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, and right ventricular MI Work-up Telemetry Serial 12 lead ECGs Troponins and CK-MB q8 hours x3 Electrolytes (K, Ca, Mg), Cr, CBC, coags, urine toxicology, FLP Management STEMI* Medical therapy Reperfusion NSTEMI, UA Medical therapy Early risk stratification TIMI 0-2: Conservative management (=Stress testing) TIMI 3-4: MKSAP 15 recommends invasive management, but these patients usually undergo invasive management only if stress testing suggests that the patient may benefit from PCI^ TIMI 5-7: Invasive management (=PCI within 48 hours; Avoid fibrinolysis) TIMI score (1 point per item) Age 65 yrs 3 coronary artery ds RFs 50% coronary stenosis on angiography ST-segment change 0.6 mm 2 anginal episodes 24 hours prior to presentation Elevated cardiac enzymes Use of aspirin within 7 days of presentation *Or any ACS p/w: Persistent or recurrent rest angina despite optimized medical therapy Cardiogenic shock New severe ventricular dysfunction Hemodynamic instability d/t a new structural defect (mitral regurgitation, VSD) Sustained VT or VF Wellens sign/syndrome ^In practice, patients undergo invasive management w/out prior stress testing only if they have new ST depressions > 1mm, increased cardiac enzymes, (worsening angina over the past 2 months, or recent PCI or CABG) Early Medical therapy Drug Dose Contraindications Oxygen 2-4 LPM Aspirin 325 mg po daily
Nitroglycerin Morphine sulfate Βeta-blocker Clopidogrel Anticoagulant 0.4 mg sl q5 minutes PRN (up to 3 doses) 2-4 mg iv q10 minutes PRN (may increase dosage by 2-8 mg every 10 minutes) atenolol 25-50 mg po bid or metoprolol tartrate 25-50 mg po q6-12 hours 300 mg po once (600 mg po once if PCI w/in 24 hours and 75 mg po once in patients >= 75 yo regardless of management type) Initially UFH (no bolus protocol w/ PTT goal 60-80) then you may switch to LMWH treating for 2-8 days duration Right ventricular MI SBP <90, pulse <50, second degree AVB (only Mobitz type II?); Alternatively may use a CCB Ongoing/recent bleeding, platelets <50,000 Ongoing/recent bleeding; Alternatively may use bivalirudin or fondaparinux Late medical therapy and risk stratification (prior to discharge) Continue ASA 81 mg daily Clopidogrel 75 mg daily BMS: x1-12 months DES: x6-12 months Medical therapy: x9-12 months Continue beta-blocker Start a high-dose statin and an ACE-inhibitor or ARB Measure resting LVEF In patients treated w/ medical therapy only, stress testing Complications and broad treatment principles Complication Broad treatment principles Arrhythmias Avoid arrhythmogenic medications Keep K 4.0-4.6 Rate and/or rhythm control Cardiogenic shock Vasopressors (dobutamine) + HF Avoid CCB Consider pre-load reduction and loop diuretics Contact CTS in patients w/ structural causes leading to HF (papillary muscle rupture causing MR or VSD) Recurrent MI Revascularization
Chronic stable angina Choosing a stress test Diagnostic: Patient's pre-test probability of coronary artery disease? Pre-test probability (Diamond NEJM 1979, Weiner NEJM 1979)* Age Non-anginal Atypical angina Typical angina^ M F M F M F 30-39 4 2 34 12 ~ 76 26 40-49 13 3 51 22 ~ 87 55 50-59 20 7 65 31 93 73 60-69 27 14 72 51 94 86 *Not included: Prior ACS, on digitalis, resting EKG w/ LBBB or LVH, inability to reach 85% max exercise capacity ^Typical angina: 1) Substernal chest pain or discomfort 2) Aggravated by activity or psychological stress 3) Alleviated by rest or NTG ^Atypical angina: 2/3 ^Non-anginal: 1/3 or 0/3 ~ Low pre-test probability per MKSAP 15 Need to localize lesions or determine cardiac viability? Resting EKG Can the patient exercise? Co-morbidities General considerations Obtain a stress test only in patients with intermediate or high pre-test probabilities Exercise stress testing is superior to pharmacologic stress testing Intermediate or high pre-test probability Need to localize lesions or determine cardiac viability?* Abnormal EKG? On digitalis? No Yes to any Able to exercise? Able to exercise? Yes No Yes No Stress EKG Pharmacologic stress test Exercise stress test *Usually needed in patients in whom you re considering revascularization (patients w/ high pre-test probability or w/ prior revascularization and worsening symptoms) Pharmacologic stress test Types of pharmacologic stress test Pharmacologic stress test Contraindications Prior to the stress test Dobutamine TTE or NPS Severe arrhythmias or HTN Hold beta-blockers Adenosine or dipyridamole NPS *Nuclear perfusion scan Severe airway disease (not Lexiscan = regadenoson) and high degree second and third degree) AVB Hold caffeine and theophylline
EKG atlas - ACS LBBB Ddx: A Pw precedes every QRS QRS > 120 ms Absent qw in I, (avl), V5, V6 Broad notched or slurred Rw in I, avl, V5, V6 ST and Tw usually opposite in direction to QRS QRS and Tw pos Okay QRS and depressed ST or Tw neg Suggests underlying ischemia Ventricular tachycardia and accelerated idioventricular rhythm: Has AV dissociation Ventricular pacing: Pacing spike replaces Pw WPW: Has a short PR Wellens sign/syndrom me = Critical plad stenosis in patients w/ UA Deep symmetric TWI and/or biphasic TW usually in V2 and V3, but may occur in V1-V6 when the patient is w/out chest pain RBBB w/ deep symmetric TWI in V3-V4 and biphasic TW in V5-V6
Deep symmetric TWI in V1-V2 and biphasic TW in V3-V5 Biphasic Tw Right ventricular MI Suspect in patients w/ inferior wall STEMI + STE in III > STE in II STE in V1 ST in V1 more upright than ST in V2 Confirm w/ STE anywheree from V3R-V6R Posteriorr wall MI Suspect in patients who have the following changes in V1-V3 Horizontal STD (as opposed to down-sloping or up-sloping) Very tall Rw Upright Tw Confirm w/ STE anywheree from V7-V9