The moment of maximal educational mediocrity

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Acute Coronary SyndromeBogus Chest Pain to STEMI and Beyond….

Mr. Dr. Jodi Wieters2

The Problem….•CV disease still #1 killer in USA  •5-6 million CP pts/yr  

• 2nd most common “cc”  

• 1.1 million dx’d with AMI annually  • 550,000 dx’d in the ED

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The Problem…•434,877 patients with confirmed MI  

• 33% without Chest Pain  

•Cantos JG. JAMA. 2000;283:3223-3229.4

Mortality

20%

Missed?

20% of malpractice awards  Most dollars paid in malpractice in EM

The EKG

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Normal EKG

•1-8% AMI have a normal ECG  

•Approx 50% of AMI patients have diagnostic changes on their initial ECG  

•Peter J. Zimetbaum, M.D., N Engl J Med 2003;348:933-40.

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Cath  Lab?

CVICU?Rule-­‐out  Inpatient? ED  

Rule-­‐out?

Cath    Lab

Options?Bogus  

 Chest  Pain

Her  EKG

•History and Exam Suggestive of AMI

•It Doesn’t Sound Cardiac?

• Pain in Chest or Left Arm • CP Radiation

• Right Shoulder • Left Arm • Both Left & Right Arm

• Diaphoresis • 3rd Heart Sound • SBP < 80 mm Hg • Pulmonary Crackles

LR 2.7

LR 2.9 (1.4-6.0) LR 2.3 (1.7-3.1) LR 7.1 (3.6-14.2) LR 2.0 (1.9-2.2) LR 3.2 (1.6-6.5) LR 3.1 (1.8-5.2) LR 2.1 (1.4-3.1)

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Atypical pain…

• Clinical Examination – • Pleuritic Chest Pain • Sharp or Stabbing Pain • Positional Chest Pain • Reproducible Chest Pain

Against AMI • LR 0.2 (0.2-0.3) • LR 0.3 (0.2-0.5) • LR 0.3 (0.2-0.4) • LR 0.2-0.4

Panju AA. JAMA. 1998;280:1256.

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Josh Sonnier facebook archives circa 2011

• Shry EA. AM J Card. Vol 90; 2002 • with ACS 88% responded • without ACS 92% responded

• Henrickson CA. Ann Int Med.Vol 139; 2003 • with ACS, 35% responded • without ACS, 41% responded

• Chandra A. 5, 10, 15 minutes on a VAS. • sensitivity 33%, 33%, and 42% • specificity 76%, 45%, and 44%

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•NTG Response…..Not so good

There is no combination of historical and physical exam characteristics which can, by themselves, exclude ACS.

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Md  calc  Timi  Grace  Heart  Talk  about  each.  

Md  calc  Timi  Grace  Heart  Talk  about  each.  

More  interested  in  Drink/food–                                            

Wears  Sunglasses-­‐                                                                              

Values  Dilaudid  >  ASA-­‐                                                                

Explitavies:English  ratio  >0.5                      

Wants  to  have  a  cig  before  cath-­‐                      

       

If  score  >2  pt  has  99%  chance  of    

bogus  Chest  pain  

Wieters  Bogus  Chest  Pain  Score

Low risk chest pain?•Age  •RF  

•Symptomatology  •EKG  

•EKG  

•Enzymes  •Enzymes

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I think I want to send them home…☑Very atypical symptoms in low risk patient  ☑NORMAL EKGs  

☑Negative enzymes after 8 hrs of onset symptoms  

☑Very good follow up/ DC instructions ☑Shared decision making ☑Understand you will still miss some…

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• Acc  guidelines  with  stress  test  • What  does  a  stress  test  test?

His  EKG

•STEMI  

•ST morphology. Most benign elevation presents with concave (scooped) ST segments; convex (rounded) elevation is a fairly specific for STEMI.  

•Changes on serial ECGs  

•Brady et al. Electrocardiographic ST-segment elevation: the diagnosis of acute myocardial infarction by morphologic analysis of the ST segment. Acad Emerg Med. 2001 Oct;8(10):961-7.

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•Conditions that can mimic or conceal ST elevation

•A few STEMI mimics  • BBB  

• Left ventricular hypertrophy  • Benign early repolarization  

• Pericarditis  • WPW  

• Brugada Syndrome  • Ventricular aneurysm  

• Hyperkalemia

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•Inferior STEMI

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•K 6.8 not STEMI

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K  6.8  Not  STEMI

•High lateral STEMI D1 branch of the LAD

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•High lateral STEMI proximal LAD

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•Pericarditis

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•Ischemic changes

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•High lateral STEMI

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•Early Repolarization

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brugadda

• Explain  brugadda

•POST STEMI- L Circumflex

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Scarbosa  critera

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How  accurate  is  Scarbossa?  

