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ACS

Background

  • Completely or partially occluding thrombus on a disrupted atherothrombotic coronary plaque leading to myocardial ischemia/infarction
  • STEMI: Elevated troponin & elevation in ST segment or new LBBB with symptoms
    • > 0.1 mV in at least 2 contiguous leads
    • Exception, in V2-V3:
    • > 0.2 mV in men older than 40 y/o
    • > 0.25 in men younger than 40 y/o
    • > 0.15 mV in women
  • NSTEMI: Evidence of myocardial necrosis (elevated troponin) w/o ST segment elevation
  • Unstable Angina: Angina without evidence of myocardial necrosis (normal troponin)
  • Other causes of myocardial injury: coronary spasm, embolism, imbalance of oxygen demand and supply 2/2 fever, tachycardia, hypo-/hypertension

Chest Pain/Angina Pectoris

  • Chest Pain in the ED (M4s)
  • HEART vs. TIMI vs. GRACE1
  • [Diagnosis]3
    • Update on Stress Testing2
      • Not interpretable for ischemia if:
        1. Old LBBB
        2. Unable to reach target HR
        3. Baseline ST elevation
        4. Digoxin use
      • Get Stress Testing with Imaging (MPI, CMR, or Echo) if unable to do Exercise Stress Test
        • Indications
          1. Unable to exercise
          2. Baseline EKG abnormalities limiting interpretation
          3. Indeterminate findings on Exercise Stress Test
        • No adenosine in asthmatics, hypotension (stimulate A2A receptors on vascular smooth muscles, magnified from rest)
      • Positive Findings (Findings associated with poor outcomes)
        • Poor exercise capacity (<5 METs)
        • Exercise-induced angina during minimal expenditure
        • Inability to achieve 85% age-predicted maximum HR with exercise
        • Fall in SBP below baseline during exercise
        • ST elevation
        • ≥ 2mm ST-depression during minimal expenditure
        • Early onset or prolonged duration of ST depression during testing
        • ST depression in multiple leads
        • Ventricular couplets or tachycardia during minimal expenditure or recovery
      • Balanced Ischemia
        • High risk features on Exercise testing
        • Coronary blood low is equally or nearly equally impaired
        • ST depression in multiple leads during peak stress but no evidence of ischemia on radionuclide MPI

Myocardial Infarction

  • Definition
  • Management
    • P2Y12
      • PLATO3: Ticagrelor > Clopidogrel in ACS including mortality
      • DAPT4: Continuing Thienopyridine after 12 months decreased risk of In-stent thrombosis and MI at 18 months, increased risk of bleeding
      • WOEST5: Bleeding w/AC + Plavix < Triple Therapy w/o change in MI/Stroke/MACE
      • COGENT6: PPI with DAPT reduces GIB 87%, no CV event change
    • Statins
      • PROVE-IT7: Significantly reduced CVD events following MI with High-dose Lipitor vs. Pravastatin
    • ACEI
      • SAVE8: ACEI improve survival/morbidity/mortality in LV dysfunction after MI
    • MADIT-II9: ICD improves survival in pts with prior MI and severe LV dysfunction

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