Cancel the Cath Lab Activation; Its only an NSTEMI

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By Andrew Barbera, PGY3

Who Needs a Cath?

 

63 year old male with history of HTN, OA s/p R hip replacement, PTSD was BIBEMS after syncopal event. Pt states that evening he felt acute general weakness when he was on the subway. The weakness worsened when he got off the subway and was walking in the street. He then developed acute severe SOB and he stopped and rested himself on the trunk of a car. Pt then lost consciousness and awoke in the ambulance. Pt stated upon awakening he was alert and oriented. Pt denied CP, palpitations, diaphoresis or dizziness before passing out or during initial ED evaluation. Pt also denied any recent exercise intolerance, recent chest pain, orthopnea or additional symptoms. Pt reported normal stress test done 6 months ago at VA for unknown reason. Initial EMS ekg showed sinus rhythm, slight left axis deviation, LBBB with 0.5 mm ST depression II, III, avF, I, aVL. Repeat EKG on ED presentation showed NSR, slight left axis deviation, with no ST-T depression/elevations or rhythm issues. Pt had received 162mg of asa by ems prior to ED arrival. During ED evaluation pt developed an episode of acute, moderate, left sided, pressure like CP. Pt was given sublingual nitro and morphine with full resolution within 45 min. Repeat EKG during this episode showed NSR, comparing the previous one, new TWI in III and aVF. Pt’s initial troponin was negative at 0.021, but repeat troponin was positive at 3.37. Cardiology was consulted. Pt diagnosed with NSTEMI. Cardiology at the time declined emergent transfer for coronary cath, and wanted to optimize the patient on medical management. Pt was loaded with 600mg of Plavix and heparin bolus and drip was started. Pt was transferred to CCU for additional medical management and cardiac monitoring.

 

CCU course pt remained chest pain free, serial EKG’s remained unchanged and pt had serial troponins that were down trending. Pt was additionally risk stratified with ECHO for wall motion abnormalities (hypokinesis) and LVEF and found to be normal. Pt was optimized on medical management with metoprolol, atorvastatin, Plavix and asa. Pt was discharged home with close cardiology follow up.

 

This made me think what are the indications for cardiac revascularization (aggressive) vs. medical management (conservative) in pts with NSTEMI. According to the 2011 ACCF/AHA Focused Update of the Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction, Pt’s with NSTEMI who have signs of persistent angina or electrical and or hemodynamic instability should receive early cardiac revascularization.[1] Pt’s with acute decreased LVEF (40% or less) or signs of heart failure should also be considered for early cardiac revascularization. Additionally pts with any signs of continued or repeat ischemia, or new serious arrhythmia.[2]

Additionally there are several randomized trials including FRISC II, TACTICS-TIMI 18, both of which showed a significant lower rate of primary end point of death or repeat MI, especially in high risk individuals. [3]

 

In summary it seems that high-risk patients with NSTEMI/Unstable angina should undergo early cardiac revascularization. Patients with signs and symptoms of ongoing or repeat ischemia have better outcomes after reperfusion vs. conservative therapy, along with patients who have failed medical therapy. Pts that are lower risk for repeat or continued ischemia may have greater risk/benefit from the conservative medical management.

 

 

[1] Wright RS, Anderson JL, Adams CD, et al. 2011 ACCF/AHA Focused Update of the Guidelines for the Management of Patients With Unstable Angina/ Non-ST-Elevation Myocardial Infarction (Updating the 2007 Guideline): A Report of the American College of Cardiology Foundation/American Heart Association . Circulation 2011:2022–2060.

[2] Unstable Angina Treatment & Management. Unstable Angina Treatment & Management: Approach Considerations, Initial Medical Management, Further Medical Management. Available at: http://emedicine.medscape.com/article/159383-treatment. Accessed September 2016.

[3] Kumar A, Cannon CP. Acute coronary syndromes: diagnosis and management, part I. Mayo Clin Proc. 2009;84(10):917-38.

2 Comments

  • Tonynap

    Well done. Another thought should come to mind. Why do we admit syncope. We have been brainwashed for so long to admit all syncope regardless that we have forgotten what we are afraid of. I don’t admit a lot of syncope patients but there is NO WAY this one gets away.
    Admit syncope patients for three reasons, and this guy has all three of them.
    1. Syncope that could have have resulted in the sudden loss of 40% of the patients cardiac output. No blood to the brain, down you go. For the same reason be afraid of EPISODIC vertigo with signs that could be attributed to syncope/brainstem lesions (VBSyndrome)
    2. Tachyarrythnias resulting in the same thing
    3. Bradyarrythmias resulting in the same thing

  • pik

    Nice post. 2 very large cans of worms opened. Let’s do the easy one first.

    1: You quoted guidelines that NSTEMI’s who are unstable or have persistent angina need cath. So: IS it angina when you’re admitting or OBS unit-ing? Sure, after the Trop comes back positive. Before then they MAY have unstable angina. Or it might be GERD. Those are stable pts. who it would be tough to get your cath team out of bed for, since you wouldn’t have done nothing for them before the Trop if they weren’t stable. When the Trop comes back, you’ve made a dx but nothing else has changed. Also, prepare for a discussion of “demand ischemia,” “what’s their Cr.?” and Type II MI if you call Cards. But what if they’re UN-stable? Then you may have more traction pushing for cath.

    2: The distinction between STEMI and NSTEMI is largely artificial, dictated by our ability to measure with an EKG. If ECHO was the easy, ancient tech, and EKGs were new, we’d have FWM vs. PWM (full wall motion abnormality vs. partial wall motion abnormality). Chew on that for a little while. What it comes down to is that we cath STEMI, and don’t always find occlusion, but don’t cath NSTEMI and sometimes miss occlusion. This false dichotomy is difficult to get your head around, but very much understood by any EM attending who works in a little community place and has to get on the phone and rally the troops to cath his NSTEMI with persistent symptoms. Or alert Cards to subtle EKG changes that don’t quite meet “criteria.”

    If the pt. above had “ROSC” instead of “syncope, resolved” think how much easier the cath conversation would have gone.

    Hi Nap.

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