Chest pain of recent onset and ACS

few highlights

GP - meeting at NNUH13 September 2011

Toomas Särev Consultant Cardiologist

NNUH-JPUH

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2

Challenges - Chest pain + ECG & Lab

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Concept of Supply - Demand

O2 supply O2 demand

Coronary anatomyDiastolic BPHeart RateCharacteristics of bloodO2-extraction •Hb •PaO2

Heart RatePreloadAfterloadContractility

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Pathophysiology Clinical Diagnosis

UNST

ABLE

ANGIN

A

ASYM

PTOMAT

IC/

SYMPT

OMAT

IC

CHRO

NIC

ACUTE

STE

MI

Markers of myocardial injury (TnI, CK-Mb)

ECG

RISK

PLAQUE RUPTURE

INTRACORONARYTHROMBUS

DECREASED FLOW

MYOCARDIAL HYPOXIA

ISCHAEMIA IN MYOCYTES

→

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Rupture of a plaque

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The spectrum of ACS

Dia

gnos

tic C

halle

nges

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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

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How to identify high risk patients?

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ECG - when should you

be concerned?

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• collateral circulation• “double” supply• preconditioning

Grade of ischaemia in EGG depends on

• normal ECG does not rule out ACS

• negative T waves indicate open vessel

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This patient developed

cardiogenic shock shortly after

debut of his chest pain

LM

normal RCAThe patient died

despite initial success with PPCI

Occlusion in the LEFT MAIN STEM: deep ST-depressions and negative T waves in inferolateral

and antero-septal leads

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Culprit in the proximal LAD (before the take-off of a Diagonal branch) - no protection

LAD

Diagonal

Intermediate

ST elevations in I, aVL and V2-V5

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RCAa 100%

RCA POST-PTCA

Occlusion in the proximal RCA:

ST-elevaton in in II, III, aVF + V1 & V4R

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The spectrum of ACS

Dia

gnos

tic C

halle

nges

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Abnormal Troponinpossible 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

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ACS in the elderly

• clinical presentation might be different (dyspnea)

• more extensive and severe CAD,

• more comorbidities, level of frailty very individual

• worse prognosis

• different benefit/risk ratio with usual therapies

• higher rate of secondary effects and complications

© Gary Larson 2002 17

How to manage?

When to refer?

© Gary Larson 2002

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decision-making algorithm in ACS

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Targets for Management

O2 supply O2 demand

Revascularisation (PCI, CABG)Antithrombotic therapy•Antiplatelet therapy•AnticoagulationPreventive and plaque stabilising•Statins•ACEiOptimal hemodynamics (anti-ishcaemic therapy)•Beta blockers•NitratesOptimise PaO2Optimise Hb

Optimal hemodynamics•Beta blockers•Nitrates•IvabradineRespiratory support (CPAP)PainkillersSedation

GUIDELINES

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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

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new guidelines summary

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Thank You!

this presentation can be downloaded from:

www.slideshare.net/kardiostar

comments: kardostar@mac.com

© Gary Larson 2002

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