10/22/16. Lay of the land. Definition of ACS. Why do we worry about ST elevations?
|
|
- Alisha Welch
- 5 years ago
- Views:
Transcription
1 Lay of the land Update on Acute Coronary Syndrome: Five Things Hospitalists Must Know Dhruv S. Kazi, MD, MSc, MS Assistant Professor Department of Medicine (Cardiology), Department of Epidemiology and Biostatistics, Center for Vulnerable Populations, and Center for Health Care Value University of California San Francisco Division of Cardiology Zuckerberg San Francisco General Hospital Case studies with an emphasis on discussions Focus on five key take-home points Grounded in evidence, not acronyms Conflicts of Interest: None Definition of ACS Spectrum of clinical conditions that produce acute myocardial ischemia and/or infarction, usually due to an abrupt reduction in coronary blood flow. Asymptomatic coronary dz à Stable angina à Unstable angina à NSTEMI à STEMI Why do we worry about ST elevations? We used to define MIs by Q waves: but those are fickle (early/transient, transient) EKG criteria: ST elevations of 1mm in 2 contiguous leads or 2 mm in V2-V3. ST elevation is a powerful predictor of occlusion or highgrade stenosis of epicardial coronary artery, determines management (early reperfusion), and is a marker of a higher in-hospital mortality 1
2 Case 1: Presenting EKG: A 62 year old woman with diabetes and hypertension presents with nausea, vomiting, 4/10 substernal discomfort, and 6/10 abdominal pain. In the ED, she is noted to be afebrile with a heart rate in the 90s, BP 155/95. Audience Response 62yo woman with DM, HTN presenting with substernal discomfort, nausea, vomiting, and abdominal pain, with LBBB on initial EKG. What do you do next? a. Don t know if the LBBB is new, contact primary care doc for an old EKG b. LBBB makes the initial EKG uninterpretable, repeat EKGs every 10 minutes c. Request a stat echocardiogram for wall motion abnormalities d. Send off stat cardiac troponins, drill deeper into the history and clinical presentation e. LBBB is a STEMI-equivalent, activate the cath lab 2
3 Anatomy of the conducting system Right bundle is a discrete structure that is subendocardial for the proximal and distal thirds of its course (Cue: fragile) Left bundle is a fan-like structure that quickly divides into the anterior and posterior fascicles (Cue: relatively resilient) So why fret over LBBB? 7% of patients who present with an acute MI have a LBBB on the presenting EKG Almost half these patients did not have concomitant CP Abnormal depolarization leads to abnormal repolarization, so ST-T changes not interpretable. Produces delays in diagnosis and initiation of evidencebased therapies, and therefore adversely affects outcomes. 3
4 Caveat emptor: Patients with old LBBB can occlude a coronary, we just wouldn t see it on the EKG Patients can have a new LBBB from causes other than ischemia LBBB is not a STEMI equivalent it simply makes a STEMI more challenging to diagnose. What do you do next? a. Don t know if the LBBB is new, call around for an old EKG b. LBBB makes the initial EKG uninterpretable, repeat EKGs every 10 minutes c. Request a stat echocardiogram for wall motion abnormalities d. Send off stat cardiac troponins, drill deeper into the history and clinical presentation e. LBBB is a STEMI-equivalent, activate the cath lab Take-Home Point #1 What do you do next? a. Don t know if the LBBB is new, call around for an old EKG b. LBBB makes the initial EKG uninterpretable, repeat EKGs every 10 minutes c. Request a stat echocardiogram for wall motion abnormalities d. Send off stat cardiac troponins, drill deeper into the history and clinical presentation e. LBBB is a STEMI-equivalent, activate the cath lab The primary challenge with LBBB in the setting of acute chest pain is that it may mask an ongoing MI. In the setting of LBBB, the diagnosis of ACS comes down to a good clinical story. But even when ACS is established, cannot distinguish between an NSTEMI and a STEMI à hence the cath lab. 4
5 Case 2: 68 yo man with obesity, hypertension, and diabetes, 30 pack-year smoking history was driving home from work when he had a head-on collision with a truck operated by a drunk teenager. In the ED, he was in pain but hemodynamically stable, and noted to have multiple, displaced fractures of the pelvis and both lower extremities. On hospital day 4, he notes shortness of breath and new 7/10 substernal chest pain. He is tachycardic 120s, normotensive, sating 94% on 2L nc. EKG showed sinus tachycardia and non-specific ST-T changes. Audience Response What would you NOT do next? a. Obtain serial EKGs b. Send off cardiac troponins c. Request an echocardiogram d. Obtain a CT chest with contrast e. Activate the cath lab 5
6 Suspicion for ACS but initial EKG nonspecific: Look carefully for ST elevations: Serial EKGs every 5-10 minutes right-sided or posterior leads Right-sided infarct Infarct of the RIGHT ventricle Complicates inferior MI or isolated event Obtain a right-sided EKG Look for ST elevations in V4R Echo may help Posterior infarct infarct the LEFT ventricle Complicates inferior MI or isolated event Obtain a posterior EKG Look for ST elevations in V7-9 Echo may help Bottom line: Suspicion for ACS, evaluation must include Right-sided + Posterior EKGs. Detectable Tropoinin = Death of Myocytes Cath lab? Ischemia-mediated myocardial injury: Decreased supply due to coronary disease: Plaque rupture, coronary vasospasm, dissection, vasculitis, embolic disease, cocaine/meth use Decreased supply due to non-coronary conditions: shock, hypoxia, pulmonary embolism Increased demand: tachycardia or severe hypertension, cocaine/meth use Direct myocardial injury: Myocarditis, chest trauma, toxic meds, electrical shock, CO exposure, heart failure, malignancy Myocardial injury from other systemic conditions: Sepsis, stress-cardiomyopathy, infiltrative diseases, stroke, subarachnoid hemorrhage, acute respiratory failure. Patients presenting with a NSTEMI may still benefit from an early invasive therapy if there are high-risk features: Ongoing pain despite antiplatelet + anticoagulation Electrical or hemodynamic instability Heart failure Note that contemporary data suggest patients with NSTEMI and those presenting with a STEMI have similar one-year mortality. 6
