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Acute Coronary Syndromes - Coggle Diagram

- - - - Supplies anterior wall (some) and lateral wall (large portion)
    - - Courses down anterior aspect of heart
      - Supplies anterior and septal regions
- - - - Hemoglobin concentration and oxygen saturation
      - Coronary artery blood flow
        
        Duration of diastolic relaxation
        
        Peripheral vascular resistance
    - - Fever, tachycardia, thyrotoxicosis
  - - - Adhesion via collagen, fibronectin, laminin, and glycoprotein IIb receptor to vWF
      - Activation triggered by ADP, Thromboxane A2, Serotonin, and Thrombin
      - Aggregation via cross-linking of glycoprotein IIb/IIIa receptors by fibrinogen or vWF
- - - - Pressure, heaviness, tightness, fullness, squeezing
      - Less commonly knife-like, sharp, stabbing
      - Substernal or left chest location with radiation to arm, neck, or jaw
      - Precipitated by exercise, stress, cold environment
    - - Stable angina usually <10 min (up to 10-20 min), resolves in 2-5 min with rest or nitroglycerin
      - Acute myocardial ischemia prolonged, severe, with little response to sublingual nitroglycerin
    - - Common in advanced age, female gender, diabetes mellitus
      - 37.5% of women and 27.4% of men present without chest pain
      - Atypical term is misleading because nonclassic features are common
  - - - Comfortable, uncomfortable, pale, cyanotic, respiratory distress
    - - Bradycardic rhythms common with inferior MI
      - New heart block or bradycardia in acute anterior MI is poor prognostic sign
    - - Normal, elevated (hypertension, sympathetic stimulation, anxiety), or decreased (pump failure, low preload)
    - - S3 present in 15-20% of AMI, indicates failing myocardium
      - New systolic murmur indicates papillary muscle dysfunction, flail leaflet with MR, or VSD
      - Rales with or without S3 indicates LV dysfunction and left-sided heart failure
      - JVD, hepatojugular reflex, peripheral edema suggest right-sided heart failure
- - - - Occurs at rest, prolonged usually >20 min
    - - Markedly limits physical activity (walking 1-2 blocks, 1 flight of stairs)
    - - More frequent, longer duration, or lower threshold
  - - - Accelerating tempo in preceding 48 h
      - Prolonged ongoing rest pain >20 min
      - Pulmonary edema, new/worsening MR murmur, S3, rales, hypotension, bradycardia, tachycardia
      - Age >75 y
      - Transient ST changes >0.5 mm, new bundle branch block, sustained VT
      - Elevated cardiac troponins
    - - Prior MI, PVD, CVD, CABG, prior aspirin use
      - Resolved rest angina >20 min, nocturnal angina, new onset 2 wk to 2 mo before presentation
      - Age >70 y
      - T-wave changes, pathologic Q waves, resting ST depression <1 mm in multiple lead groups
      - Slightly elevated cardiac troponins
    - - Chest discomfort reproduced by palpation
      - Normal or unchanged ECG
      - Normal cardiac markers
- - - - ST elevation in V1, V2, possibly V3
    - - ST elevation in V1, V2, V3, V4
    - - ST elevation in V3-V6, I, aVL
    - - ST elevation in I, aVL
    - - ST elevation in II, III, aVF
    - - ST elevation in II, III, aVF, V5, V6
    - - Initial R in V1, V2 >0.04 s and R/S ratio >=1
      - 0.5 mm ST elevation in V7-V9
    - - ST elevation in II, III, aVF with ST depression in lateral leads
      - ST elevation in RV leads V3R-V6R
  - - - Lead III ST elevation > Lead II plus ST depression >1 mV in I, aVL indicates RCA
      - ST elevation in V4R or V1 indicates proximal RCA
      - ST elevation in I, aVL, V5, V6 with ST depression in V1-V3 indicates Left Circumflex
    - - ST elevation in V1-V3 plus ST elevation >2.5 mm in V1 or RBBB with Q wave indicates proximal LAD
      - ST elevation in V1-V3 plus ST depression >1 mm in II, III, aVF indicates proximal LAD
      - ST elevation in V1-V3 plus ST depression <=1 mm or ST elevation in II, III, aVF indicates distal LAD
    - - ST elevation >0.5 mm in aVR (and >=1 mm in V1) indicates Left Main or severe multivessel disease
      - Wellens Sign
        
