ACUTE CORONARY SYNDROME 3.

Angina at rest
- USA, NSTEMI, STEMI * USA no cardiac enzyme elevation
- d/t atherosclerotic rupture and
coronary occlusion [Dx] – same as S. Angina

Stable angina pectoris [Tx] – (treat like MI except fibrinolysis)

[CF] 1. Cardiac monitoring
1. Chest pain 2. Give oxygen
a. <10-15 mins 3. Medicine
b. heavy, tightness, squeezing, a. Aspirin
pressure b. Clopidogrel
c. gradual onset c. B-blockers
2. On exertion d. Low-molecular weight heparin
3. Relieved by rest // GTN (nitroglycerine) (LMWH) – enoxaparin
* do NOT change with breathing or change of 4. Surgical
position. NO chest wall tenderness a. PCI
b. CABG
[Dx]
1. ECG: normal After acute Tx:
2. Stress test - Continue anti-platelet, B-blocker,
a. ECG nitrates
b. Echocardiography - Treat co-morbids
 ST depression, hypotension, chest
pain, significant arrhythmia => +ve Variant [Prinzmetal] Angina
3. Coronary angiography = transient coronary vasospasm in fixed
- Identify presence & severity of CAD atherosclerotic lesion OR normal coronary art.

[Tx] [CF]
1. Smoking cessation 1. Chest pain
2. Exercise 2. Occur at rest
3. Control co-morbids 3. Typically at night
a. HTN 4. Ass/w ventricular dysrhythmias
b. DM
c. Hyperlipidemia [Dx]
d. Obesity (Weight loss) 1. ECG
4. Diet:  Fat,  Cholesterol - Transient ST elevation during chest pain
5. Medicine 2. Coronary angiography
a. Aspirin - Give IV ergonovine// acetylcholine – to
b. B-blocker (atenolol, Metoprolol) provoke vasoconstriction
c. Nitrates
d. CCB [Tx]
6. Surgical: >70% stenosis 1. Vasodilators
a. Percutaneous coronary a. CCB
intervention [PCI] - Angioplasty b. Nitrates
 Ballooning, stenting 2. Life style modification
b. CABG
Myocardial Infarction (MI)
Unstable angina pectoris [CF]
= oxygen demand unchanged. Supply decreased 1. Chest pain
a. > 15 minutes
[CF] b. Substernal pressure “crushing”
1. Chronic angina with  frequency, duration, c. Radiate: neck, jaw, arm, or back
CP intensity  Usually left side
2. Severe and worsening d. More severe than angina
 e. Not relieved by GTN
f. +/- epigastric discomfort
2. Asymptomatic (in 1/3 of patients)
a. Postoperative,
b. Elderly,
c. Diabetic,
d. Women
3. Other
a. Dyspnoea
b. Diaphoresis
c. Weakness, fatigue
d. Nausea, vomiting
e. Sense of impending doom
f. Syncope
4. Sudden cardiac death – usually d/t
ventricular fibrillation (Vfib)
Chest pain + diaphoresis
+ >30 minutes = acute MI
[Dx]
1. ECG
a. Ischaemia/infarction
 Peaked T waves (early)
 ST elevation – transmural injury, acute
infarct
 Q wave – necrosis (late, specific)
 T-wave inversion (not specific)
 ST depression – subendocardial injury
** Cardiac enzyme taken on admission and
every 8 hours
Right ventricular infarct:
- ECG changes, hypotension, raised JVP,
hepatomegaly, CLEAR lungs
- Preload dependant – DO NOT
givenitrates or diuretics.  CV
collapse
[Tx]
1. Oxygen
2. Aspirin
3. B-blocker – atenolol, metoprolol
4. ACE-I – captopril, enalapril
5. Nitrates
6. Morphine
7. Heparin – initiate in all patients with MI. do
not decrease mortality
8. Revascularize
a. Thrombolytics – Altepase,
streptokinase
 NOT in prev. stroke, active
bleeding, trauma, dissecting
aortic aneurysm, recent
surgery
b. PCI
c. CABG
9. Cardiac Rehab

b. STEMI: Transmural
c. NSTEMI: subendocardial
2. Cardiac enzyme
a. Troponin I and T
 Falsely elevated in renal failure
 Increase in 3-5 hours, lasts 5-14
days.
b. CK-MB
 Increase in 4-8 hours, lasts 2-3
days.
 Detect recurrent infarct (return
to baseline faster than
troponin)
Congestive Heart Failure
[Causes]
- HTN  myocardial hypertrophy
- Valvular disease
- Restrictive cardiomyopathy (amyloidosis,
sarcoidosis)

[CF]
1. Dyspnoea
2. Orthopnoea, PND
3. Nocturnal cough
4. Confusion, memory loss
5. Diaphoresis & cool extremities at rest

Left-sided Right-sided
1. Pathological S3 1. Pitting edema
2. S4 gallop 2. Hepatomegaly
3. Lung bases 3. JVP
crackles and rales 4. Parasternal heave
4. Pleural effusion, 5. Ascites
Pulmonary HTN 6. Nocturia

[Dx]
1. CXR
a. (TLF P.edema, cardiomegaly,
pleural effusion)
2. ECG
a. (TLF chamber enlargement,
ischaemia)
3. Echocardiography
a. EF <40% = systolic dysfunction
b. Determine cause of CHF
4. Cardiac enzymes (TRO MI)

[Tx]
Systolic dysfunction
1. Diuretics
a. Loop: furosemide
b. Thiazide: hydrochlorothiazide
2. B-blocker
3. ACE-I
4. ARB
5. Spironolactone
6. Digoxin

Diastolic dysfunction
1 B-blocker & diuretic
CIx: digoxin and spironolactone