ACUTE CORONARY SYNDROMES

BY
ABDUL MALEEK MORO (kunaama MD)
OUTLINE/OBJECTIVES
• DEFINITIONOF ACS
• BRIEF ANATOMY OF THE CORONARY CIRCULATION
• CAUSE/PATHOPHYSIOLOGY
• RISK FACTORS
• CLINICAL PRESENTATIONS
• DIAGNOSIS/DIFFERENTIATION
• MGT
• COMPLICATIONS
• CASE PRESENTATION
DEFINITION OF ACS

• Acute coronary syndrome (ACS) refers to a spectrum of conditions

due to an abrupt reduction of blood flow in
the coronary arteries such that, part of the heart
muscle is unable to function properly or dies.
It’s basically a demand-supply mismatch. Comprising UA, NSTEMI and
STEMI

• Stable angina?
Brief anatomy of the coronary circulation
Sub types
• Unstable angina:
• An unprovoked or prolonged episode of chest pain raising suspicion of acute myocardial infarction (AMI)
• Without definite ECG or laboratory evidence
• NSTEMI:
• Chest pain suggestive of AMI
• Non-specific ECG changes (ST depression/T inversion/normal)
• Laboratory tests showing release of troponins
• STEMI:
• Sustained chest pain suggestive of AMI
• Acute ST elevation or new LBBB
causes
• Atherosclerosis • Non-Atherosclerotic
• 1. Congenital anomalies

Major cause of acs • 2. Embolus

• 3. Dissection
• 4. Spasm
• 5. Trauma
• 6. Arteritis
• 7. Metabolic disorders
• 8. Intimal proliferation
• 9. External compression
• 10. Thrombosis without underlying atherosclerotic plaque
• 11. Substance abuse
• 12. Myocardial oxygen demand-supply disproportion
• 13. Intramural coronary artery disease (small-vessel disease
Pathogenesis

• Epithelial injury
• Migration of
monocytes/macrophag
es
• LDL lipids consumed 
foam cells
• Growth factors 
smooth muscle,
collagen, proteoglycans
• Atheromatous plaque
forms
RISK FACTORS
• Modifiable • Non-modifiable
• Smoking • Increasing age
• Obesity • Gender (male )(after menopause
• Diet , risk is virtually same in both
genders)
• Sedentry life
• Ethnicity
• Dyslipidemia
• Family history
• Hpt
• Dm
• Dm
PRESENTATION
• HISTORY
The cardinal symptom Is CHEST PAIN

 central, precordial, Left anterior chest

 described as tightness, pressure/ heaviness, dull, crushing
 sometimes difficult to describe
 radiating to the left arm, Left shoulder, the jaw, the neck, upper abdomen
sometimes back
 usually lasting more than 20-30 minutes

Approx 50% of ACS patients

Associated with • May present with only
diaphoresis • Neck pain
nausea • Pain in the jaw
vomiting • Pain in the left arm or shoulder
shortness of breath • Pain in the ear
anxiety • Epigastric pain/ discomfort
a sense of impending doom (angor
animi)
• May not have pain at all
collapse/ syncope
• DM, OLDER PATIENTS
PHYSICAL EXAMINATION
• Signs of sympathetic activation: pallor, sweating, tachycardia
• Signs of vagal activation: vomiting, bradycardia
• Signs of impaired myocardial function
• Hypotension, oliguria, cold peripheries
• Raised JVP
• Third heart sound
• Quiet first heart sound
• Diffuse apical impulse
• Lung crepitations
• Pansystolic murmur
• Signs of tissue damage: fever
• Signs of complications: e.g. MR, pericarditis, VSD
WORKUP
• A 12-lead ECG is mandatory defines the initial triage, management
and treatment
• Cardiac biomarkers
• CK-MB
• cardio-specific proteins, troponins T and I
• Other blood tests
• Chest X-ray
• Echocardiography
• Coronary angiogram
• Typical ecg findings in ACS
-st-elevation
-st depression
-t wave inversion
-lbbb
- a normal ecg
STEMI ECG CRITERIA
• ≥ 2 mm of ST segment elevation in 2 contiguous precordial leads in
men (1.5 mm for women)
• ≥ 1mm in other leads (2 contiguous)
• An initial Q wave or abnormal R wave develops over a period of
several hours to days.
• Within the first 1-2 weeks (or less), the ST segment gradually returns
to the isoelectric baseline, the R wave amplitude becomes markedly
reduced, and the Q wave deepens. In addition, the T wave becomes
inverted.
STEMI

• http://www.thrombosisadviser.com/html/images/library/atherothrombosis/stemi-and-nstemi-ecg-illustration-PU.jpg
NSTEMI
• There is partial occlusion of a major vessel or complete occlusion of a
minor vessel