7 What would you NOT do next? a. Obtain serial EKGs b. Send off cardiac troponins c. Request an echocardiogram d. Obtain a CT chest with contrast e. Activate the cath lab What would you NOT do next? a. Obtain serial EKGs b. Send off cardiac troponins c. Request an echocardiogram d. Obtain a CT chest with contrast e. Activate the cath lab Take-home point #2 Ask yourself: Would this person benefit from early reperfusion? ST elevations? LBBB? à Think it through Neither? Obtain serial EKGs Obtain right-sided and posterior-ekgs Are there high-risk features? Consider alternative explanations for an elevated troponin level Take-home point #3 Even if it s just a NSTE-ACS, many patients benefit from an early-invasive approach Evidence of ongoing injury (e.g., unrelenting pain) Electrical or hemodynamic instability Heart failure 7
8 Case 3: 63 yo man with diabetes and ongoing 1pack per day cigarette use presents with chest pain that woke him up from his sleep at 6am. In the emergency room, he is hemodynamically stable and chest pain free. Presenting EKG shows 2mm ST depressions in II, III, avf, with no ST elevations in right-sided or posterior leads. Troponin I is 0.2 ng/dl (reference value < 0.04). A diagnosis of NSTEMI is made. Aspirin, statin, heparin, and metoprolol are initiated. The next day, coronary angiography reveals a 60% lesion of the mid-rca and 50% lesion of the left anterior descending. LV systolic function is normal on the transthoracic echocardiogram. A decision is made to medically manage the coronary disease with aspirin, statin, an ACE-inhibitor, and a betablocker. Would our patient with an NSTEMI benefit from a second antiplatelet agent, even though he did not undergo PCI? a. No, patients who present with an NSTEMI but do not undergo a PCI were not included in trials of dual antiplatelet therapy, and bleeding risk exceeds any potential benefit b. Yes, I would start clopidogrel for six months because it is the only agent studied in this context c. Yes, I would pick prasugrel for nine months because it is a more potent antiplatelet agent that is not affected by CYP2C19 polymorphisms d. Yes, I would pick ticagrelor and use it for at least one year. Audience Response Does a patient who presents with an NSTEMI but does not undergo PCI still benefit from dual antiplatelet therapy? Yes, this has been VERY WELL studied in randomized trials and observational data One year of DAPT after medically managed NSTEMI Remains an enormous evidence-practice gap in ACS management. 8
9 All these categories of patients benefit from dual antiplatelet therapy: STEMI, s/p PCI STEMI, s/p fibrinolytics STEMI, unrevascularized NSTEMI, s/p PCI NSTEMI, medical management Unstable angina Stable angina s/p PCI Dual Antiplatelet Therapy for NSTEMI: The devil is in the details Clopidogrel Most well studied Inexpensive ($10 per month) Pro-drug, carriers of some polymorphisms of CYP2C19 may not achieve adequate platelet inhibition. Kazi, el al. Annals of Internal Medicine, 2014 Dual Antiplatelet Therapy for NSTEMI: Prasugrel Potent antiplatelet agent, once a day dosing Expensive ($400 per month) Only indicated for ACS patients who have undergone PCI Contraindicated in patients with a history of stroke or TIA Ticagrelor Potent, reversible, twice a day Expensive ($350 a month) Indicated for ACS patients, regardless of PCI Ticagrelor-related dyspnea: usually self-limited Would our (NSTEMI) patient benefit from a second antiplatelet agent, even though he did not undergo PCI? a. No, patients who present with an NSTEMI but do not undergo a PCI were not included in the dual antiplatelet therapy studies, and bleeding risk likely exceeds any potential benefit b. Yes, I would start clopidogrel for six months because it is the only agent studied in this context c. Yes, I would pick prasugrel for nine months because it is a more potent antiplatelet agent that is not affected by CYP2C19 polymorphisms d. Yes, I would pick ticagrelor and use it for at least one year. 9
10 Take-Home Point #4: Would our (NSTEMI) patient benefit from a second antiplatelet agent, even though he did not undergo PCI? a. No, patients who present with an NSTEMI but do not undergo a PCI were not included in the dual antiplatelet therapy studies, and bleeding risk likely exceeds any potential benefit b. Yes, I would start clopidogrel for six months because it is the only agent studied in this context c. Yes, I would pick prasugrel for nine months because it is a more potent antiplatelet agent that is not affected by CYP2C19 polymorphisms d. Yes, I would pick ticagrelor and use it for at least one year. Patients with medically managed NSTE-ACS still benefit from one year of dual antiplatelet therapy. Individualize the decision: choose clopidogrel when cost or adherence are important considerations and ticagrelor otherwise. Prasugrel is not approved in this setting (NSTE-ACS without PCI). : Audience Response Which of the following statements is NOT true: a. CKD is common among patients presenting with ACS b. Patients with CKD are more likely to present with atypical complaints with ACS, resulting in diagnostic delays c. Cardiac troponins are useful in diagnosing ACS in patients with CKD d. CKD is associated with increased cardiovascular and all-cause mortality after ACS e. PCI and CABG are clinically equivalent in CKD patients with multivessel coronary disease 10