        Deeply inverted (75%) or biphasic (25%) T waves in V2, V3 (often V1, V4)
        
        Indicates critical proximal LAD stenosis
        
        Present when pain free, normalizes during pain
      - de Winter ST-T Complex
        
        Upsloping ST segment with overall ST depression
  - - - Concordant ST elevation >=1 mm in same direction as QRS (OR 25.2)
      - Concordant ST depression >=1 mm in V1, V2, or V3 (OR 6.0)
      - Discordant ST elevation >=5 mm in opposite direction to QRS (OR 4.3)
    - - ST elevation >=5 mm in leads with negative QRS
      - Concordant ST elevation in positive QRS is highly specific
      - ST depression in V1-V3 has 80% specificity
- - - - Serial interval as short as 2 h with TIMI <2 excludes AMI
      - ESC recommends 3 h interval or 0 h and 1 h rapid delta algorithm
- - - - No evidence of benefit in non-hypoxemic patients
      - High-flow oxygen may have negative effect
  - - - PCI capability hospital: Door-to-balloon <=90 min
      - Non-PCI hospital: Door-to-balloon <=120 min
      - Fibrinolysis within 30 min of ED arrival if PCI not available within timeframes
    - - Aspirin, antiplatelets, antithrombins, nitrates
  - - - Recurrent angina/ischemia with or without CHF
      - Elevated cardiac troponins
      - New ST depression
      - Depressed LV function, hemodynamic instability, sustained VT
      - PCI within 6 months or prior CABG
- - - - 162-325 mg PO as soon as possible
      - Irreversible COX inhibitor, prevents Thromboxane A2 formation for 8-12 days
      - Reduces relative mortality by 23% in STEMI
    - - Loading dose 300-600 mg PO, then 75 mg PO daily
      - No loading dose if >75 y receiving fibrinolytics
      - 600 mg superior to 300 mg for urgent PCI
      - Omeprazole reduces antiplatelet effect by 50%
      - CYP2C19 variant impairs metabolism
      - Withhold 5 days prior to CABG
    - - Loading dose 60 mg PO (within 1 h after PCI once coronary anatomy defined)
      - Contraindicated in prior CVA, TIA, or pathologic bleeding
      - Caution if age >=75 y
    - - Reversible P2Y12 inhibitor (effect gone within 3 days)
      - Loading dose 180 mg PO, then 90 mg PO BID
    - - IV P2Y12 inhibitor used during PCI
  - - - Irreversible chimeric antibody
      - 0.25 mg/kg IV bolus, then 0.125 mcg/kg/min infusion
    - - Reversible synthetic peptide
      - 180 mcg/kg IV bolus, then 2.0 mcg/kg/min infusion
    - - Reversible small molecule
      - 0.4 mcg/kg/min for 30 min, then 0.1 mcg/kg/min infusion
    - - Not recommended for routine ED initiation
      - Preferred for high-risk patients undergoing early invasive PCI
  - - - Bolus 60 units/kg (max 4000 units), infusion 12 units/kg/h (max 1000 units/h)
      - Titrated to PTT 1.5-2.5x control
      - Cease after 48 h to reduce HIT risk
    - - STEMI: 30 mg IV bolus followed by 1 mg/kg SC q12h
      - UA/NSTEMI: 1 mg/kg SC q12h
      - Hold 12-24 h before CABG with UFH bridge
    - - 2.5 mg SC daily
      - Specific Factor Xa inhibitor
      - Must not be used as monotherapy for PCI (add UFH or bivalirudin)
    - - Direct thrombin inhibitor
      - 0.75 mg/kg IV bolus, then 1.75 mg/kg/h infusion
      - Reduced 30-day major bleeding compared to UFH plus GPIIb/IIIa
  - - - STEMI with symptom onset <6-12 h and >=1 mm ST elevation in >=2 contiguous leads
    - - Alteplase: Weight >67 kg: 15 mg bolus, 50 mg over 30 min, 35 mg over 60 min
      - Tenecteplase: Single bolus based on weight (<60kg: 30mg; >=90kg: 50mg max)
      - Reteplase: 10 units IV over 2 min, repeat 10 units 30 min later
      - Streptokinase: 1.5 million units over 60 min
    - - Any prior intracranial hemorrhage
