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Emergency Medicine: Cardiology 213

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  1. Acute Coronary Syndromes: A Focus on STEMI
    10 Topics
    |
    3 Quizzes
  2. Acute decompensated heart failure
    10 Topics
    |
    3 Quizzes
  3. Hypertensive Urgency and Emergency Management
    11 Topics
    |
    3 Quizzes
  4. Acute aortic dissection
    9 Topics
    |
    2 Quizzes
  5. Arrhythmias (Afib, SVT, VTach)
    10 Topics
    |
    2 Quizzes

Participants 220

  • April
  • Alyssa
  • Ashley
  • Amber
  • Sherif
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  • Diagnostic tools for ACS include: ECG, cardiac enzymes, and imaging studies such as cardiac CT or nuclear myocardial perfusion imaging

Risk stratification and use of appropriate diagnostic tests is essential for accurate diagnosis and timely treatment of ACS


History and Physical Exam


Electrocardiography

  • Provides information about the heart’s electrical activity and rhythm
  • Helps identify changes associated with ischemia, injury, and infarction
  • Can reveal ST segment elevation, T wave inversions, and Q waves
  • Should be performed as soon as possible in patients with suspected ACS
  • Repeat ECGs should be obtained for dynamic ECG changes
  • Serial ECGs can also be useful for monitoring response to treatment
  • Can help determine the appropriate reperfusion strategy for STEMI patients
STEMINSTEMI
IndicatesTransmural ischemia and infarctionSubendocardial ischemia and/or nontransmural infarct
ST segment elevationPresentAbsent
T wave inversionsMay be presentMay be present
Q wavesPresent, indicating transmural infarctionMay be present, indicating prior MI or ischemia
Dynamic changesECG changes may evolve over timeECG changes tend to be more stable
Serial ECGsUseful for monitoring response to treatmentUseful for monitoring response to treatment
Appropriate reperfusion strategy for STEMI patientsECG findings help determine the appropriate reperfusion strategy for STEMI patientsECG findings do not directly determine reperfusion strategy but can help with risk stratification and treatment planning

Cardiac biomarkers

  • Biomarkers are substances released into the bloodstream in response to myocardial cell injury or death
  • Troponin is the most sensitive and specific biomarker for myocardial infarction
  • Elevated troponin levels confirm the diagnosis of MI and help with risk stratification
  • CK-MB is a less specific biomarker but can still be useful in some clinical scenarios
  • Biomarker levels should be obtained at presentation and at 3-6 hours after symptom onset
  • Serial biomarker testing can help monitor response to treatment and risk for complications
  • High-sensitivity troponin assays are increasingly used for early detection and risk stratification of ACS
BiomarkerDescriptionTimingSensitivitySpecificityClinical Utility
TroponinRegulatory protein released during myocardial injuryMeasured at presentation and repeatedHighHighDiagnosis, risk stratification, monitoring response to treatment
CK-MBEnzyme released during myocardial injuryMeasured at presentation and repeatedLowModerateDiagnosis
MyoglobinHeme protein released during myocardial injuryMeasured at presentation onlyLowLowRule-out ACS in low-risk patients
BNPHormone secreted by the heart in response to stress or volume overloadMeasured at presentation onlyLowHighDiagnosis, risk stratification, monitoring response to treatment

Other diagnostic tests and imaging


Stratification in ACS

  • Multiple risk assessment tools are available for evaluating patients with ACS
  • TIMI (Thrombolysis in Myocardial Infarction) score, HEART (History, Electrocardiogram, Age, Risk factors, Troponin) score, and GRACE (Global Registry of Acute Coronary Events) score are commonly used
  • These tools can aid in risk stratification, guiding management decisions, and identifying patients who may benefit from more aggressive treatment

Calculating Risk Scores