Acute Coronary Syndrome (Assessment and Plan): Difference between revisions
No edit summary |
(added myocarditis to differential and caution regarding inferior MI) |
||
| (One intermediate revision by the same user not shown) | |||
| Line 1: | Line 1: | ||
Author: [[User:William J Gibson|William J Gibson MD, PhD]] | Author: [[User:William J Gibson|William J Gibson MD, PhD]] | ||
Patient presents with XX hour history of [substernal] chest pain that radiates to [jaw/arm], associated with [diaphoresis, shortness of breath]. EKG on admission showing XX. Troponin on admission XX and subsequently trended to XX XX hours later. [Most likely type 1 MI given abrupt onset, ST-segment elevation OR History suggests type 2 MI given high concern for supply-demand mismatch. Differential includes coronary dynamic/non-occlusive obstruction (including vasospasm, microvascular ischemia, Takutsubo cardiomyopathy), non-plaque associated thromboembolism (Afib, cardioversion, PFO), coronary dissection, vascular steal, vasculitis. | Patient presents with XX hour history of [substernal] chest pain that radiates to [jaw/arm], associated with [diaphoresis, shortness of breath]. EKG on admission showing XX. Troponin on admission XX and subsequently trended to XX XX hours later. [Most likely type 1 MI given abrupt onset, ST-segment elevation OR History suggests type 2 MI given high concern for supply-demand mismatch. Differential includes coronary dynamic/non-occlusive obstruction (including vasospasm, microvascular ischemia, Takutsubo cardiomyopathy, myocarditis), non-plaque associated thromboembolism (Afib, cardioversion, PFO), coronary dissection, vascular steal, vasculitis. | ||
Dx: | Dx: | ||
| Line 7: | Line 7: | ||
- Serial EKG (Q30 mins initially), if STEMI | - Serial EKG (Q30 mins initially), if STEMI | ||
- Serial troponins (admission, 2H and 6H) if concern ACS rapidly evolving, 3x Q6H for rule-out | - Serial troponins (admission, 2H and 6H) if concern ACS rapidly evolving, 3x Q6H for rule-out (if 5th generation hsTn: Serial troponins Q3H sufficient) | ||
Risk stratification: | |||
- TIMI Risk Score (NSTEMI): | - TIMI Risk Score (NSTEMI): https://www.mdcalc.com/timi-risk-score-ua-nstemi | ||
- If GRACE Score > 140, early invasive strategy may be preferred (cath <72h [1]) http://www.outcomes.org/grace | |||
- | - HbA1c, lipid panel | ||
- | - Consider further risk stratification (stress test vs CT angio vs coronary angiography) | ||
- TTE to rule out new wall motion abnormality | |||
Tx: | Tx: | ||
| Line 25: | Line 27: | ||
Initial therapy: | Initial therapy: | ||
- Anticoagulation/Anti-platelet: ASA (325), Heparin drip (goal PTTT 60-80), defer clopidogrel given unclear if patient will need CABG | - Anticoagulation/Anti-platelet: ASA (325), Heparin drip (goal PTTT 60-80), defer clopidogrel on admission given unclear if patient will need CABG | ||
- | - Rate: Metoprolol 25mg PO Q6H, titrate to HR 50-60 (will hold if evidence of shock, AV-block) | ||
- | - Pain: sublingual nitro PRN (caution if inferior MI), defer morphine given interference with P2Y12 inhibitors and retrospective analyses suggesting increased adverse events. | ||
Post-stenting: | - Defer oxygen given randomized evidence of increased infarct size in STEMI without hypoxia [2] | ||
- Lipids: Atorvastatin 80mg [3] | |||
Long term: Plan for ASA 81mg QD, P2Y12 (preference: ticagrelor>prasugrel>clopidogrel), Beta blocker, Statin, ACE (esp if EF<40%)/ARB, consider spironolactone (RALES), ezetimibe (IMPROVE-IT), low-dose rivaroxaban (ATLAS-2), empagliflozin if DM (EMPA-REG). | |||