Larson  et  al:  44%  false  activation    Chang  et  al:  80.8%  false  activation    Jain  et  al:  86%  false  activation

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53>0.25  more  concerning

Modified  Scarbossa

LBBB

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Brugadda

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•Ventricular Aneurysm

•LMCA

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•I think it’s a STEMI… Now What?

•Oxygen  

•Nitrates  •ASA  

•Beta blockers  •2 options  

• Thrombolytics  • PCI  

•Heparin/Lovenox?  •Plavix/Effiant?  •Iib/IIIa or Bivalirudin?

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•325mg  

•Reduces mortality by 23%  

•Greatest mortality benefit of all treatments.

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•Decrease cardiac work and myocardial O2 requirements  •Use Cautiously in MI’s involving the Right ventricle  •Side effects:

• Headaches • Hypotension • Hypoxemia from V/Q mismatch • Bradycardia

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•ACC/AHA Guidelines  •Start PO (not IV) BB in pts with STEMI or NSTEMI within 24 hrs provided the

patient has none of the following:  • 1) Heart failure  • 2) Evidence of low EF  • 3) Increased risk of Cardiac Shock  • 4) Standard relative contraindications to BB

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•COMMIT/CCS-2  •Increase rate of cardiogenic shock,  •No improved mortality  •Did decrease re-infarction and VF

•Reduced mortality when used with Fibrinolytic therapy, heparin, and aspirin in acute MI  

•CLARITY-TIMI 28 and COMMIT trail show improved 30 day outcomes when clopidogrel is added to standard therapy  

•Pt’s with aspirin allergy show receive 600mg loading dose of clopidogrel as soon as possible in setting of acute MI  

•Triton-TIMI 38: Prasugrel (Effiant) compares more favorably to clopidogrel (Plavix) may see increase use  • Esp. diabetic pts

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•Anticoagulants•Lovenox  

•Less reversible  •Less monitoring  •IV and SQ dosing  •Debate about benefit over heparin

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•Anticoagulants•Heparin  

•IV dosing, reversible  •Modest reduction in mortality in USA/STEMI  •Monitoring intensive

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•Thrombolytics • Indications  •ST elevation 1 mm in 2 contiguous limb leads  •ST elevation 2 mm in 2 contiguous chest leads  •New left bundle branch block  •Chest pain consistent with AMI < 12 hours duration  •No contraindications to thrombolysis or anticoagulation  

•Guided by regional protocols.

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•Might not when….• Absolute

Contraindications  • Hx of any hemorrhagic cerebrovascular

event  • Hx of non-hemorrhagic cerebrovascular

event or TIA in last year  • Intracranial neoplasm  • Active internal bleeding except menses  • Suspected aortic dissection

❿ Relative Contraindications  

❿ Recent 9within 10 days) puncture of non-compressible vessel  

❿ Uncontrolled hypertension DBP>110, SBP> 180  

❿ Diabetic retinopathy or ocular hemorrhage  ❿ Anticoagulated with INR>2-3  ❿ Pregnancy  ❿ Predisposition to bleeding  ❿ > 5min of CPR or intubation trauma  ❿ Within 4 weeks of surgery at non-

compressible site

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•Timing is everything…•ACC, AHA, ESC recommend PCI as the preferred method of reperfusion if the door to balloon time is <90 minutes (evidence showing that 120 minutes shows favor of PCI vs Fibrinolysis)  

•Door to balloon time of 90 minutes

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•PCI•Cardiac cath plus procedure to restore patency  •Angioplasty  •Stents  •Glycoprotein (GP) IIb/IIIa inhibitors  •Bivalirudin  

•Improved survival rates over thrombolytics  •Only available 18% US hospitals

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•Strategies for reducing door-to-balloon time

•1. EM physicians activate Cath Lab  

•2. Central Pager for all personel  •3. Activate Cath Lab when pt is still in route  •4. Except Cath Lab staff to arrive within 20 mins  •5. Attending Cardiologist always on site  •6. Feedback Data

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•Complications•Cardiogenic Shock  •CHF  

•Acute Mitral Regurgitation  

•Ventricular septal rupture  •Myocardial rupture  •Pericarditis  •Seizure, Coma, Death

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•References not listed in slides•ACC.org  

•Peer IV/ Peer IV  

•http://lifeinthefastlane.com/ecg-library/lateral-stemi/  •Interview with Dr Bruce Bollinger “Why you shouldn’t dick around!”  

•http://www.radiologyassistant.nl  •Learntheheart.org  

• CDEMCurriculum.org  

• Dr.  Sonnier  facebook  page  circa  2005

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