Reviews Before becoming PGY: acute coronary syndrome

Reviews Before becoming PGY: acute coronary syndrome

Reference: ACLS training center website; 麻州總醫院內科學手冊第六版
 
1. Algorithm from ACLS training center
https://www.acls.net/images/algo-acs.pdf
 
2. 症狀與鑑別診斷

• Prinzmetal's
• UA, NSTEMI, STEMI, +/- Heart failure?, right side or left side?
• Aortic dissection

3. 確定時間點
Q: 離症狀開始已經有多久？
A: STEMI一定是以reperfusion為目標，12hrs 以內做reperfusion比較有效，超過則跑UA/NSTEMI的流程。
 
Q: 處置需要多快？
A: door to needle 30 mins, door to balloon 90 mins
4. ACS初步處置(<10 mins)與實驗室檢查
- initial medications: pain control, oxygen, cath team activation, aspirin(160~325mg)
- 確定沒有contraindications(右心梗塞、主動脈狹窄、低血壓、使用PDE5 inhibitor) 再用NTG
- EKG:一般AMI應該大家都會看，[特殊]如果有舊的LBBB，判讀時看STD in V1-V3, STE>=5mm(QRS反向)或STE>=1mm(QRS同向)
- cardiac enzymes: prefer using troponin> CKMB> CK
- CXR(<30 mins)


from AHA 2007

5. PCI前其他處置？
- beta blocker: for HTN，一旦有HF症狀、低血壓、2度以上AVB等就不能用，goal of HR=50~60 bpm
 - other antiplatelet, anticoagulant: Ticagrelor, Prasugrel> Clopidogrel; Enoxaparin
- statin: atorvastatin 80mg QD
 
- ACEI/ARB: 尤其是有共病(CKD, HTN, DM)、HF(EF<40%)
- diuretics: LV failure
- inotropes for vital signs stability: dopamine, dobutamine, milrinone
 
6. 其他相似病症初步處置
- Prinzmetal's: high dose CCB + standing nitrite ; 避免aspirin, non-selective beta blocker
 
7. UA/NSTEMI，或STEMI從症狀開始已超過12小時

- 區分risk groups(如TIMI score)，high risk　 三分以上(含)-->dual antiplalet
                                                                             + UFH or Enoxaparin or Bivalirudin
                                                                             +/- GPI (除了已經用Bivalirudin)
                                                                            -->24hrs內做 early PCI
                                                                            (early vs. late, 可看GRACE score決定)

                                                         low risk     三分以下--> dual antiplalet
                                                                             + UFH or Enoxaparin or Fondaparinux
                                                                            --> stress test(treadmill<-11視為high risk)
　
TIMI for UA/NSTEMI: https://www.mdcalc.com/timi-risk-score-stemi


 

Grace score: https://www.mdcalc.com/grace-acs-risk-mortality-calculator

 





 8. Complications and prognosis
- RV infartion: AVB

- papillary muscle rupture, VSD,  free wall rupture, arrhythmia(Afib, VT/VF), LV thrombus, ventricular aneurysm/pseudoaneurysm, pericarditis, Dressler's syndrome 

- STEMI prognosis: TIMI score, 30 days mortality

https://www.mdcalc.com/timi-risk-score-stemi

9. 長期用藥/處置

- low dose aspirin(80 mg QD)

- Ticagrelor or Prasugrel 至少一年
- statin: atorvastatin 80 mg QD + ezetimibe?
- beta blocker

- EF差、有共病可考慮ACEI, aldosterone inhibitor

- 舌下NTG 備用
- ICD if EF<40%, VT/VF for 2 days (post MI)