11 Cardiac troponins in CKD CKD is common among patients presenting with ACS Patients with CKD are more likely to present with atypical complaints with ACS, resulting in diagnostic delays. Typically, we use 99 th percentile of the troponin levels in the general population as the cut-off for diagnosing ACS But CKD patients may have higher baseline levels (more so for Troponin T than Troponin I) This compromises accuracy of a single lab value high sensitivity but lower specificity But serial labs still helpful, with a 20% change (increase or decrease) consistent with recent myocardial injury. CKD and multivessel disease : PCI increased risk of in-stent restenosis and need for repeat revascularization CABG increased risk of periop complications On balance, patients with CKD and multivessel disease appear to have better clinical outcomes with CABG than PCI, with at least two large observational studies showing lower all-cause mortality in community-dwelling populations of CKD. Which of the following statements is NOT true: a. CKD is common among patients presenting with ACS b. Patients with CKD are more likely to present with atypical complaints with ACS, resulting in diagnostic delays c. Cardiac troponins are useful in diagnosing ACS in patients with CKD d. CKD is associated with increased cardiovascular and all-cause mortality after ACS e. PCI and CABG are clinically equivalent in CKD patients with multivessel coronary disease 11
12 Take-Home Point #5 CKD is a high-risk marker among patients presenting with ACS. Troponins are still useful in diagnosis if serial values are used. Patients with multivessel coronary disease likely have better outcomes with CABG than with PCI. Summary: 1. LBBB may mask a STEMI, so diagnosis of ACS must rely on the clinical story. 2. Before diagnosing a NSTEMI, exclude right-sided or posterior ST elevations, and rule out non-acs causes of elevated troponin levels. 3. Patients with an NSTEMI and ongoing pain, or hemodynamic or electrical instability may benefit from urgent coronary angiography 4. Medically managed patients with NSTEMI should receive one year of dual antiplatelet therapy: clopidogrel when cost, adherence are concerns, else ticagrelor. 5. CKD is a high-risk marker among patients with ACS. Optimize medical therapy, and consider surgical revascularization for multi-vessel disease. Off hand, I d say you re suffering from an arrow through your head, but just to play it safe, let s get an angiogram. Thank you! 12
What oral antiplatelet therapy would you choose? a) ASA alone b) ASA + Clopidogrel c) ASA + Prasugrel d) ASA + Ticagrelor
76 year old female Prior Hypertension, Hyperlipidemia, Smoking On Hydrochlorothiazide, Atorvastatin New onset chest discomfort; 2 episodes in past 24 hours Heart rate 122/min; BP 170/92 mm Hg, Killip Class
More informationNon ST Elevation-ACS. Michael W. Cammarata, MD
Non ST Elevation-ACS Michael W. Cammarata, MD Case Presentation 65 year old man PMH: CAD s/p stent in 2008 HTN HLD Presents with chest pressure, substernally and radiating to the left arm and jaw, similar
More informationAcute Myocardial Infarction
Acute Myocardial Infarction Hafeza Shaikh, DO, FACC, RPVI Lourdes Cardiology Services Asst.Program Director, Cardiology Fellowship Associate Professor, ROWAN-SOM Acute Myocardial Infarction Definition:
More informationMedical Management of Acute Coronary Syndrome: The roles of a noncardiologist. Norbert Lingling D. Uy, MD Professor of Medicine UERMMMCI
Medical Management of Acute Coronary Syndrome: The roles of a noncardiologist physician Norbert Lingling D. Uy, MD Professor of Medicine UERMMMCI Outcome objectives of the discussion: At the end of the
More informationOVERVIEW ACUTE CORONARY SYNDROME SYMPTOMS 9/30/14 TYPICAL WHAT IS ACUTE CORONARY SYNDROME? SYMPTOMS, IDENTIFICATION, MANAGEMENT
OVERVIEW ACUTE CORONARY SYNDROME SYMPTOMS, IDENTIFICATION, MANAGEMENT OCTOBER 7, 2014 PETE PERAUD, MD SYMPTOMS TYPICAL ATYPICAL IDENTIFICATION EKG CARDIAC BIOMARKERS STEMI VS NON-STEMI VS USA MANAGEMENT
More informationUPDATE ON THE MANAGEMENTACUTE CORONARY SYNDROME. DR JULES KABAHIZI, Psc (Rwa) Lt Col CHIEF CONSULTANT RMH/KFH 28 JUNE18
UPDATE ON THE MANAGEMENTACUTE CORONARY SYNDROME DR JULES KABAHIZI, Psc (Rwa) Lt Col CHIEF CONSULTANT RMH/KFH 28 JUNE18 INTRODUCTION The clinical entities that comprise acute coronary syndromes (ACS)-ST-segment
More informationLearning Objectives. Epidemiology of Acute Coronary Syndrome
Cardiovascular Update: Antiplatelet therapy in acute coronary syndromes PHILLIP WEEKS, PHARM.D., BCPS-AQ CARDIOLOGY Learning Objectives Interpret guidelines as they relate to constructing an antiplatelet
More informationAcute Myocardial Infarction. Willis E. Godin D.O., FACC
Acute Myocardial Infarction Willis E. Godin D.O., FACC Acute Myocardial Infarction Definition: Decreased delivery of oxygen and nutrients to the myocardium Myocardial tissue necrosis causing irreparable
More informationAcute Coronary Syndrome. Cindy Baker, MD FACC Director Peripheral Vascular Interventions Division of Cardiovascular Medicine
Acute Coronary Syndrome Cindy Baker, MD FACC Director Peripheral Vascular Interventions Division of Cardiovascular Medicine Topics Timing is everything So many drugs to choose from What s a MINOCA? 2 Acute
More informationMyocardial Infarction. Reading Assignment (p66-78 in Outline )
Myocardial Infarction Reading Assignment (p66-78 in Outline ) Objectives 1. Why do ST segments go up or down in ischemia? 2. STEMI locations and culprit vessels 3. Why 15-lead ECGs? 4. What s up with avr?
