One of my best presentations of medical school.

1. ACUTE CORONARY SYNDROME BY: TIKAL KANSARA BARODA MEDICAL COLLEGE (BMC)

3. Non-ST segment elevation myocardial infarction (NSTEMI)

4. ST segment elevation myocardial infarction (STEMI)ACUTECORONARY SYNDROME

5. ANATOMY OF CORONARY CIRCULATION

9. MYOCARDIAL INFARCTION

10. TREND OF DISEASE PROGRESSION

12. PATHOPHYSIOLOGY

13. http://upload.wikimedia.org/wikipedia/commons/thumb/f/f1/Atherosclerosis,_aorta,_gross_pathology_PHIL_846_lores.jpg/230px-Atherosclerosis,_aorta,_gross_pathology_PHIL_846_lores.jpg http://1.bp.blogspot.com/_TZRga5MgAqc/SlH2zWwQpnI/AAAAAAAAAMs/zOCV4MdVpZc/s400/atherosclerosis-1.jpg

14. http://www.nature.com/nature/journal/v420/n6917/images/nature01323-f1.2.jpg

15. http://www.live-in-green.com/features/images/diet_soda/atherosclerosis_development_process.jpg

17. RISKFACTORS

18. Intense exertion Physical Psycological Pneumonia Chlamydophiliapneumoniae CAUSES

20. It occurs at rest (or with minimal exertion), usually lasting > 10 mins,

21. It is severe and of new onset,

22. It occurs in a cresendo pattern (i.e., distinctly more severe, prolonged, or frequent than previously)UNSTABLE ANGINA

23. UA occurs due to reduction in oxygen supply and/or by an increase in myocardial oxygen demand superimposed on an atherosclerotic coronary plaque, with varying degrees of obstruction. Plaque rupture or erosion with superimposed non occlusive thrombus (MC) Dynamic spasm Progressive mechanical obstruction Decreased supply v/s increased demand PATHOPHYSIOLOGY

24. http://drsvenkatesan.wordpress.com/2008/09/10/why-thrombolysis-is-contraindicated-in-unstable-angina/

25. A syndrome of ischemic pain that occurs at rest but not usually with exertion and is associated with transient ST-segment elevation. Due to focal spasm of an epicardial coronary artery, leading to severe myocardial ischemia. Focal spasm can be due to vasoconstrictor mitogens, leukotrienes, or serotonin. Associations – migraine, Raynauld’s Phenomenon, or aspirin-induced asthma. PRINZMETAL’SVARIANT ANGINA

26. UA + Raised cardiac markers NSTEMI

27. A 2007 consensus document classifies myocardial infarction into five main types: Type 1 – Spontaneous myocardial infarction related to ischemia due to a primary coronary event such as plaque erosion and/or rupture, fissuring, or dissection Type 2 – Myocardial infarction secondary to ischaemia due to either increased oxygen demand or decreased supply, e.g. coronary artery spasm, coronary embolism, anemia, arrhythmias, hypertension, or hypotension Type 3 – Sudden unexpected cardiac death, including cardiac arrest, often with symptoms suggestive of myocardial ischaemia, accompanied by presumably new ST elevation, or new LBBB, or evidence of fresh thrombus in a coronary artery by angiography and/or at autopsy, but death occurring before blood samples could be obtained, or at a time before the appearance of cardiac biomarkers in the blood Type 4 – Associated with coronary angioplasty or stents: Type 4a – Myocardial infarction associated with PCI Type 4b – Myocardial infarction associated with stent thrombosis as documented by angiography or at autopsy Type 5 – Myocardial infarction associated with CABG

28. Chest pain Dyspnoea Epigastric discomfort Diaphoresis Pale cool skin Sinus tachycardia 3rd &/or 4th heart sound Basilar rales Occasionally, hypotension. CLINICAL FEATURES

29. Chest Pain

30. Electrocardiogram Cardiac biomarkers Cardiac imaging Nonspecific indices of tissue necrosis & inflammation DIAGNOSIS

31. UNSTABLE ANGINA ST- segment depression Transient ST-segment elevation T-wave inversion For patients presenting with clinical features of UA, the presence of new ST-segment deviation, even of 0.05 mV is important predictor of adverse outcome. ELECTROCARDIOGRAM

32. http://t2.gstatic.com/images?q=tbn:ANd9GcSZHFhpkVykyCcvRgdWTRm_5Z1DO6s95JfuivLOiRWojbnK2S_A

33. http://t0.gstatic.com/images?q=tbn:ANd9GcRfQ9vhakX9DUOOMFZ00KjaDgJfQIxB0kD8yBBr03hPn1N0mtnCIQ http://t1.gstatic.com/images?q=tbn:ANd9GcTpKHVspKnAzenrh8e3stJG5juj2g8nK3C8RZFD9dp_JYm6Auxe

34. http://www.cathlabtoday.com/wp-content/plugins/rss-poster/cache/9380f_0314-ECG-small-2.jpg

