I'm gonna go through some of the elements
in a little bit more detail.
When we talk about history and the heart score
again, I mentioned you get a lot of points
if you've got a really great history
but what does that mean?
we're all taught in med school that patients with MIs
have 10 out of 10 crushing sub-sternal chest pain
that radiates down their left arm or up into their jaw.
The reality is
that that presentation is more common in younger white men
than in other members of the population
and the presentation among women,
minority patients, and the elderly is much more variable.
So we wanna think about coronary syndromes
in the case of unexplained arm or jaw pain without chest pain.
We wanna think about it in patients who are dyspneic
but don’t have chest pain,
especially if their dyspnea is exertional.
We wanna definitely think about in our patients
who have epigastric pain or indigestion.
That's kind of a classic presentation of MI
that you don't wanna miss.
And we really wanna think about it
in patients who have any kind of autonomic dysregulation.
So maybe they're just diaphoretic, or light headed,
or fatigued, or nauseous.
These are patients in whom we wanna be concerned
about coronary syndromes,
especially our elderly patients.
Moving on to ECG changes.
I mentioned ST segment depressions.
ST segment elevations indicate a STEMI.
So if your patient has significant ST elevations,
we’re hopefully not even doing a heart score on them
because they've already gone to the Cath Lab, right?
So this is just for patients who have EKG changes
that are not diagnostic of STEMI.
ST segment depressions are by far
the most specific and concerning changes among these patients,
and you can see some examples of significant
ST depressions here outlined on the slide.
T-wave inversions are much less specific.
They can indicate coronary syndrome
but they can actually indicate a lot of other things as well,
and ST segments can flip among healthy volunteers
placed under different types of physiologic stress.
So while it’s interesting to note,
it’s not as diagnostic as an ST-depression
and doesn't get you the same number of points.
Now a normal ECG gets you no points in the heart score
but I do wanna emphasize,
if you're really concerned
about your patient having a coronary syndrome
and their ECG is normal,
consider getting serial ECGs.
A lot of times these patients will develop changes
in 10, 20, 30 minutes after their initial presentation
and you can have the opportunity to see
the evolution of those changes
and make better decisions about your patient.
So if you have a high level of suspicion,
don't give up on the ECG.
Five to ten percent of patients
who have confirmed coronary syndromes
have normal ECG's at the time of hospital presentation.
I mentioned cardiac risk factors before,
and I just wanna review what the classic cardiac risk factors are
so you know which ones are included in the heart score.
The history of hypertension, diabetes,
significant obesity, so a BMI of 30 or more.
Family history but only family history at a young age.
Older people unfortunately,
just get coronary syndromes
even without inheritable risk.
So if they had a father who was 78 when he had an MI
that doesn't tell you a lot.
Whereas if dad was 42 when he had an MI,
you should definitely be concerned about heritability.
And then lastly, any kind of known cardiovascular disease.
So prior coronary syndromes, TIA’s, strokes,
peripheral arterial disease,
any evidence of vascular disease one place
should raise your suspicions for vascular disease in the heart.
So when we use the heart score,
we stratify patients into low, medium, and high risk.
A patient with a score of zero to three is low risk
and these patients have a very low incidence,
less than one to two percent of having major coronary events
within 30 days of their hospital presentation.
So these patients can be safely discharged.
patients who were at the four to six level,
they have an intermediate risk
of having significant coronary events
and they really merit observation,
coronary risk reduction, and some type of testing
to quantify how significant their coronary disease is,
and identify which ones
might benefit for more invasive testing or intervention.
Patients with heart scores of 7 to 10,
these patients are high-risk.
They have up to a 65% chance
of having major adverse coronary events within the next 30 days.
So these patients all need to be admitted,
they all need aggressive medical management,
and they should really be considered for early invasive testing.
In particular, coronary angiography with intervention
if it's indicated by the angio findings.
So again, heart score includes history, EKG, age,
risk factors, and troponin.
You put all of those together into a final score
and stratify your patient accordingly.
So for moderate risk patients,
I mentioned that they might need some type
of noninvasive testing
but what am I talking about?
Really I’m talking about stress testing
or coronary CT angiography.
So, we're not sticking a wire in the artery and taking pictures
the way you would if you were performing a catheterization,
but you are using IV contrast injected systemically
in order to visualize the coronaries
and get a sense of whether there any blockages.
Alternately, you can use stress testing which is done
either with exercise or with medication,
and is complemented by cardiac imaging
to identify whether there's any evidence
of ischemia under physiologic stress
All of these modalities,
nuclear medicine stress testing,
echocardiographic stress testing,
coronary CT angiography,
they all have about 80-85% sensitivity
so they're pretty good
but not perfect tests,
and that's why they can't be substituted
for invasive coronary angiography in really high risk patients,
because these are the patients who are at risk
of having a false negative result on a non-invasive test.
So the sensitivity’s good for this moderate risk group
but it's not good enough for the high risk group,
very important concept.
Non-invasive testing can rule out coronary disease
in low to moderate risk patients
but not in high risk patients.
Management for these moderate risk patients
is gonna include basically,
a control of their risk factors,
so blood pressure reduction, better control of their diabetes,
lipid-lowering, smoking cessation, weight loss
basically, behavioral interventions designed
to enhance their overall cardiac health.
We also should place all of these patients on daily aspirin.
Daily antiplatelet therapy
has been shown to reduce the incidence of coronary events,
and can be very beneficial for this group
who’s not gonna directly to the Cath Lab for further testing.
What do we do with those high risk patients?
Well, I already told you,
we’re not gonna be doing stress tests on them, right?
'Cause stress testing isn't good enough.
We are gonna bring them into the hospital
to check serial troponins
over a 6 to 12 hour period depending on your local protocols.
We’re gonna get serial ECGs to see if they evolve,
ischemic ECG changes over time.
We’re gonna consider early coronary angiography.
Now, we’re not rushing these patients
off to the Cath Lab from the ED
but we are admitting them to the hospital,
and considering performing catheterization the next day
or the day after that
so we can figure out what’s going on with them.
coronary angiography is the gold standard for evaluation of ACS,
and if you have a strong suspicion
your patient has a coronary syndrome,
you should be advocating for them to make the way to the Cath Lab
at some point during their hospitalization.
In terms of management,
again, all these patients should get aspirin
but this is a group
that should get more aggressive medical management.
So they should also get antiplatelet therapy
with either Ticagrelor or Clopidogrel.
They should get anticoagulation typically with Heparin.
Oral beta blockade,
again, if there’s not a contraindication to doing that.
They definitely if they do undergo angiography
should receive angioplasty or stenting
if it's indicated based on their angiographic results,
and they should all get aggressive risk modification
to lower their long-term coronary risk.
So in summary,
coronary syndromes are a continuum of disease.
Not every patient with a coronary syndrome is gonna come in
with a big dramatic MI and a classic looking ECG.
You do wanna check an ECG for everybody urgently,
because you wanna identify that subset of patients
who have STEMIs,
'cause that group needs to go rapidly to the Cath Lab
and they need to get re-vascularized
in order to save their jeopardized myocardium.
But for patients who don’t meet STEMI criteria,
we wanna optimize medical management, reduce their risk,
and certainly perform some type of coronary risk stratification
to get to the bottom of which patients
should go on and have further testing and which shouldn’t.
Patients who don't have STEMI again,
based on the heart score,
low risk can go home.
Intermediate risk should have non-invasive testing
either stress testing or coronary CTA,
and high-risk patients
should be considered for invasive angiography
at some point early in their hospital course.
I hope that this was a helpful talk
about management of coronary syndromes.