More informationCABG Surgery following STEMI
CABG Surgery following STEMI Susana Harrington, MS,APRN-NP Cardio-Thoracic Surgery Nebraska Methodist Hospital February 15, 2018 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction:
More informationSTEMI, Non-STEMI, Chest Pain?
Minnesota Chest Pain / Acute Coronary Syndrome Tool-Kit Patient with Chest Pain Or Potential Acute Coronary Syndrome STEMI, n-stemi, Chest Pain? Follow MN STEMI Guideline Follow MN n-stemi Guideline Follow
More informationCardiovascular Disorders Lecture 3 Coronar Artery Diseases
Cardiovascular Disorders Lecture 3 Coronar Artery Diseases By Prof. El Sayed Abdel Fattah Eid Lecturer of Internal Medicine Delta University Coronary Heart Diseases It is the leading cause of death in
More informationChoosing the Appropriate Stress Test: Brett C. Stoll, MD, FACC February 24, 2018
Choosing the Appropriate Stress Test: Brett C. Stoll, MD, FACC February 24, 2018 Choosing the Appropriate Stress Test: Does it Really Matter? Brett C. Stoll, MD, FACC February 24, 2018 Conflicts of Interest
More informationAcute Coronary Syndromes
Overview Acute Coronary Syndromes Rabeea Aboufakher, MD, FACC, FSCAI Section Chief of Cardiology Altru Health System Grand Forks, ND Epidemiology Pathophysiology Clinical features and diagnosis STEMI management
More information2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction
2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction Developed in Collaboration with American College of Emergency Physicians and Society for Cardiovascular Angiography and
More informationECG Workshop. Nezar Amir
ECG Workshop Nezar Amir Myocardial Ischemia ECG Infarct ECG in STEMI is dynamic & evolving Common causes of ST shift Infarct Localisation Left main artery occlusion: o diffuse ST-depression with ST elevation
More informationChest pain and troponins on the acute take. J N Townend Queen Elizabeth Hospital Birmingham
Chest pain and troponins on the acute take J N Townend Queen Elizabeth Hospital Birmingham 3 rd Universal Definition of Myocardial Infarction Type 1: Spontaneous MI related to atherosclerotic plaque rupture
More informationSTEMI ST Elevation Myocardial Infarction
STEMI ST Elevation Myocardial Infarction Breakout Session One Moderators: Quinn Capers IV, MD and Scott M. Lilly, MD, PhD Cases Presented by: Umair S. Ahmad, MD 1 Outline 1. Multivessel Revascularization
More informationSTEMI update. Vijay Krishnamoorthy M.D. Interventional Cardiology
STEMI update Vijay Krishnamoorthy M.D. Interventional Cardiology OVERVIEW Current Standard of Care in Management of STEMI Update in management of STEMI Pre-Cath Lab In the ED/Office/EMS. Cath Lab Post
More informationWhat is a myocardial infarction and how do we treat it? Paul Das Consultant Cardiologist North Wales Cardiac Centre Glan Clwyd Hospital
What is a myocardial infarction and how do we treat it? Paul Das Consultant Cardiologist North Wales Cardiac Centre Glan Clwyd Hospital What is a myocardial infarction? THEY AINT WHAT THEY USED TO BE Case
More informationIndications of Coronary Angiography Dr. Shaheer K. George, M.D Faculty of Medicine, Mansoura University 2014
Indications of Coronary Angiography Dr. Shaheer K. George, M.D Faculty of Medicine, Mansoura University 2014 Indications for cardiac catheterization Before a decision to perform an invasive procedure such
More informationCindy Stephens, MSN, ANP Kelly Walker, MS, ACNP Peter Cohn, MD, FACC
Cindy Stephens, MSN, ANP Kelly Walker, MS, ACNP Peter Cohn, MD, FACC Define Acute Coronary syndromes Explain the Cause Assessment, diagnosis and therapy Reperfusion for STEMI Complications to look for
More information2010 ACLS Guidelines. Primary goals of therapy for patients
2010 ACLS Guidelines Part 10: Acute Coronary Syndrome Present : 內科 R1 鍾伯欣 Supervisor: F1 吳亮廷 991110 Primary goals of therapy for patients of ACS Reduce the amount of myocardial necrosis that occurs in
More informationBelinda Green, Cardiologist, SDHB, 2016
Acute Coronary syndromes All STEMI ALL Non STEMI Unstable angina Belinda Green, Cardiologist, SDHB, 2016 Thrombus in proximal LAD Underlying pathophysiology Be very afraid for your patient Wellens
More informationQuinn Capers, IV, MD
Heart Attacks Mended Hearts Presentation, January, 2017 Quinn Capers, IV, MD Associate Professor of Medicine (Cardiovascular Medicine) Director, Transradial Coronary Interventions Division of Cardiovascular
