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Diagnosis ACS-PIB Unhas

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DIAGNOSIS OF ACUTECORONARY SYNDROME

Pendrik Tandean

Cardiology Department Medi!alFa!"lty o# $a%an"ddin Uni&er%ityMaka%%ar

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Cla%%i'!ation A!"te !oronary %yndrome% in!l"de

  ST(ele&ation MI )STEMI*

  Non ST(ele&ation MI ) NSTEMI*

  Un%ta+le Angina

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A!"te Coronary SyndromeIschemic Discomfort

Unstable Symptoms

 No ST-segment

elevation

 ST-segment

elevation

Unstable Non-Q Q-Wave

angina AMI AMI

ECG

Acute

eperfusion

!istory

"hysical E#am

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Un%ta+le Angina angina at re%t ), -. min"te%*

ne/(on%et )0 - mont1%* e2ertional

angina )at lea%t CCSC III in %e&erity* re!ent )0 - mont1%* a!!eleration o#

angina )in!rea%e in %e&erity o# at

lea%t one CCSC !la%% to at lea%tCCSC !la%% III*

Agency for !ealth Care "olicy esearch - $%%&

Cana'ian Car'iovascular Society Classification

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CANADIAN CARDIO3ASCU4ARSOCIETY FUNCTIONA4

C4ASSIFICATION C4ASS I No angina /it1 ordinary 

a!ti&ity5 Angina /it1 %tren"o"% rapid orprolonged e2ertion5

C4ASS II Slig1t limitation o# ordinarya!ti&ity 6 angina /1en /alking "p %tair%+ri%kly or /alking on a !old or /indy day5

C4ASS III Marked limitation 6 angina

/1en /alking at normal pa!e "p 7ig1t o#%tair% or /alking 8(- +lo!k% di%tan!e5 C4ASS I3 Angina on minimal e2ertion or

at re%t5

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Clini!al Feat"re% o# MI Cr"%1ing 1ea&y %"+%ternal !1e%t

pain radiating to t1e ne!k andmedial a%pe!t o# t1e le#t arm

Pain may +e atypi!al )like a

+"rning* lo!ali9ed )only in t1e :a/* or a+%ent

Sta+le angina i% "%"ally !a"%ed+y e2er!i%e or an2iety i% %1ort(li&ed and i% relie&ed +y re%t

and;or NTG Un%ta+le angina o!!"r% at re%t

and la%t% longer<ne/ painaltered %ta+le angina patternna"%ea;%/eating and radiation tone/ %ite% al%o %"gge%t% "n%ta+le

angina

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Clini!al #eat"re% !ont< Myo!ardial in#ar!tion %ign%;%ymptom%

A+r"pt on%et o# %e&ere prolonged pain

A"tonomi! %ymptom% )%/eating na"%ea* Dy%pnea

An2iety

 Ta!1y!ardia or +rady!ardia depending on

%ite o# MI $ypoten%ion

Gallop 1eart r1yt1m

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Determining;!on'rming an

MI Serial E=G>% Angina

 T /a&e in&er%ion ST depre%%ion Cond"!tion de#e!t% )eg(+"ndle +ran!1 +lo!k%*

MI S"+endo!ardial )doe%n>t go all t1e /ay t1r" t1e m"%!le*

ST depre%%ion  T /a&e in&er%ion

 Tran%m"ral )goe% all t1e /ay t1r" t1e m"%!le* Pre%en!e o# ? /a&e Ele&ated ST %egment

Cardia! en9yme% Myo!ardial ne!ro%i% relea%e% !ardia! en9yme% into t1e

pla%ma<CTT and C=(M@ peak /it1in - 1o"r%<4D$(8 peak%at B( day% o"t

In!rea%ed !ardia! troponin T )CTT* at 8- 1r% make% diagno%i% In!rea%ed 4D$(8%"gge%t% late pre%entation MI Do"+ling o# +a%eline C=(M@ !on'rm% MI

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Ele!tro!ardiogram A normal ECG doe% not e2!l"de ACS

$ig1 pro+a+ility in!l"de ST %egment

ele&ation in t/o !ontig"o"% lead% orpre%en!e o# /a&e%

Intermediate pro+a+ility ST

depre%%ion T /a&e in&er%ion% are le%% %pe!i'!

