Acute Coronary

Syndrome
PREPARED BY HAFASHIMANA EMMANUEL
 OBJECTIVES
•Definition of ACS
• UA, NSTEMI, and STEMI
• Risk stratification in NSTEMI
•causes
• Management
Acute Coronary Syndrome
Definition:
 constellation of symptoms related to obstruction of coronary arteries with chest pain being the
most common symptom in addition to nausea, vomiting, diaphoresis etc.
Chest pain concerned for ACS is often radiating to the left arm or angle of the jaw, pressure-like in
character, and associated with nausea and sweating. Chest pain is often categorized into typical and
atypical angina
Coronary artery disease: The etiology of ischemic heart disease in pregnant women is similar to
that of non-pregnant women.
12% die within 1 month. 20% die within 6 months.
Nearly 1.5 million hospital discharges involve patients with ACS. According to statistics from the
American Heart Association (AHA), approximately 18% of men and 23% of women over the age of
40 will die within 1 year of having an initial recognized MI.
Acute coronary syndrome
Based on ECG and cardiac enzymes, ACS is classified into:
• STEMI: ST elevation, elevated cardiac enzymes
• NSTEMI: ST depression, T-wave inversion, elevated cardiac enzymes
• Unstable Angina: Non specific EKG changes, normal cardiac enzyme
Unstable Angina

• Occurs at rest and prolonged, usually lasting >20 minutes

• New onset angina that limits activity
• Increasing angina: Pain that occurs more frequently, lasts longer periods or is increasingly
limiting the patients activity
Cardiac Enzymes
• Troponin is primarily used for diagnosing MI because it has good sensitivity and specificity.
Rise after 3-5 h.,Peak at 24-48 h and Return to normal in 5-14 d.
• CK-MB is more useful in certain situations such as post reperfusion MI or if troponin test is not
available Rise after 4-8 h. oPeak at 24-36 h. o Return to normal at 2 d.
• Other conditions can cause elevation in troponin such as renal failure or heart failure
• The increasing troponin trend is the important thing to look for in diagnosing MI.
Order Troponin together with ECG when doing serial testing to rule out ACS.
Aetiologies
Most common cause:
• Acute thrombus.
Rarer causes:
•Coronary artery embolism.
• Coronary spasm → Spasm-induced MI
•Spontaneous coronary artery dissection.
Risk Stratification: TIMI score (
Infarction)
Thrombolysis in Myocardial

NSTEMI or unstable angina are risk stratified:

• Age>=65
• >= 3 CAD risk factors: ( HTN, hyperlipidemia, diabetes, smoker, family hx of early MI)
• Documented CAD with >=50% stenosis
• ST segment deviation • ≥ 2 aginal episodes in past 24 hours
• Aspirin use in the past week (marker for more severe case)
• Elevation of cardiac enzymes
Stratify risk based on number of variables
 Risk: • 0-2: Low 3-4: Intermediate 5-7: High risk
complications
 Acute Management
 Initial: MONAH
M: Morphine
O: Oxygen (if SO2 < 94)
N: Nitrates (nitroglycerin) --- first line therapy for chest pain
A: Aspirin + Clopidogrel
H: Heparin (LMWH
Definitive:
o UA: PCI
o STEMI: 1st choice: PCI → 2 nd choice: fibrinolytic therapy
o NSTEMI o High-risk patients: antiplatelets, anticoagulants, B-blockers. Consider: Glycoprotein IIb/IIIa
inhibitors and revascularization (angioplasty + stenting) o Low-risk patients: monitor ECG and cardiac
markers
After Acute Management
Lifestyle modification:
•Quit smoking
•Reduce alcohol intake
•Eating healthy
•Losing weight
• Exercise/training
•Treat diabetes, HTN, hyperlipidaemia
 Pharmacological therapy: (ABAS) oA: ACE-Is + Angiotensin receptor blockers. o B: B-blockers
(first line therapy if there are no contraindications) oA: Aspirin + clopidogrel (for 8-12 months)
o S: Statins
https://www.ncbi.nlm.nih.gov/books/NBK537261/#:~:text=Coronary%20artery%20disease%3A
%20The%20etiology,obesity%2C%20smoking%2C%20and%20immobility
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