Acute Coronary Syndrome [Unstable angina, NSTEMI, STEMI: Dx, algorithms of treatment]; Myocarditis and Rheumatic fever

Question 1

How is Acute Coronary Syndrome broadly classified?

Answer 1

Non-ST elevation Acute Coronary Syndrome:
- NSTEMI [Troponin activity]
- Unstable Angina [no Troponin activity]

ST-elevation Acute Coronary Syndrome:
- STEMI

Question 2

Presenting symptoms that suggest ACS

Answer 2

• Acute Retrosternal pain [dull, squeezing, pressure, tightness that often radiates]
• Dyspnea
• Diaphoresis
• Dizziness, Lightheadedness, Syncope
• Pallor
• Nausea, Vomiting
• Tachycardia, Arrhythmias
• Epigastric pain
• Bradycardia
• Hypotension, Elevated Jugular venous pressure, clear lung fields

A combination of these findings, but most importantly, has an acute presentation that prompts patients to seek medical attention, is highly suggestive of ACS and must be evaluated through immediate management guidelines

Question 3

Immediate Management strategy for any patient presenting with suggestive ACS symptoms

Answer 3

• Focused Clinical Eval and ABCDE survey
• 12-lead ECG within 10 mins of patient arrival
• Establish IV access and obtain blood samples for labs and Troponin levels
• Continuous Telemetry and Pulse Oxymeter
• Supplementary O2 for hypoxemia presentation and respiratory distress
• Aspirin if no contraindication present
• Sublingual Nitroglycerin for chest pain relief
• Manage Tachyarrhythmias, Acute HF, Cardiogenic shock, Complete Heart block

Question 4

Dx and Treatment strategy for STEMI

Answer 4

Dx findings for STEMI:
- ST-Elevations in 2 contiguous leads
- STEMI equivalents like NEW LBBB or RBBB

Treatment Strategy for STEMI indication:
More than 120 mins nearest PCI-capable Facility:
- NO active bleeding or Coagulopathy = Fibrinolysis
- Aspiring + Clopidogrel + Anticoagulant
- Direct transfer to PCI-capable facility
- Supportive therapies [Supplemental O2, Nitroglycerin, Analgesia with morphine, High-intensity Statins, Beta blockers or ACE inhibitors if necessary]

Less than 120 mins nearest PCI-capable Facility:
- DO NOT delay Revascularization for any treatments
- Aspirin + ADP receptor blocker + Anticoagulant [until PCI can be done]
- Supportive therapies until PCI can be done

The ultimate treatment for STEMI is Revascularization and the time it takes between STEMI appearance to Revascularization is critical

First Medical Contact to PCI should ideally be less than/equal to 90 mins and it SHOULD NOT exceed 120 mins

Question 5

Dx strategy for NSTEMI and UA

Answer 5

• Serial ECG and Troponin assessment [to catch ST changes, T wave changes, new BBB or Heart blocks, tachyarrhythmias]
• If patient is hemodynamically unstable, has V.fib/ sustained V.tach, has refractory angina, has acute HF, has new valvular complications, or new LBBB/RBBB - REVASCULARIZATION without delay [< 2 hrs]
• If patient is none of the above, calculate GRACE and TIMI scores to help stratify patients and guide treatment

Question 6

Treatment Strategy for NSTEMI and UA

Answer 6

• Start Antiplatelet and Anticoagulation therapy
• Administer Supportive ACS therapy
• Order continuous Telemetry, serial ECG, and serum Troponins every 3-6 hours

Question 7

What is Myocarditis?

