Acute Coronary Syndrome

Presented by:Dr. Asim Siddig AbdelrahmanHO Medicine Department

Contents

• Definition of ACS.• Classifications.•Management.• Complications.

Definition

a constellation of symptoms related to obstruction of coronary arteries with chest pain being the most common symptom in addition to nausea, vomiting, diaphoresis

etc.often radiating to the left arm or angle of

the jaw, pressure-like in character

ACS is classified into:

Unstable AnginaSTEMI

NSTEMI

UNSTABLE ANGINA• Pain occurring at rest –

duration > 20min. • Worsening of chest pain,

increases in frequency, duration.

• Angina becoming resistance to drugs that previously gave good control.

• NB! ECG – normal, ST depression(>0.5mm), T wave changes

MI• Leading cause of death in US• Thrombosis in atherosclerotic artery causes 90%

of MIs.• A region of the myocardium is abruptly deprived

of blood supply due to restricted coronary blood flow.• Ischemia results and may lead to necrosis within

6 hours.

Risk Factors

• Age• Sex• FH : MI in 1st degree relatives <55 yrs.• Smoking.• Obesity, sedentary lifestyle.• HTN, DM.• Hyperlipidemia.

Females, when compared to males:

-present with MI later in life.-have poorer prognosis and high morbidity.-are 2x as likely to die in the first weeks.-are more likely to die from the first MI.-have higher rates of unrecognized MI.

Study in US

Features suggesting MI • The pains are usually more

severe .• There are more associated

symptoms such as sweating, palpitation, nausea, or vomiting.

• Duration is > 20 minutes.• Usual relieving factors such as

rest or GTN spray do not help.• May be silent in elderly or

diabetics.• Patients often tells you they

think they are going to die (EXTREME distress, sweatiness, anxiety, pulse, BP or ).

DiagnosisBrief History and physical Examination………

Generally DO:

• CBC.• U&E.• Random BG.• Lipid profile.• CXR: but do not delay treatment waiting

for it.

ECGCardiac Enzymes

STEMI:• ST elevation, Q waves , hyper

acute T waves; followed by T wave inversions.

• Clinically significant ST segment elevations:

• > than 1 mm (0.1 mV) in at least two limb contiguous leads

• or 2 mm (0.2 mV) in two contiguous chest leads (V2 and V3)

• Note: LBBB and pacemakers can interfere with diagnosis of MI on ECG.

The ECG changes

ST elevationInferior MI

NSTEM: ST depressions (0.5 mm at least) or T wave inversions ( 1.0 mm at least) or normal ECG.

• Troponin:• The most sensitive and specific marker of myocardial

necrosis.• Serum level increases within 3-12 hrs from the onset of

Chest pain.• +ve in both STEMI and NSTEMI, but –ve in U. angina.

• CK-MB.• Myoglobin.

Management of ACS

Management of ACS• Good IV access• Supplemental O2• Aspirin 300mg ; consider Clopidogrel 300mg too.• Nitrates 1-2 tabs SL.• Morphine 5-10mg IV.• Beta blocker, eg Atenolol 5mg IV (unless Asthma

or LVF).• Restore coronary perfusion : PCI or thrombolysis

in STEMI .• Heparin (LMW) in NSTEMI and U.angina.• Call cardiology fellow! …….. CCU.

Subsequent management• Bed rest 48hrs, continuous ECG monitoring.• Daily Ex.• Prophylaxis againest thromboembolism until fully

mobile (consider warfarin for 3 mo if large Ant.MI).• Aspirin eg 75mg to decrease vascular events.• Long term B blockers.• Starts statin. • ACE inhibitors in all pts ...stop if EF normal.• Address modifiable risk factors eg smoking. • If uncomplicated discharge after 5-7 days.

thrombolysis

Criteria:• ST elevation; >1mm in 2 or more limb leads or

>2mm in 2 or more chest leads.• Newly developed LBBB.• Posterior changes deep ST depression and tall R

waves in V1 toV3.Contraindications;• Internal bleeding, recent surgery and severe

HTN.eg Streptokinase.

Complications:

• Cardiac arrest….. vent. Arrhythmias.• Bradycardias or heart block.• Tachyarrhythmias.• CHF.• Pericarditis.• DVT and PE.

Attention…..SUMMARY

Unstable Angina STEMI

NSTEMI

Non occlusive thrombus

Non specific ECG

Normal cardiac Enzymes.Ttt: +heparin

Non-occlusive thrombus sufficient to cause tissue damage & mild myocardial necrosis

ST depression +/- T wave inversion on ECG, non significant.

Elevated cardiac Enzymes.Ttt: +heparin

Complete thrombus occlusion

ST elevations on ECG or new LBBB

Elevated cardiac enzymesMore severe Symptoms.Ttt: +thromolytics.

Thanks