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Acute coronary
SyndromesBy
Dr N Aravinthan
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Pathophysiology
Factors those encourages the premature
coronary arteries narrowing
a) Smokingb) Hypertension
c) Hypercholesterolemia
d) Diabetes mellitus
e) Obesity
f) Family history
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Clinical scenarios
A. Stable angina Only occurs with exercise
Pain last for < 30ml
B. Unstable angina Typical chest pain at rest
Pain last for < 30min
C. Myocardial infarction
Un remitting , lasting several hours Sweating, nausea
Sometimes vomiting and breathlessness
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Diagnosis of MI
a. Typical history
b. ECG changes
c. Elevation of serum cardiac
enzymes
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ECG
Complete occlusion of coronary artery causingfull thickness MI(STEMI)
Partial occlusion-ST depression/ T-waveinversion(NSTEMI)
Site of MI suggested by the ECG- importantprog-significant
E.g. Anterior MI V2-V4 leads changes Occlusion of left anterior descending artery
Lead to left ventricle wall affected worse prognosis
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Cardiac enzymes elevation
Troponins- I and T- prolong release pattern up
to 10 days. They are more cardiac specific
However not specific for ischemic injuryE.g. myocarditis, pulmonary embolus
and arrhythmias
CKMB-best use in find out timing of aninfarct or size of the infarct
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Other investigations
Echo - regional wall motion abnormalityventricular septal defect etc
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Mx-routine measures
A. Relieve chest pain Nitroglycerin(0.4mg sublingual tablets or aerosol spray) given
up to 3 doses
If chest pain persist
Morphine 5 mg given by slow IV; can be repeated every 5 to 10 minB. Antiplatelet therapy
Chewable aspirin 150-300mg-irreversible inhibition of plateletaggregation. this initial dose fallowed by 75-150 mg daily dose
Clopidogrel inhibit ADP-mediated platelet aggregations300mg fallowed by 75mg daily
Combined therapy with both-have very law mortality thaneach alone
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Mx cont..
receptor blockade atenolol and metoprolol
Recommended for all ACS patients except those
with bradycardiaOral therapy is suitable for most cases
IV form to pt with HT or Tachyarrhythmias
Oral- 50mg every 6 hours for 48 hours.
Iv form add 5 mg metoprolol to 50 ml DW and infuseover 15-30min. Repeat every 6 hours
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Mx cont..o ACE inhibitors
o reduce cardiac work
o also useful in inhibition of post MI cardiac
remodelingo Can be useful in all patient except severe
hypotension, SK > 2.5 mg/all and bilateral
renal artery stenosis
o Oral therapy only recommended doses 5 mg
enalapril/D
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Reperfusion therapy
thrombolytic
mechanical
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Thrombolytic
Indications
Onset of chest pain within 12 hours
12 lead ECG
shows ST elevation in two contiguousleads or a new left bundle branch block
Coronary angioplasty not immediately available
No hypotension or evidence of heart failure
No contraindication to thrombolytic therapy
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Contraindications to thrombolytic
therapy Absolute
previous hemorrhagic stroke
Any stroke within previous 2 months
Intracranial neoplasm
Active bleeding within previous month(except menstrual)
aortic dissection
Major surgery in last 3 weeks
Relative Stroke > 2 months < 1 2months
Pregnancy
Active peptic ulcer disease
Serve hypertension on presentation(> 180/110 mm hg)
Surgery/trauma within previous month
Bleeding diathesis
CPR > 10 min
Non compressible vascular puncture
allergy
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Thrombolytic agents
Agent Dose comments
Streptokinase
(SK)
1.5 million UTV over 60
min
First thrombolytic agent
Side effects fever, allergic
reaction etc
Alteplase (TPA) 15 mg IV holus
+0.75 mg/kg 30 min
+0.75 g/kg 60 min
Most frequently used
Fewer side effects
Reteolase 10 unit in holus repeat in
30 min
Rapid clot lysis than TPA bolus
doses easier to give
Plasmin
Plasminogen
Bresks tinrin
strands
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Problems with thrombolytic agents
A. bleeding Systemic fibrinolysis with depletion of circulating fibrinogen
levels
Interacerebral haemorrhages 0.5 1%
Severe bleeding- treated with cryoprecipitate, fresh frozenplasma, antifribrinolytic agents epsilon aminocaproic acid
B. Re occlusion this risk can be treated with antithrombotictherapy Asprin inhibit formation of thromboxane
Platelet glycoprotein inhibitors inhibit platelet aggregationsEg tirofiban, abciximab
ADP mediated platelet inhibitors - clopidogrel
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Percutaneus coronary angioplasty
Use of balloon tipped catheters with or
without a stent to open occluded arteries
Several clinical trials showsPC
A havingreduction in both mortality rate and rein -
farction rate than thrombolytic therapy who
present within 12 hours
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Early complications of ACS
I. Mechanical
a) Acute mitral regurgitation result of papillary
muscle rupture
b) Ventricular septal rupture
c) Ventricular free wall rupture
II. Arrhythmias
III. Cardiac pump failure
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Thank you very much
for listening
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