      - Known structural cerebral vascular lesion
      - Known intracranial neoplasm
      - Ischemic stroke within 3 mo
      - Active internal bleeding (excluding menses)
      - Suspected aortic dissection or pericarditis
    - - Severe uncontrolled BP (>180/100 mmHg)
      - History of chronic severe poorly controlled hypertension
      - Prior ischemic stroke >3 mo
      - Current anticoagulant use with INR >2-3
      - Recent trauma (past 2 wk) or major surgery (<3 wk)
      - Prolonged CPR (>10 min)
      - Noncompressible vascular punctures
      - Pregnancy
      - Active peptic ulcer disease
    - - Intracranial hemorrhage in 0.5-1.0% (risk factors: age >65, weight <70 kg, initial HTN)
  - - - Sublingual: 0.4 mg q5min x 3 PRN
      - IV: Start 10 mcg/min, titrate to 10% MAP reduction in normotensive, 30% MAP reduction in hypertensive
      - Avoid in inferior MI with RV involvement (preload reduction causes severe hypotension)
      - Contraindicated with PDE-5 inhibitors (sildenafil within 24 h, tadalafil within 48 h)
    - - Oral initiation within 24 h (Metoprolol 50 mg PO q12h, Atenolol 25-50 mg PO)
      - Avoid IV route routinely due to cardiogenic shock risk (COMMIT/CCS-2 trial)
      - Withhold if signs of heart failure, low output, age >70, SBP <120, HR >110 or <60
    - - Oral start within 24 h for STEMI, heart failure, pulmonary congestion, or LVEF <40%
      - Contraindicated in hypotension, bilateral renal artery stenosis, renal failure, history of angioedema
    - - Indicated for documented hypomagnesemia or Torsades de Pointes
    - - Verapamil and diltiazem used for ongoing ischemia or AF with RVR when beta-blockers contraindicated
      - No mortality reduction in AMI
- - - - Prominent in anterior AMI, associated with poor prognosis
    - - Occurs in 4-10% within first 24 h
      - Unstable treated with synchronized DC cardioversion
      - Stable treated with beta-blockers or amiodarone, digoxin, CCB
    - - Common in inferior MI (35-40%), atropine used if symptomatic/hypotensive
    - - Inferior MI mortality 15% (rises to >30% with RV involvement)
      - Anterior MI CHB portends grave prognosis
    - - Transcutaneous: Unresponsive symptomatic bradycardia, Mobitz II, 3rd-degree AVB, new LBBB/bifascicular block
      - Transvenous: Asystole, Mobitz II, 3rd-degree AVB, alternating BBB
  - - - No HF: 10%
      - Mild HF: 15-20%
      - Pulmonary edema: 40%
      - Cardiogenic shock: 50-80%
  - - - Occurs 1-5 days post-AMI, causes pericardial tamponade and death (>90%)
      - Diagnosis via bedside echocardiography, requires surgical repair
    - - Presents with chest pain, dyspnea, new holosystolic murmur with thrill at LLSB
      - Oxygen step-up >10% from RA to RV on PA catheter, requires surgical repair
    - - Occurs 3-5 days post-AMI, common in inferior MI (posteromedial papillary muscle)
      - Presents with acute pulmonary edema, severe mitral regurgitation murmur
  - - - Occurs 2-4 days post-AMI in <5%
      - Treatment: Aspirin 650 mg PO q4-6h or Colchicine 0.6 mg BID (avoid NSAIDs like Ibuprofen)
    - - Occurs 2-10 weeks post-AMI with pleuropericarditis and fever
      - Treatment: Aspirin and Colchicine
  - - - Inflates during diastole (increases coronary perfusion), deflates during systole (reduces LV afterload)
      - Indicated for hemodynamic instability or refractory ischemia bridging to definitive care
- - - - Requires ECG and troponin evaluation
      - Mainstay therapy: Aspirin, nitrates, benzodiazepines
      - Beta-blockers contraindicated in first 24 h
      - PCI preferred for STEMI
    - - ECG may show false-positive ST elevation
      - Medical management is mainstay