More information2017 AHA/ACC Clinical Performance and Quality Measures for Adults With ST-Elevation and Non ST-Elevation Myocardial Infarction
2017 AHA/ACC Clinical Performance and Quality Measures for Adults With ST-Elevation and Non ST-Elevation Myocardial Infarction Ramzi Khalil MD FACC Assistant Professor Allegheny Gen.Hospital AHN Speakers
More informationAcute heart failure in a patient with lower urinary tract infection Case report of an infection-induced Reverse Takotsubo syndrome
Acute heart failure in a patient with lower urinary tract infection Case report of an infection-induced Reverse Takotsubo syndrome N.Μoschos, A.Dimitra, E.Tsakiri, D.Stavrianakis, A.Nouli CARDIOLOGY DEPARTMENT
More informationPERIOPERATIVE MYOCARDIAL INFARCTION THE ANAESTHESIOLOGIST'S VIEW
PERIOPERATIVE MYOCARDIAL INFARCTION THE ANAESTHESIOLOGIST'S VIEW Bruce Biccard Perioperative Research Group, Department of Anaesthetics 18 June 2015 Disclosure Research funding received Medical Research
More informationEssam Mahfouz, MD. Professor of Cardiology, Mansoura University
By Essam Mahfouz, MD. Professor of Cardiology, Mansoura University Agenda Definitions Classifications Epidemiology Risk stratification What is new? What is MI? Myocardial infarction is the death of part
More informationAcute Coronary Syndrome. Emergency Department Updated Jan. 2017
Acute Coronary Syndrome Emergency Department Updated Jan. 2017 Goals and Objectives To reduce mortality and morbidity for people who have cardiovascular disease, with a focus on those who experience an
More informationThe use of Cardiac CT and MRI in Clinical Practice
The use of Cardiac CT and MRI in Clinical Practice Matthew W. Martinez, MD Assistant Professor of Medicine LVPG - Lehigh Valley Heart Specialists Lehigh Valley Health Network Oct. 3, 2009 DISCLOSURE Relevant
More informationAngina Luis Tulloch, MD 03/27/2012
Angina Luis Tulloch, MD 03/27/2012 Acute coronary syndromes ACS STE > 1 mm, new LBBB* Increased cardiac enzymes STEMI Yes Yes NSTEMI No Yes UA No No *Recognize Wellen s sign/syndrome, posterior wall MI,
More informationTiming of Surgery After Percutaneous Coronary Intervention
Timing of Surgery After Percutaneous Coronary Intervention Deepak Talreja, MD, FACC Bayview/EVMS/Sentara Outline/Highlights Timing of elective surgery What to do with medications Stopping anti-platelet
More informationAcute Coronary syndrome
Acute Coronary syndrome 7th Annual Pharmacotherapy Conference ACS Pathophysiology rupture or erosion of a vulnerable, lipidladen, atherosclerotic coronary plaque, resulting in exposure of circulating blood
More informationSTEMI Presentation and Case Discussion. Case #1
STEMI Presentation and Case Discussion Scott M Lilly MD PhD, Interventional Cardiology The Ohio State University Contemporary Multidisciplinary Cardiovascular Conference Orlando, Florida September 17 th,
More informationPreoperative Cardiac Risk Assessment: Approach & Guidelines
Preoperative Cardiac Risk Assessment: Approach & Guidelines By, Liam Morris, MD., FACC (02/03/18) CPG : Clinical Practice Guidelines GDMT : Guidelines Directed Medical Therapy GWC : Guideline Writing Committee
More informationManagement of Stable Ischemic Heart Disease. Vinay Madan MD February 10, 2018
Management of Stable Ischemic Heart Disease Vinay Madan MD February 10, 2018 1 Disclosure No financial disclosure. 2 Overview of SIHD Diagnosis Outline of talk Functional vs. Anatomic assessment Management
More informationContinuing Medical Education Post-Test
Continuing Medical Education Post-Test Based on the information presented in this monograph, please choose one correct response for each of the following questions or statements. Record your answers on
More information2/26/2013. Appropriateness Use Criteria (Drilldown) Disclosures. Tony Hermann has nothing to disclose. Mark Hutcheson has nothing to disclose
Appropriateness Use Criteria (Drilldown) Disclosures Tony Hermann has nothing to disclose Mark Hutcheson has nothing to disclose Connie Anderson has nothing to disclose Issam Moussa has nothing to disclose
More informationAcute coronary syndromes
Acute coronary syndromes 1 Acute coronary syndromes Acute coronary syndromes results primarily from diminished myocardial blood flow secondary to an occlusive or partially occlusive coronary artery thrombus.
