سيمنارات

Dr. Ahmed M. Hussein

Spectrum of coronary artery disease

-Silent ischemia

-Chronic stable angina
-Acute coronary syndromes (ACS)
NSTE-ACS (Unstable angina , NSTEMI)
STEMI

-Heart failure

-Arrhythmia

-Sudden death



Chronic stable angina
Angina pectoris is the clinical syndrome caused by transient myocardial ischaemia. It may occur whenever there is an imbalance between myocardial oxygen supply and demand. Coronary atheroma is by far the most common cause of angina.

Investigations

Resting ECG often normal.

Exercise ECG.

Myocardial perfusion scanning.
Stress echocardiography.
Coronary arteriography

ST depression

ST Segment Depression

• Upward sloping depression of ST segment is not indicative of IHD
• It is called J point depression or sagging ST seg
• Downward slopping or Horizontal depression of ST segment leading to T↓is significant of IHD
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Exercise (stress) ECG

Coronary Angiography
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Management

Risk factors modification such as smoking, hypertension and hyperlipidaemia.
Drugs
Antiplatelet therapy
Low-dose aspirin reduces the risk of adverse events such as MI and should be prescribed for all patients with coronary artery disease indefinitely .Clopidogrel (75 mg daily) is an equally effective.
Anti-anginal drug treatment
Nitrates
Beta-blockers


Calcium channel antagonists
Potassium channel activators
Invasive treatment
Percutaneous coronary intervention PCI.
CABG

ACUTE CORONARY SYNDROMES

No ST Elevation
ST Elevation
Unstable Angina
NSTEMI STEMI
Myocardial Infarction
NSTEMI

Pathogenesis of ACS

Sequence of events
Plaque Rupture
Platelet Adhesion
Platelet Activation
Platelet Aggregation
Thrombotic Occlusion
Anti-platelet drugs
Platelet rupture
Platelet Adhesion
Platelet Activation
Platelet Aggregation
Thrombotic Occlusion

MI

Thrombus Formation and ACS

UA
NSTEMI

Plaque Disruption/Fissure/Erosion

Thrombus Formation

Non-ST-Segment Elevation Acute Coronary Syndrome (ACS)

ST-Segment Elevation Acute Coronary Syndrome (ACS)

Terminology:

High Serum Troponin

Differential diagnosis:

• Pericarditis
• Pulmonary embolism
• Pneumothorax
• Aortic dissection
• Esophageal spasm

Ischemia and Infarction

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TRANSMURAL Injury ST Elevation

T Wave Inversion
Deep symmetric inverted T waves
In more than 2 precardial leads
85% of the patients with such T wave↓had > 75% stenosis of the coronary artery
T wave ↓are significantly associated with MI or death during follow up

Stages of STEMI

ST elevation

Arrangement of Leads on the EKG

Acute Anterior MI

Cardiac Enzymes

Cardiac imaging

2D echocardiography
reveals regional wall motion abnormality also useful to identify mechanical complications of MI


Radionuclide imaging
used infrequently in the diagnosis of acute MI
mainly used to risk stratify patients with CHD

Very Striking

Acute Antero-Lateral MI

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Severe Chest Pain – Why ?

Acute Inferior wall MI

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What is striking ?

Acute Inf Post

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Where are the ST ↑ ?

Inf Lysed

Acute ST segment elevation

Reciprocal ST segment depression


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What changes we see ?



34
Why Acute changes disappeared ?
r TPA



35
Guess How Old is this MI !

Acute True Posterior MI

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Decipher V1, V2, V3

Identify the Double wall MI

Inferior STEMI + Hypotension = ??

Next ??

Look at the Right Chest Leads


R
R
R
R
R
R


Management

Prehospital care:

Major elements include
Recognition of symptoms by the patient and
prompt medical attention

Rapid deployment of EMS capable of
resuscitation and defibrillation

Goals of Initial management in ED

Control of cardiac pain

Rapid identification of patients suitable for reperfusion

Triage of low risk patients for subsequent care

Avoiding inappropriate discharge of patients with MI

Initial management

• Focused history and Focused examination

• Reassurance
• Ensure IV access + Basic investigations
• Aspirin: 160-325 mg chewable aspirin + Clopidogril
• Oxygen by nasal cannula if hypoxemia is present
• Sublingual nitroglycerine followed by IV infusion if needed
• Intravenous beta blockers (decrease myocardial oxygen demand, control chest pain and reduce mortality)
• Morphine for pain relief (given IV in small doses)+ Metelopromide
• Monitor
• 12 Leads ECG
• Consider Reperfusion

Reperfusion therapy

Primary percutaneous coronary intervention (PCI).
Thrombolysis.

Absolute Contraindications

Any prior intracranial hemorrhage
Known structural cerebral vascular lesion (e.g., AV malformation)
Malignant intracranial neoplasm
Ischemic stroke in last 3 months
Suspected aortic dissection
Active bleeding or bleeding diathesis
Closed head or facial trauma in last 3 months


Relative Contraindications
Recent (3 weeks) major surgery
Recent (3 weeks) trauma
Cardiopulmonary resuscitation of >10min
BP > 180/110
Ischemic stroke more than 3 months old
Internal bleeding in last month
Noncompressible vascular punctures
For streptokinase/Anistreplase: prior exposure or allergy
Pregnancy
Active peptic ulcer
Currently on anticoagulants (sodium warfarin, Coumadin); the higher the INR, the higher the risk

Complications of acute coronary syndrome

Arrhythmias VF,AF, BRADYCARDIA
Ischemia
Acute circulatory failure
Pericarditis
Mechanical complications
Embolism
Impaired ventricular function HF
Ventricular aneurysm


Maintenance Therapy
Life style changes
Aspirin
Clopidogril
B blocker
ACE inhibitors
Calcium channel blocker
Statins ( Antilipids)

Normal initial ECG exclude STEMI??

23 min. later

1 hr post revascularization