Answer 7

Inflammatory disease of the myocardium, most often affecting young people [~ 40 years old patients] which is ~10% causative agent for sudden death

Question 8

Clinical Features of Myocarditis

Answer 8

The range of symptoms include asymptomatic to acute presentations to chronic inflammatory states

The following symptoms [usually combination] should suggest Myocarditis:
- Chest pain
- Arrhythmias [Sinus tachycardia, Ventricular extrasystole, Heart blocks and Bradyarrhythmias]
- New onset Heart failure [acute decompensated stage]
- Cardiogenic shock
- Flulike symptoms 1-2 weeks prior to myocarditis event

Question 9

Viral, Bacterial, Fungal, Parasitic, Non-infectious

Etiology of Myocarditis

Answer 9

Viral:
- Parvovirus B19
- Coxsackie A, B
- HHV-6
- HCV
- HIV

Bacterial:
- Group A beta hemolytic Strep
- C. diphtheria
- B. burgdorferi
- Mycoplasma pneumonia
- TB

Fungal:
- Candida
- Aspergillus

Parasitic:
- Toxoplasma
- Trypanosoma
- Echinococcus

Non-infectious:
- Connective Tissue diseases [SLE, Sarcoidosis, Polymiositis]
- Vasculitidis [kawasaki disease, etc]
- CO poisoning
- Chemo drugs
- Alcohol and drug abuse
- Radiation therapy

Question 10

Dx of Myocarditis

Answer 10

Suspect Myocarditis in any patient presenting with:
- Chest pain, arrhythmias, new onset heart failure
- Young age
- No ASCVD risk
- Recent potential trigger [like URI, acute pericarditis]

Obtain the following for suspection of Myocarditis:
- 12-lead ECG
- Lab studies that include CK, CK-MB, Troponin I/T, BNP, NT-proBNP, ESR, CRP, CBC, Blood cultures for fever, HIV test, Hepatitis panel, ANA, tox screens
- Transthoracic Echocardiography [Findings include, wall motion abnormality regional or global, Reduced EF, Ventricular dilations, Increased wall thickness, Pericardial effusion]
- Endomyocardial Biopsy [considered GOLD standard test to determine etiology of Myocarditis]

Question 11

Stable patient vs Unstable patient

Treatment approach for Myocarditis

Answer 11

There is no strong evidence for treating myocarditis with underlying cause treatment

If patient is stable:
- Pain management [reserve NSAIDS for pericarditis and preserved LVEF functions]
- Acute HF management
- Management of Arrhythmias

If patient is unstable aka Fulminant Myocarditis:
- ABCDE survey
- Cardiogenic shock management
- End-organ damage marker tests [Lactate, ABG/VBG, LFTs, BMP]
- Consider consultation for heart transplant

Question 12

What is Rheumatic Fever?

Answer 12

It is a delay inflammatory complication of Group A Streptococcus pharyngitis infection usually occuring 2-4 weeks AFTER acute infection starts

Rheumatic Heart Disease refers both, Acute Pancarditis as a sequelae for GrpA Step pharyngitis and Chronic cardiac valvular changes [post acute rheumatic fever]

Question 13

JONES

Clinical Features of Rheumatic Fever

Answer 13

• Constitutional symptoms [fever, malaise, chills]
• Joint involvement [migratory polyarthritis]
• Heart involvement [Pancarditis, Valvular lesion, Dilated Cardiomyopathy due to severe valve lesions, Myocarditis]
• CNS involvement [Sydenham chorea]
• Skin Involvement [Subcutaneous nodules, Erythema marginatum]

Question 14

Dx approach for Rheumatic Fever

Answer 14

• Throat culture for GAS pharyngitis preceding current symptoms [antigen or antibody testing]
• Revised JONES criteria to evaluate for Rheumatic Fever
• Routine Labs [CBC, CRP, ESR]
• GAS confirmation via Antistreptolysin O Titre [ASO] and Antistreptococcal DNAse B Titre [ADB]
• Assessment for Cardiac involvement [ECG - Second degree AV block, Complete Heart block, Sinus tachy, Accelerated junctional rhythm, pericarditis signs | Echocardiography - Mitral and Aortic regurgitations, Mitral stenosis | CXR - enlarged LA, LV, Pulmonary edema findings]

Question 15

Treatment for Rheumatic Fever

Answer 15

GAS Eradication:
- Penicillin V
- Cephalosporins OR Macrolides [if Penicillin allergy present]

Symptomatic Treatment:
- NSAIDS [Aspirin, Naproxen]
- Glucocorticoids [Prednisone]