Acute Coronary Syndrome

ImPRINT Module Presenter: P. David Soran MD Clin. asst prof Cardiac Anesthesia

Goals for module:

Recognize Acute Coronary Syndrome (ACS) Prepare you to initiate workup and initiate therapy of ACS

0300 Night Float call from RN

Nurse: Doctor, Mr. Jones in D315 is complaining of chest pain You: Im on the way. Are his vital signs OK? Walk over to D3 and on the way start thinking about what this could be and what to do about it

Chest Pain
Ominous things
ACS Pulmonary embolus Pneumothorax Aortic Dissection

Not so ominous
GERD Esophageal spasm

Acute Coronary Syndrome

Can manifest as many things
Chest pain Nausea Hypotension Dysrhythmia Arm pain SOB

Need to be wary and always have ACS on your radar

ACS
For some reason, myocardium isnt getting enough oxygen to meet its needs Problem is one of Supply and Demand Common on POD #2-3 More often in patients with CAD risk factors
Smoking, lipids, HTN, PVD etc But can happen to anyone

Supply and Demand

Supply decrease
Coronary occlusion Acute platelet plug from ruptured plaque

Demand increase
Tachycardia Fever Pain Mobilization of fluid post surgery HTN

Baseline coronary blockage and supply cant meet demand

Workup
Vital signs: BP/ HR/ SaO2 History: onset of pain, severity, associated symptoms, similarity to prior episodes, clinical context Exam: General appearance, brief physical EKG Cardiac enzymes CALL YOUR SENIOR

EKG
In an MI,
see T wave inversion ST segment elevation New Q waves

In ischemia
May just see ST depression

Location, location, location

Anterior Infarct
V1-V6

Inferior
II,III, AVF

Lateral
I,AVL,V5

Back to Mr. Jones

68 yo M on vascular surgery service 2 days s/p femoral-popliteal bypass Chest pressure started at 0230 Feel some pain in the chest and I feel like Im gonna throw up Doc HR 112, BP 159/99, SaO2 95% Nurse says, What should we do?

Mr. Jones
Quick exam Put him on monitor if hes now already Order EKG stat Call your senior Start thinking and acting on supply demand issues

Poor Mr. Jones

Phone calls
Call your senior Call the surgeon and discuss anticoagulation Call cardiology Be prepared for hemodynamic changes and arrhythmia

Improve your supply / demand

Supply
Plaque rupture and coronary occlusion ASA 325 mg Consider heparin gtt unless contraindicated Inadequate coronary O2 delivery Give supplemental O2

Demand
HR fast high demand on poorly supplied heart B-Blocker metoprolol 12.5 mg PO or 1-5 mg IV unless contraindicated Pain causes increased sympathetic tone, more dmand Pain control dilaudid/ morphine Mobilizing fluid post Consider lasix

Poor coronary blood flow NTG sublingual

Discussion
Be wary of ACS. It may present atypically Go see any patient with chest pain Call your senior Start the workup Start initial supply/ demand therapy
ASA, NTG, pain control, B-blockers

Be prepared for a dynamic situation