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Ischemia & Infarction

• Indications of an acute infarction• Usually no ECG changes are seen in the first few minutes after occlusion

•  Appearance of tall narrow T-waves or ST-segment elevation• 5 to 3 minutes post occlusion

•  A few hours later! the T-waves invert "ischemia#

• in an $%! the T-wave inversion is symmetrical an may persist for years

• inverte& T-waves without other in&ications are not &iagnostic of an $%

• ST-segment elevation ' in&ication of in(ury "although it may )e reversi)le#

• ST-elevation may also in&icate transmural ischemia• usually the first &efinite sign of an infarction

• may or may not )e accompanie& )y T-wave inversion

• *mm or more in lim) lea&s or +mm or more in precor&ial lea&s

• &ifferentiate )etween early repolari,ation or .-point elevation/

•  the larger the ischemic area! the greater the ST &isplacement

• ST elevation persisting for more than a few hours may in&icate ventricular aneurysm

• ST &epression may )e seen in reciprocal lea&s0

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ST %egment Ele&ation

http122www0eme&u0org2

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ST %egment Ele&ation

http122www0eme&u0org2

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ST SEGMENT E4E3ATION

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ST %egment depre%%ion

http122www0eme&u0org2

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Cardia! @iomarker% Cardia! +iomarker% are protein

mole!"le% relea%ed into t1e +lood

%tream #rom damaged 1eart m"%!le Sin!e ECG !an +e in!on!l"%i&e

+iomarker% are #re"ently "%ed to

e&al"ate #or myo!ardial in:"ry T1e%e +iomarker% 1a&e a

!1ara!teri%ti! ri%e and #all pattern

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 Troponin T and I T1e%e i%o#orm% are &ery %pe!i'!

#or !ardia! in:"ry

Pre#erred marker% #or dete!ting

myo!ardial !ell in:"ry

Ri%e -( 1o"r% a#ter in:"ry

  Peak in 8-(8 1o"r%

  Stay ele&ated #or (8 day%

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Creatine =ina%e )M@*

 Time %e"en!e a#ter myo!ardialin#ar!tion

  @egin% to ri%e ( 1o"r%  Peak% - 1o"r%

  ret"rn% to normal in - day%

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Ischemia & Infarction

• Biomarkers in an MI:

ays after $% 4nset

   $  u   l   t   i  p   l  e  s  o   f   t   h  e   A   $   %  c

  u   t  o   f   f   5   i  m   i   t

* + 3 6 5 7 8 9

$yoglo)in

Car&iac Troponin

C:-$;

Car&iac Troponin after unsta)le angina

*

+

5

*

+

5

 A$% &ecision limitUpper normal limit

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Determining MI !ont<

E!1o!ardiograp1y May %1o/ dy%kine%ia o# m"%!le

m"ral t1rom+"% per#oration%ane"ry%m% papillary m"%!le r"pt"reand &al&e le%ion%

N"!lear %!an%

 Te!1neti"m pyrop1o%p1ate Con!entrate% in area o# damage

 T1alli"m %!an% S1o/ !old %pot% in non(per#"%ed

myo!ardi"m and demon%trate area% o#

re&er%i+le i%!1emia

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E!1o!ardiograp1y

U%e -(dimentional and M modee!1o!ardiograp1y /1en e&al"ating

o&erall &entri!"lar #"n!tion and/all motion a+normalitie%

 E!1o!ardiograp1y !an al%o identi#y

!ompli!ation% o# MI ) eg5 3al&"lar orperi!ardial e"%ion 3SD*

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Coronary Angiography

a&<hah

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!AN" #$U