Acute Coronary Syndrome - Essential Concepts | The EM Boot Camp Course
The Center for Medical Education・32 minutes read
Efficient evaluation of acute coronary syndromes involves quick EKGs to determine reperfusion therapy needs and risk assessment tools like the HEART score for patient stratification. Identifying ST-elevation myocardial infarction, managing ACS, and assessing risk in low-risk chest pain cases are key considerations, with guidelines emphasizing redefining chest pain symptoms, especially in women.
Insights
- Rapidly performing an ECG within 10 minutes is vital in evaluating patients with acute coronary syndromes (ACS) to determine the need for reperfusion therapy like PCI or thrombolytics.
- The OMI concept challenges traditional ACS definitions, aiming to identify patients who may benefit from reperfusion therapy despite not meeting STEMI criteria, emphasizing the importance of individualized patient care based on risk assessment tools like the HEART score.
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Recent questions
How is acute coronary syndrome diagnosed?
Through ECG within 10 minutes.
What are the key topics in managing ACS?
Identifying STEMI, medical management, and risk assessment.
What is the OMI concept in ACS?
Identifying patients for reperfusion therapy.
What is the role of dual antiplatelet therapy in STEMI?
Aspirin and Clopidogrel/Ticagrelor for STEMI.
What are the considerations for thrombolytic therapy in ACS?
If PCI is not feasible within 90-120 minutes.
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Summary
00:00
"Managing Acute Coronary Syndromes: Key Considerations"
- The primary goal in evaluating patients with acute coronary syndromes (ACS) is to quickly perform an ECG within 10 minutes to identify those who may benefit from PCI or thrombolytics for reperfusion therapy.
- Initiating medical therapy for patients showing ischemia and using risk assessment tools like the heart score to stratify patients are crucial goals when managing chest pain or suspected ACS cases.
- Identifying ST-elevation myocardial infarction (STEMI) and STEMI equivalent ECGs, understanding medical management of ACS, and assessing risk for low-risk chest pain patients are key topics of discussion.
- The EKG leads correspond to specific areas of the heart, aiding in diagnosing different types of myocardial infarctions (MI) based on the location of EKG changes.
- Traditionally, ACS includes STEMI, NSTEMI (non-ST-elevation MI), and unstable angina, with specific criteria for each, such as EKG changes and troponin elevation for STEMI.
- The OMI (occlusion myocardial infarction) concept challenges rigid definitions of ACS, aiming to identify patients who may benefit from reperfusion therapy despite not meeting traditional STEMI criteria.
- Unstable angina is symptom-based without troponin elevation, characterized by concerning chest pain changes, prompting the need for careful clinical evaluation.
- Recent guidelines emphasize redefining chest pain as discomfort and considering accompanying symptoms like shortness of breath, especially in women who may present differently than men.
- EKG criteria for diagnosing STEMI include new ST elevation >1mm in two contiguous leads, with specific criteria for anterior MI based on age and gender.
- Initial assessment of ACS patients involves IV access, monitoring, chest x-ray to rule out other causes, and administering aspirin and unfractionated heparin for emergent reperfusion therapy.
15:08
Optimal STEMI Treatment Guidelines: Key Considerations
- Dual antiplatelet therapy for STEMI patients includes aspirin and either Clopidogrel or Ticagrelor, with the addition of nitroglycerin based on blood pressure and the distribution of the STEMI.
- Consideration of glycoprotein 2b3a inhibitors in discussion with Cardiology, based on institutional practices.
- The old regimen MONA (Morphine, Oxygen, Nitroglycerin, Aspirin) is no longer favored due to concerns about mortality and antiplatelet drug efficacy.
- Oxygen should only be administered if oxygen saturation is low, as excessive oxygen can be harmful.
- Nitroglycerin is recommended for patients with pulmonary edema post-MI, with IV and sublingual administration preferred over transdermal.
- Avoid nitroglycerin in patients taking sildenafil or allopurinol due to potential adverse effects.
- Aspirin is recommended unless there are bleeding concerns, with a small number needed to treat for mortality benefit.
- Beta blockers should be avoided in patients at risk for cardiogenic shock or with low cardiac output.
- Heparin is used as a bolus and infusion for procedural benefits in PCI and as a bridge to definitive therapy.
- Thrombolytics are considered if PCI cannot be achieved within 90-120 minutes, with careful review of contraindications and the need for transfer to a PCI-capable facility post-thrombolysis.
29:05
Identifying and Diagnosing Different Types of MI
- Inferior MI is identifiable on EKG by ST elevation in leads II, III, and aVF, with reciprocal ST depressions in AVL.
- Posterior MI may be deceptive on initial observation due to ST depression, but the tall R wave in V1 and V2 with significant ST depression in V1 through V4 indicates its presence.
- Posterior MI can be diagnosed without posterior leads, but adding posterior leads can confirm the diagnosis by showing ST elevation in V7, V8, V9.
- Stemi equivalents include de Winter T waves, left bundle branch block with modified Scarborough criteria, and right ventricle pacemakers meeting modified criteria.
- Risk stratification using the HEART score is crucial, with low-risk patients not needing urgent follow-up within 30 days, while moderate-risk patients may benefit from imaging and shared decision-making.