More informationDavid A. Orsinelli, MD, FACC, FASE Professor, Internal Medicine The Ohio State University Division of Cardiovascular Medicine Columbus, Ohio
1 STABLE ISCHEMIC HEART DISEASE: A NON-INVASIVE CARDIOLOGIST S PERSECTIVE 2018 Cardiovascular Course for Trainees and Early Career Physicians APRIL 20, 2018 David A. Orsinelli, MD, FACC, FASE Professor,
More informationACUTE CORONARY SYNDROME
12 LEAD ECG INTERPRETATION in ACUTE CORONARY SYNDROME WAYNE W RUPPERT, CVT, CCCC, NREMT-P Cardiovascular Clinical Coordinator Bayfront Health Seven Rivers Crystal River, FL Education Specialist St. Joseph
More informationDual Antiplatelet Therapy Made Practical
Dual Antiplatelet Therapy Made Practical David Parra, Pharm.D., FCCP, BCPS Clinical Pharmacy Program Manager in Cardiology/Anticoagulation VISN 8 Pharmacy Benefits Management Clinical Associate Professor
More informationDIFFERENTIATING THE PATIENT WITH UNDIFFERENTIATED CHEST PAIN
DIFFERENTIATING THE PATIENT WITH UNDIFFERENTIATED CHEST PAIN Objectives Gain competence in evaluating chest pain Recognize features of moderate risk unstable angina Review initial management of UA and
More informationAcute Coronary Syndrome. Sonny Achtchi, DO
Acute Coronary Syndrome Sonny Achtchi, DO Objectives Understand evidence based and practice based treatments for stabilization and initial management of ACS Become familiar with ACS risk stratification
More information12 Lead ECGs: Ischemia, Injury & Infarction. Kevin Handke NRP, FP-C, CCP, CMTE STEMI Coordinator Flight Paramedic
12 Lead ECGs: Ischemia, Injury & Infarction Kevin Handke NRP, FP-C, CCP, CMTE STEMI Coordinator Flight Paramedic None Disclosures Objectives Upon completion of this program the learner will be able to
More informationObjectives. Identify early signs and symptoms of Acute Coronary Syndrome Initiate proper protocol for ACS patient 10/2013 2
10/2013 1 Objectives Identify early signs and symptoms of Acute Coronary Syndrome Initiate proper protocol for ACS patient 10/2013 2 Purpose of this Education Module: Chest Pain Center Accreditation involves
More informationAcute Coronary Syndrome (ACS) Initial Evaluation and Management
Acute Coronary Syndrome (ACS) Initial Evaluation and Management Symptoms of Possible ACS Chest discomfort with or without radiation to the arm(s), jaw, or epigastrium Short of breath Weakness Diaphoresis
More informationRichard Grocott Mason
Richard Grocott Mason What to do with a 50 year old man with chest pain? Does the pain sound cardiac? Is this a possible acute coronary syndrome? Does patient have a previous cardiac history? Natural history
More informationEmergency surgery in acute coronary syndrome
Emergency surgery in acute coronary syndrome Teerawoot Jantarawan Division of Cardiothoracic Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
More informationTests I Wish You Had Not Ordered. Scott Girard D.O. FACOI Hospitalist
Tests I Wish You Had Not Ordered Scott Girard D.O. FACOI Hospitalist Disclosures None No company or person has decided to pay me to be here, give this talk, or want me to represent them in any way. Who
More information12 Lead EKG Chapter 4 Worksheet
Match the following using the word bank. 1. A form of arteriosclerosis in which the thickening and hardening of the vessels walls are caused by an accumulation of fatty deposits in the innermost lining
More informationIschemic heart disease
Ischemic heart disease Introduction In > 90% of cases: the cause is: reduced coronary blood flow secondary to: obstructive atherosclerotic vascular disease so most of the time it is called: coronary artery
More informationGoals: Widen Your Understanding of the Wide QRS!
Goals: Widen Your Understanding of the Wide QRS! 1. Describe an approach to diagnosis of LBBB 2. Describe the predictive value of New LBBB 3. Describe the ST segment changes that are diagnostic of AMI
More informationA Cardiologist s Guide to Love
A Cardiologist s Guide to Love A brief overview of what everyone should know about Palpitations, Heartache and Heartbreak! Eric J Dueweke, MD FACC Disclosure No one has yet to offer to pay me for my opinion.
More informationManagement of Acute Myocardial Infarction
Management of Acute Myocardial Infarction Prof. Hossam Kandil Professor of Cardiology Cairo University ST Elevation Acute Myocardial Infarction Aims Of Management Emergency care (Pre-hospital) Early care
More informationChest Pain. Dr Robert Huggett Consultant Cardiologist
Chest Pain Dr Robert Huggett Consultant Cardiologist Outline Diagnosis of cardiac chest pain 2016 NICE update on stable chest pain Assessment of unstable chest pain/acs and MI definition Scope of the
More informationIschaemic heart disease. IInd Chair and Clinic of Cardiology
Ischaemic heart disease IInd Chair and Clinic of Cardiology Definition Syndrome due to chronic insufficient oxygen supply to myocardial cells Nomenclature: ischaemic heart disease (IHD), coronary artery
More informationCommon Codes for ICD-10
Common Codes for ICD-10 Specialty: Cardiology *Always utilize more specific codes first. ABNORMALITIES OF HEART RHYTHM ICD-9-CM Codes: 427.81, 427.89, 785.0, 785.1, 785.3 R00.0 Tachycardia, unspecified
More informationST Elevation Myocardial Infarction (STEMI) Reperfusion Order Set
Form Title Form Number CH-0454 2018, Alberta Health Services, CKCM This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License. The license does not
More information2018 Acute Coronary Syndrome. Robert Bender, DO, FACOI, FACC Central Maine Heart and Vascular Institute
2018 Acute Coronary Syndrome Robert Bender, DO, FACOI, FACC Central Maine Heart and Vascular Institute Definitions: Acute Myocardial Ischemia Unstable Angina Non-ST-Elevation MI (NSTEMI) }2/3 ST-Elevation
More informationSafety of Single- Versus Multi-vessel Angioplasty for Patients with AMI and Multi-vessel CAD
Safety of Single- Versus Multi-vessel Angioplasty for Patients with AMI and Multi-vessel CAD Mun K. Hong, MD Associate Professor of Medicine Director, Cardiovascular Intervention and Research Weill Cornell
More informationAcute Coronary Syndrome
Acute Coronary Syndrome Vik Gongidi, DO FACOI, FACC Indian River Medical Center Vero Beach, FL Slides adapted from Robert Bender, DO, FACOI, FACC Definition: Acute Myocardial Ischemia Unstable Angina Non-ST-Elevation
More informationTROPONIN POSITIVE 2/20/2015 WHAT DOES IT MEAN? When should a troponin level be obtained?
