September 2011 Toomas Särev Consultant Cardiologist NNUH-JPUH 1
- 2. 2
- 3. Challenges - Chest pain + ECG & Lab 3
- 4. Concept of Supply - Demand Coronary anatomy Diastolic BP Heart Rate Heart Rate Preload Characteristics of Afterload blood Contractility O2-extraction •Hb •PaO2 O2 supply O2 demand 4
- 5. Pathophysiology Clinical Diagnosis PLAQUE RUPTURE ASYMPTOMATIC/ UNSTABLE ANGINA SYMPTOMATIC INTRACORONARY CHRONIC THROMBUS → ACUTE STEMI DECREASED FLOW MYOCARDIAL HYPOXIA ECG ISCHAEMIA IN MYOCYTES Markers of myocardial injury (TnI, CK-Mb) RISK 5
- 6. Rupture of a plaque 6 6
- 7. Diagnostic Challenges The spectrum of ACS 7
- 8. diagnostic challenges? • risk assessment • individuals without clear symptoms or ECG features • atypical presentations (dyspnea, syncope, abdominal pain) • older patients (> 75 y) • women • diabetes, chronic renal failure, dementia 8
- 9. How to identify high risk patients? 9
- 10. ECG - when should you be concerned? 10
- 11. Grade of ischaemia in EGG depends on • collateral supply circulation • “double” • preconditioning • normal ECG does not rule out ACS • negative T waves indicate open vessel 11
- 12. Occlusion in the LEFT MAIN STEM: deep ST-depressions and negative T waves in inferolateral and antero-septal leads This patient developed cardiogenic shock shortly after debut of his chest pain LM normal RCA The patient died despite initial success with PPCI 12
- 13. Culprit in the proximal LAD (before the take-off of a Diagonal branch) - no protection ST elevations in I, aVL and V2-V5 Intermediate Diagonal LAD 13
- 14. Occlusion in the proximal RCA: ST-elevaton in in II, III, aVF + V1 & V4R RCAa 100% RCA POST-PTCA 14
- 15. Diagnostic Challenges The spectrum of ACS 15
- 16. Abnormal Troponin possible causes • chronic or acute renal dysfunction • severe congestive heart failure - acute and chronic • hypertensive crisis • tachy- or bradyarrhythmias • pulmonary embolism, PAH • myocarditis • acute neurological disease, stroke, SAH 16
- 17. ACS in the elderly • clinical presentation might be different (dyspnea) • more extensive and severe CAD, • more comorbidities, level of frailty very individual • worse prognosis • differenttherapies with usual benefit/risk ratio • higher rate of secondary effects and complications © Gary Larson 2002 17
- 18. How to manage? When to refer? © Gary Larson 2002 18
- 19. decision-making algorithm in ACS 19
- 20. Targets for Management Revascularisation (PCI, CABG) Antithrombotic therapy •Antiplatelet therapy Optimal hemodynamics •Anticoagulation •Beta blockers Preventive and plaque stabilising •Nitrates •Statins •Ivabradine •ACEi Respiratory support Optimal hemodynamics (anti- (CPAP) ishcaemic therapy) Painkillers •Beta blockers Sedation •Nitrates Optimise PaO2 O2 supply O2 demand Optimise Hb GUIDELINES 20
- 21. Revascularisation • medical therapy if no critical coronary lesions if no options for revascularisation • PCI with stenting of the cuprit lesion • individualised decision in multivessel disease • staged PCI or all at once • PCI at first and then CABG • CABG 21
- 22. new guidelines summary 22
- 23. Thank You! this presentation can be downloaded from: www.slideshare.net/ kardiostar comments: kardostar@mac.com © Gary Larson 2002 23