Post-stenting: | |||
- if stented will give clopidogrel 75mg PO QD (30 days of BMS, 1 year for DES) | - if stented will give clopidogrel 75mg PO QD (30 days of BMS, 1 year for DES) | ||
References: | References: | ||
# Mehta SR, Granger CB, Boden WE, et al. Early versus delayed invasive intervention in acute coronary syndromes. N Engl J Med. 2009;360(21):2165-75. | |||
# Stub D, Smith K, Bernard S, et al. Air Versus Oxygen in ST-Segment-Elevation Myocardial Infarction. Circulation. 2015;131(24):2143-50. | |||
# Cannon CP, Braunwald E, Mccabe CH, et al. Intensive versus moderate lipid lowering with statins after acute coronary syndromes. N Engl J Med. 2004;350(15):1495-504. | |||
Latest revision as of 15:25, 8 July 2018
Author: William J Gibson MD, PhD
Patient presents with XX hour history of [substernal] chest pain that radiates to [jaw/arm], associated with [diaphoresis, shortness of breath]. EKG on admission showing XX. Troponin on admission XX and subsequently trended to XX XX hours later. [Most likely type 1 MI given abrupt onset, ST-segment elevation OR History suggests type 2 MI given high concern for supply-demand mismatch. Differential includes coronary dynamic/non-occlusive obstruction (including vasospasm, microvascular ischemia, Takutsubo cardiomyopathy, myocarditis), non-plaque associated thromboembolism (Afib, cardioversion, PFO), coronary dissection, vascular steal, vasculitis.
Dx:
- Serial EKG (Q30 mins initially), if STEMI
- Serial troponins (admission, 2H and 6H) if concern ACS rapidly evolving, 3x Q6H for rule-out (if 5th generation hsTn: Serial troponins Q3H sufficient)
Risk stratification:
- TIMI Risk Score (NSTEMI): https://www.mdcalc.com/timi-risk-score-ua-nstemi
- If GRACE Score > 140, early invasive strategy may be preferred (cath <72h [1]) http://www.outcomes.org/grace
- HbA1c, lipid panel
- Consider further risk stratification (stress test vs CT angio vs coronary angiography)
- TTE to rule out new wall motion abnormality
Tx:
- Treat any secondary causes of myocardial ischemia (eg AF w RVR, anemia, hypoxemia (only if O2sat <92%), infection)
Initial therapy:
- Anticoagulation/Anti-platelet: ASA (325), Heparin drip (goal PTTT 60-80), defer clopidogrel on admission given unclear if patient will need CABG
- Rate: Metoprolol 25mg PO Q6H, titrate to HR 50-60 (will hold if evidence of shock, AV-block)
- Pain: sublingual nitro PRN (caution if inferior MI), defer morphine given interference with P2Y12 inhibitors and retrospective analyses suggesting increased adverse events.
- Defer oxygen given randomized evidence of increased infarct size in STEMI without hypoxia [2]
- Lipids: Atorvastatin 80mg [3]
Long term: Plan for ASA 81mg QD, P2Y12 (preference: ticagrelor>prasugrel>clopidogrel), Beta blocker, Statin, ACE (esp if EF<40%)/ARB, consider spironolactone (RALES), ezetimibe (IMPROVE-IT), low-dose rivaroxaban (ATLAS-2), empagliflozin if DM (EMPA-REG).
Post-stenting:
- if stented will give clopidogrel 75mg PO QD (30 days of BMS, 1 year for DES)
References:
- Mehta SR, Granger CB, Boden WE, et al. Early versus delayed invasive intervention in acute coronary syndromes. N Engl J Med. 2009;360(21):2165-75.
- Stub D, Smith K, Bernard S, et al. Air Versus Oxygen in ST-Segment-Elevation Myocardial Infarction. Circulation. 2015;131(24):2143-50.
- Cannon CP, Braunwald E, Mccabe CH, et al. Intensive versus moderate lipid lowering with statins after acute coronary syndromes. N Engl J Med. 2004;350(15):1495-504.