35. http://drsvenkatesan.files.wordpress.com/2008/09/ua.png?w=500&h=122

36. MYOCARDIAL INFARCTION ST-segment elevation, in patients with total occlusion Then, presence of Q-waves In partial occlusion, Q-waves may not be present. If no ST-segment elevation, but cardiac markers raised, then, diagnosis of NSTEMI is made. ELECTROCARDIOGRAM

38. http://www.google.co.in/imgres?imgurl=http://www.trialimagestore.com/imagesDW3/mi_article_ekgs/inf_mi_2_JPEG.jpg&imgrefurl=http://www.trialimagestore.com/article_myocardial_infarction_heart_attack.html&usg=__guojgJu9pYR2ImqurueusU1DsD8=&h=371&w=668&sz=77&hl=en&start=8&zoom=1&tbnid=lfmFcyE-pQuVvM:&tbnh=77&tbnw=138&ei=-_UJToOUGNDKrAem1YyvDw&prev=/search%3Fq%3Dst%2Belevation%2Bmi%26hl%3Den%26gbv%3D2%26biw%3D1366%26bih%3D661%26tbm%3Disch&itbs=1&biw=1366&bih=661

39. http://www.frca.co.uk/images_main/resources/ECG/ECGresource44.jpg

40. The EKG shows ST elevation in leads II, III, and aVF suggesting inferior wall myocardial infarction. Reciprocal changes (ST segment depression) may be seen in leads V1 and V2 in inferior wall myocardial infarction as in this patient. In addition there is ST elevation in lead V6 suggesting lateral wall involvement. Lateral infarction produces changes in leads I, avL and V5/6.

41. ANTERIOR WALL MI

42. ANTERIOR WALL MI http://www.learntheheart.com/AnteriorSTEMI.jpg

43. 1) Sinus rhythm with 2nd degree type I AV block (Wenkebach)2) Inferior ST segment elevation MI (leads II, III, and aVF) with reciprocal ST depression (leads I and aVL) http://www.learntheheart.com/Case1.html

44. Differentiates between UA & NSTEMI Raised in state of infarction, not in angina. Markers commonly used are: CK-MB Troponin Troponin more specific and sensitive marker of myocardial necrosis. CARDIAC BIOMARKERS

45. http://upload.wikimedia.org/wikipedia/commons/thumb/8/80/AMI_bloodtests_engl.png/400px-AMI_bloodtests_engl.png

47. 2D-Echocardiography Easy Safe Quick Cannot differentiate between old myocardial scar & acute severe ischemia. Other uses: Ventricular aneurysm Pericardial effusion LV thrombus CARDIAC IMAGING

48. http://www.users.interport.net/w/s/wsc1/www.westsubcardiology.com/pages/noninvasive/echo/echo1.jpg MITRAL REGURGITATION

49. IMAGE 1 OF 2…

50. IMAGE 2 OF 2…

51. DOPPLER ECHOCARDIOGRAPHY To detect serious complications of STEMI: Ventricular septal defect Mitral regurgitation PERFUSION IMAGING 99mTc-sestamibi or 201Tl reveals a defect “cold spot” in 1st few hours after the transmural infarct. Radionucleotideventriculography, with 99mTc-labeled RBCs, detects wall motion abnormalities & reduction in ventricular ejection fraction.

52. CORONARY ANGIOGRAPHY http://98.131.235.9/images/Normal-coronary-Angiogram.jpg

53. http://98.131.235.9/images/Diseased-left-coronary-Artery.jpg

54. Coronary angiography showing lesions in the circumflex artery http://www.tkd.org.tr/TKD_DATA/dergi/images/2004-04-91s.gif

55. Initial management aims at complete bed-rest with continuous ECG monitoring for ST-segment deviation & cardiac rhythm. Ambulation permitted onlyh if patients shows no recurrence of ischemia (discomfort or ECG changes) and does not develop biomarkers of necrosis for 12-24 hours. TREATMENT OF UA/NSTEMI

56. MEDICAL MANAGEMENT

57. ANTI-ISCHEMIC TREATMENT

59. ANTI-THROMBOTIC THERAPY

61. TREATMENT OF STEMI

62. Largely based on prevention of complications: Electrical complications (arrhythmias) Mechanical complications (pump failure) Identification of patients who needs quick reperfusion therapy Symptomatic relief: Aspirin O2 therapy Nitroglycerin SL Morphine IV B-Blockers INITIAL MANAGEMENT

63. Further line of management depends on selection of either reperfusion therapy by fibrinolysis or primary PCI. Fibrinolysis includes : HOSPITAL CARE

64. Percutaneous coronary intervention Angioplasty Stenting PRIMARY PCI : without prior fibrinolysis SECONDARY PCI : prior fibrinolysis http://www.umm.edu/graphics/images/en/19006.jpg

66. CORONARY ARTERY BYPASS GRAFT (CABG) http://www.daviddarling.info/images/coronary_artery_bypass.jpg

68. THANK YOU TIKAL KANSARA INTERN CIVIL HOSPITAL AHMEDABAD