ACS defintions, PCI Flashcards
signs and symptoms of ACS
chest pain and discomfort
Chest pain or discomfort
◦ Central or substernal, upper abdominal or
epigastric discomfort
◦ Pain radiating to the neck, jaw, shoulders, back,
one or both arms
◦ Sensation of pressure, crushing, tightness,
heaviness, cramping, burning, aching
◦ Accompanying dyspnea, indigestion, nausea,
vomiting, diaphoresis
◦ Associated hypotension or ventricular arrhythmias
signs and symptoms of ACS
other sx (5)
◦ Isolated dyspnea ◦ Weakness ◦ Diaphoresis ◦ Light-headedness and/or syncope ◦ Nausea The elderly, women and patients with DM may present with symptoms that are not typical of myocardial ischemia
diagnosis of MI
At least one positive troponin PLUS one of the following:
◦ Symptoms or history
◦ ECG
◦ Imaging evidence of new loss of viable myocardium
Troponin
◦ Highly sensitive and specific test
◦ Not specific to plaque rupture
ACS defintion
MI defn
ACS – any constellation of clinical symptoms
that are compatible with acute myocardial
ischemia
range of conditions associated with sudden, reduced blood flow to the heart.
Myocardial Infarction – any amount of
myocardial necrosis caused by ischemia
NSTEMI
STEMI defn
NSTEMI – partial occlusion of infarct related artery resulting in necrosis
STEMI – total occlusion of infarct related artery resulting in necrosis
what might you see in biomarker if ST-segment elevation is absent (slide 9)
ST-segment elevation is absent is due to partially occluding thrombus
no increase in biomarker lvl = unstable angina (thrombosis mediated)
increased biomarker lvl = Non-stemi
what might you see in biomarker if ST-segment elevation is present (slide 9)
ST-segment elevation is present due to fullyoccluding thrombus
increased biomarker lvl = stemi
STEMI, NSTEMI, UA hospital discharge status
death 7% for STEMI (highest)
87% home for UA, 77% for STEMI, 78% NSTEMI
at 6 mo fu, death, stroke, rehospitalization is similar
describe the path from CV risk factors to death
CV risk factors - coronary atherosclerosis - ASx or Sx CHD - plaque rupture and coronary thrombosis
leads to ACS (MI, UA) which leads to death or arrhythmias
ACS can lead to ventricular dysfxna nd remodelling leading to congestive HF and ESHD
phases of care - STEMI (3)
prehospital: id, intiial tx
hospital: • Diagnosis • Treatment • +/- Revascularization
community: med management
goals for sTEMI and which phases of care they belong to
Rapid reperfusion to limit infarct size and
reduce mortality (prehospital)
◦ Prompt identification of STEMI
◦ Initiate reperfusion within recommended timeframe
◦ Maintain arterial patency (prehospital, hospital) being open, expanded, or unobstructed.
Prevent recurrent infarction
Limit adverse ventricular remodeling
Optimize long-term measures to reduce cardiovascular risk
factors increasing ambulance for stroke or HA
older age, distance to hospital, low neighbourbood income quintile, females
less likely: young, short distance, high income quintile, males
Reperfusion vs Revascularization
Reperfusion
◦ Restoration of blood flow within the infarct related
artery (in the setting of ACS
Infarction is tissue death (necrosis) due to inadequate blood supply to the affected area.
Revascularization
◦ Restoration of the blood flow to the heart when the
coronary arteries are blocked or narrowed by
atherosclerosis
reperfusion strategies (2)
Fibrinolysis
◦ prehospital vs. ER administration
(medical contact to treatment time)
◦ adjunctive therapy to maintain arterial patency
Invasive Strategy
◦ access to cardiac catheterization facilities
(medical contact to balloon time)
◦ adjunctive therapy to maintain arterial patency
pharmacotherapy for prehospital , hospital
what to se for coronary thrombus
supply-demand mismatch
Coronary thrombus
- ASA for antiplatelet effect
- P2Y12 inhibitor for antiplatelet effect
- Parenteral anticoagulant
Supply-demand mismatch
- Sublingual nitroglycerin for ischemia
- Intravenous nitroglycerin for persistent ischemia, heart failure or hypertension
primary PCI in hospital
A procedure advancing a balloon tipped
catheter to an area of coronary narrowing,
inflating the balloon and then removing the
catheter after inflation done to provide initial
reperfusion in the setting of STEMI
read on cardiac cath lab
nice to know
stents and jargon
DES
BMS
DES = drug eluting stent
- slowly releases a drug to block cell proliferation.
} BMS = bare metal stent
stent thrombosis
what is classified as acute vs subacute
Stent thrombosis = thrombotic occlusion of a coronary stent
◦ May result in ACS
Acute
◦ Within 24 hours
◦ Rare complication of procedure / stent deployment
Subacute
◦ Within 4 weeks for BMS
◦ Within ? weeks or months for DES
◦ Largely preventable with antiplatelet therapy
bare metal stent
what is recommended?
} Risk of subacute stent thrombosis
} Dual antiplatelet therapy for 1 month
minimum
in-stent restenosis (ISR)
} A gradual narrowing of the stent lumen due to neointimal proliferation
◦ Results in angina symptoms
} Principle cause of lack of long-term clinical success
} Not a complication – exaggerated response
to vascular injury
◦ Judged by frequency of subsequent revascularization procedures on target vessels after index procedure (TVR)
accumulation of smooth muscle cells and extra cellular matrix in the intima
in-stent restenosis (ISR)
} DES incorporate zotarolimus, everolimus, etc. with a timed release polymer
} Inhibit neointimal hyperplasia with a locally delivered antiproliferative and anti-inflammatory agent
} Delay in re-endothelialization lengthens period of risk for sub-acute stent thrombosis
} Risk of ‘late’ or delayed stent thrombosis
} Dual antiplatelet therapy for
at least 3 to 6 months - consensus
} Impact of newer technologies
drug-eluting stent
what are predictors of DES thrombosis
advanced age, ACS, diabetes
low ejection fraction, prior brachytherapy, renal failure
long stents, multiple lesions, overlapping stents, small vesels, subolptimal stent results
abs contra to fibrinolysis
} Prior intracranial hemorrhage } History of structural CNS disease } Ischemic stroke within 6 months } Suspected aortic dissection } Active bleeding or bleeding diathesis } Significant closed head or facial trauma within 3 months } Major surgery within last 3 weeks } Internal bleeding within past 30 days
relative contra to fibrinolysis
} Hx of chronic, severe, poorly controlled HTN } SBP>180 or DBP>110 at presentation } TIA within 6 months } CPR of duration greater than 10 minutes } Pregnancy } Active peptic ulcer disease } Oral anticoagulant therapy } Advanced liver disease } Infective endocarditis
PCI can be performed in which settings?
the setting of ACS
◦ Primary PCI for STEMI
◦ Rescue PCI within 12 hours for failure of fibrinolytic
◦ Urgent PCI within 24 hours
OR as an elective procedure for stable angina
Duration of antiplatelet therapy is based upon
◦ the type of stent
◦ Whether or not the procedure is associated with an
acute coronary syndrome