TROPONIN POSITIVE WHAT DOES IT MEAN? Frequently Asked Questions Regarding the Use of Troponin in the Clinical Setting What does an elevated troponin level mean? Elevated troponin is a sensitive and specific
More informationUPDATES FROM THE 2018 ANTIPLATELET GUIDELINES
UPDATES FROM THE 2018 ANTIPLATELET GUIDELINES Claudia Bucci BScPhm, PharmD Clinical Coordinator, Cardiovascular Diseases Sunnybrook Health Sciences Centre 21st Annual Contemporary Therapeutic Issues in
More informationST Elevation Myocardial Infarction
ST Elevation Myocardial Infarction Scott M. Lilly, MD, PhD Assistant Professor Clinical Department of Cardiovascular Medicine The Ohio State University Wexner Medical Center Case Presentation 46 year old
More informationPost Operative Troponin Leak: David Smyth Christchurch New Zealand
Post Operative Troponin Leak: Does It Really Matter? David Smyth Christchurch New Zealand Life Was Simple Once Transmural Infarction Subendocardial Infarction But the Blood Tests Were n t Perfect Creatine
More informationCarotid Artery Stenting
Carotid Artery Stenting JESSICA MITCHELL, ACNP CENTRAL ILLINOIS RADIOLOGICAL ASSOCIATES External Carotid Artery (ECA) can easily be identified from Internal Carotid Artery (ICA) by noticing the branches.
More informationControversies in Cardiac Pharmacology
Controversies in Cardiac Pharmacology Thomas D. Conley, MD FACC FSCAI Disclosures I have no relevant relationships with commercial interests to disclose. 1 Doc, do I really need to take all these medicines?
More informationAcute Coronary Syndromes Unstable Angina Non ST segment Elevation MI (NSTEMI) ST segment Elevation MI (STEMI)
Leanna R. Miller, RN, MN, CCRN-CSC, PCCN-CMC, CEN, CNRN, CMSRN, NP Education Specialist LRM Consulting Nashville, TN Objectives Evaluate common abnormalities that mimic myocardial infarction. Identify
More informationStress Echo Cases Sunday, October 8, :10 3:30 PM 20 min
2017 ASE Echo Florida, Orlando, FL Stress Echo Cases Sunday, October 8, 2016 3:10 3:30 PM 20 min 1 M U H A M E D S A R I Ć, M D, P H D D i r e c t o r o f E c h o c a r d i o g r a p h y L a b A s s o
More informationWhat is Your Diagnosis?
What is Your Diagnosis? A STORM R Dulgheru, Liege, Belgium Faculty disclosure Raluca Dulgheru I have no financial relationships to disclose. Case presentation 52 years old male Ongoing oppressive chest
More informationThe Universal Definition of Myocardial Infarction 3 rd revision, 2012
The Universal Definition of Myocardial Infarction 3 rd revision, 2012 Joseph S. Alpert, MD Professor of Medicine, University of Arizona College of Medicine, Tucson, AZ; Editor-in-Chief, American Journal
More informationCoronary Artery Disease: Revascularization (Teacher s Guide)
Stephanie Chan, M.D. Updated 3/15/13 2008-2013, SCVMC (40 minutes) I. Objectives Coronary Artery Disease: Revascularization (Teacher s Guide) To review the evidence on whether percutaneous coronary intervention
More informationFastTest. You ve read the book now test yourself
FastTest You ve read the book...... now test yourself To ensure you have learned the key points that will improve your patient care, read the authors questions below. The answers will refer you back to
More informationDifficult Data Definitions and Scenario s
Difficult Data Definitions and Scenario s Presenter Disclosure Information Cornelia Anderson BSN, RN To following relationships exist related to this presentation: No Disclosures Objectives Discuss key
More informationKnow the Quality of our Care at Every Step. Kansas City ACS Summit BI-State Cardiovascular Education Consortium
Know the Quality of our Care at Every Step Kansas City ACS Summit BI-State Cardiovascular Education Consortium Welcome to the Kansas City ACS Summit Objectives: Follow the flow and care of an ACS patient
More informationAntiplatelet Therapy in Primary CVD Prevention and Stable Coronary Artery Disease. Καρακώστας Γεώργιος Διευθυντής Καρδιολογικής Κλινικής, Γ.Ν.
Antiplatelet Therapy in Primary CVD Prevention and Stable Coronary Artery Disease Καρακώστας Γεώργιος Διευθυντής Καρδιολογικής Κλινικής, Γ.Ν.Κιλκίς Primary CVD Prevention A co-ordinated set of actions,
More informationOUTPATIENT ANTITHROMBOTIC MANAGEMENT POST NON-ST ELEVATION ACUTE CORONARY SYNDROME. TARGET AUDIENCE: All Canadian health care professionals.
OUTPATIENT ANTITHROMBOTIC MANAGEMENT POST NON-ST ELEVATION ACUTE CORONARY SYNDROME TARGET AUDIENCE: All Canadian health care professionals. OBJECTIVE: To review the use of antiplatelet agents and oral
More informationAdvanced Imaging MRI and CTA
Advanced Imaging MRI and CTA Who and why may benefit. Matthew W. Martinez, M.D. FACC Lehigh Valley Health Network Director, Cardiovascular Imaging Learning Objectives Review basics of CMR and CTA Review
More informationPrasugrel vs. Ticagrelor in ACS/PCI Which one to choose? V. Voudris MD FESC FACC 2 nd Cardiology Division Onassis Cardiac Surgery Center
Prasugrel vs. Ticagrelor in ACS/PCI Which one to choose? V. Voudris MD FESC FACC 2 nd Cardiology Division Onassis Cardiac Surgery Center Hospitalizations in the U.S. Due to ACS Acute Coronary Syndromes
More informationDiagnosis and Management of Acute Myocardial Infarction
Diagnosis and Management of Acute Myocardial Infarction Acute Myocardial Infarction (AMI) occurs as a result of prolonged myocardial ischemia Atherosclerosis leads to endothelial rupture or erosion that
More informationST Elevation Myocardial Infarction
ST Elevation Myocardial Infarction Scott M. Lilly, MD, PhD Assistant Professor Clinical Department of Cardiovascular Medicine The Ohio State University Wexner Medical Center Outline Case Presentation STEMI
More informationChest Pain: To Cath or Not? Part I
Chest Pain: To Cath or Not? Part I Georgios Papaioannou, MD Ioannis Karavas, MD Newton-Wellesley Hospital 5/3/2000 1 A Typical Scenario... 57 year old female, Mrs. X., presents to your office with a 2
More informationCASE from South Korea
CASE from South Korea Bon-Kwon Koo, MD, PhD, Seoul, Korea Outpatient clinic of a non-interventional cardiologist F/56 Chief complaint: Angina with recent aggravation, CCS II~III Brief history: # Stroke
More informationCardiac evaluation for the noncardiac. Nathaen Weitzel MD University of Colorado Denver Dept of Anesthesiology
Cardiac evaluation for the noncardiac patient Nathaen Weitzel MD University of Colorado Denver Dept of Anesthesiology Objectives! Review ACC / AHA guidelines as updated for 2009! Discuss new recommendations
More informationConcurrent Subarachnoid Hemorrhage and Acute Myocardial Infarction: A Case Report
Concurrent subarachnoid hemorrhage and AMI 155 Concurrent Subarachnoid Hemorrhage and Acute Myocardial Infarction: A Case Report Chen-Chuan Cheng 1, Wen-Shiann Wu 1, Chun-Yen Chiang 1, Tsuei-Yuang Huang
More informationFRACTIONAL FLOW RESERVE: STANDARD OF CARE
FRACTIONAL FLOW RESERVE: FROM INVESTIGATIONAL TOOL TO STANDARD OF CARE TCT ASIA Seoul, Korea, april 26 th, 2012 Nico H. J. Pijls, MD, PhD Catharina Hospital, Eindhoven, The Netherlands FRACTIONAL FLOW
More information12 th Annual West Virginia ACC Meeting April 8, 2017
12 th Annual West Virginia ACC Meeting April 8, 2017 Rameez Sayyed, M.D., FACC, FSCAI Associate professor of Medicine Program Director for interventional cardiology Marshall University Joan C. Edwards
More informationThe Fundamentals of 12 Lead EKG. ECG Recording. J Point. Reviewing the Cardiac Conductive System. Dr. E. Joe Sasin, MD Rusty Powers, NRP
The Fundamentals of 12 Lead EKG Dr. E. Joe Sasin, MD Rusty Powers, NRP SA Node Intranodal Pathways AV Junction AV Fibers Bundle of His Septum Bundle Branches Purkinje System Reviewing the Cardiac Conductive
More informationCPORT E Trial. Atlantic C PORT
CPORT E Trial Randomized trial comparing medical, economic and quality of life outcomes of non primary PCI at hospitals with and without on site cardiac surgery Mo#va#on for Trial Sustain primary PCI program
More informationST-elevation myocardial infarctions (STEMIs)
Guidelines for Treating STEMI: Case-Based Questions As many as 25% of eligible patients presenting with STEMI do not receive any form of reperfusion therapy. The ACC/AHA guidelines highlight steps to improve
More informationSTAT 12 Lead ECG Workshop: Basics & ACS
STAT 12 Lead ECG Workshop: Basics & ACS Part 2: Acute Coronary Syndrome WAYNE W RUPPERT, CVT, CCCC, NREMT-P Cardiovascular Coordinator Bayfront Health Seven Rivers Crystal River, Florida Interventional
More informationUse of Nuclear Cardiology in Myocardial Viability Assessment and Introduction to PET and PET/CT for Advanced Users
Use of Nuclear Cardiology in Myocardial Viability Assessment and Introduction to PET and PET/CT for Advanced Users February 1 5, 2011 University of Santo Tomas Hospital Angelo King A-V Auditorium Manila,
More informationECG in coronary artery disease. By Sura Boonrat Central Chest Institute
ECG in coronary artery disease By Sura Boonrat Central Chest Institute EKG P wave = Atrium activation PR interval QRS = Ventricle activation T wave= repolarization J-point EKG QT interval Abnormal repolarization
More informationDAMNED IF YOU DO, DAMNED IF YOU DON T. Carissa J. Tyo, MD
DAMNED IF YOU DO, DAMNED IF YOU DON T Carissa J. Tyo, MD NO DISCLOSURES I have no relevant financial relationships with the manufacturer(s) of any commercial product(s) and or provider(s) of commercial
More informationNATIONAL INSTITUTE FOR HEALTH AND CARE EXCELLENCE. Proposed Health Technology Appraisal
NATIONAL INSTITUTE FOR HEALTH AND CARE EXCELLENCE Proposed Health Technology Appraisal Vorapaxar for the secondary prevention of atherothrombotic events after myocardial infarction Draft scope (pre-referral)
More informationDISCUSSION QUESTION - 1
CASE PRESENTATION 87 year old male No past history of diabetes, HTN, dyslipidemia or smoking Very active Medications: omeprazole for heart burn Admitted because of increasing retrosternal chest pressure
More informationDisclosures. Inpatient Management of Non-ST Elevation Acute Coronary Syndromes. Edward McNulty MD, FACC. None
Inpatient Management of Non-ST Elevation Acute Coronary Syndromes Edward McNulty MD, FACC Assistant Clinical Professor UCSF Director, SF VAMC Cardiac Catheterization Laboratory Disclosures None New Guidelines
More information