• This is usually associated with ST-segment depression and/ or T-wave

changes

• ECG may also be normal

NSTEMI

• http://www.virtualmedstudent.com/links/cardiovascular/acute_coronary_syndromes.html
WHERE IS THE PROBLEM?
• II, III, aVF= RCA
• V1-V4 = ANT-SEP =LAD
• V3-V6-ANT-LAT=LAD
• ST DEPRESION IN V1-V3
=POSTERIOR INFARCT =LEFT
CIRC/RCA
BLOOD WORKS
• CARDIAC ENZYMES
• The CK-MB starts to rise at 4–6 hours, peaks at about 12 hours and
falls to normal within 48–72 hours
• Troponins T and I are released within 4–6 hours and remain elevated
for up to 2 weeks.
• High sensitivity cardiac Troponins (hs-cTnT, hs-cTnI)
• Myoglobin
• Old cardiac markers
• Aspartate aminotransferase (AST)
• Lactate dehydrogenase (LDH)
Classification/
Acute Coronary Syndromes
differentiation
ECG

NSTE-ACS STEMI
(Non ST-Elevation ACS) (ST elevation MI)

cardiac markers

negative positive

Unstable Angina Non ST-Elevation MI

(UA) (NSTEMI)

2014 AHA/ACC NSTE-ACS Guideline

DDX
• Cardiac causes
• Acute pericarditis
• Cardiomyopathies
• Tachyarrhythmias
• Acute heart failure
• Hypertensive emergencies
• Aortic valve stenosis
• Tako-Tsubo cardiomyopathy
• Coronary spasm
• Cardiac trauma
• Pulmonary
• Pulmonary embolism
• Pneumothorax (tension)
• Pneumonia/ Bronchitis
• Vascular
• Aortic dissection
• Gastro-intestinal
• Oesophagitis, oesphageal reflux or spasm
• Peptic ulcer, gastritis
• Pancreatitis
• Cholecystitis
• Orthopaedic
• Musculoskeletal disorders
• Costochondritis
• Chest trauma/ muscle injury or
inflammation
• Cervical spine pathologies
• Other
• Anxiety disorders
• Herpes zoster
• Anaemia
 INITIAL MGT
• Initial mgt for acs should focus on stabilization of clients condition,
relieving ischaemic pain, preventing more ischeamia
• -M-ORPHINE
• -O-XYGEN
• -N-ITROGLYCERIN
• -A-ANTIPLATELETS( ASA + CLOPIDOGREL)
• -B-B BLOCKER
• -ACE/ARB
• -S -STATIN
• -H- EPARIN, MRA (LVEF <40%)
---CABG-- LATER
STEMI MGT

• “Time is muscle”

DEFINITIVE MGT IS REPERFUSION

• Two types of reperfusion therapy
• Fibrinolytics, or

• Primary PCI
STEMI MGT
NSTEMI/UA
AFTER THE INITIAL STABILIZATION A CORONARY ANGIOGRAPHY
SHOULD BE CONSIDERED WITHIN 72 HRS
LONG-TERM MANAGEMENT
• Continuous ECG monitoring as inpatient/ ICU
• Aspirin 75mg OD (lifelong)
• Clopidogrel 75mg (1 year)
• Beta blocker (1 year - lifelong)
• ACE inhibitor
• Statin
• Modification of risk factors
COMPLICATIONS
EARLY (72 HRS) LATE
• Death • Ventricular wall rupture
• Cardiogenic shock • Valvular regurgitation
• Heart failure • Ventricular aneurysms
• Ventricular arrhythmia • Cardiac tamponade
• Myocardial rupture • Dresslers syndrome
• Thromboembolism • Thromboembolism
REF
• MEDSACAPE
• DAVIDSON PRINCIPLES &PRATICES OF MED 21ST ED.
• Dr. Mohammad AliMBBS, MD (Cardiology)FCPS part I, MRCP part
IIAssociate ConsultantCardiology Department,Bangladesh Specialized
Hospital
CASE PRESENTATION
DEMOGRAPHICS
MAD. E.A , 38
PC- CHEST PAIN + LEFT FLANK PAIN 30MINS
HPC-CLIENT DIANOSED OF HPT ABOUT 7 YRS AGO PRESENTED TO THE
CARDIOCLINIC/OPD FOR A MEDICAL REVIEW WHEN SHE SUDDENLY
DEVELOPED A SUDDEN ONSET CHEST PAIN MORE IN THE LEFT CHEST ,
GRADED 8/10 ASSOCIATED WITH A LEFT FLANK PAIN , PALPITATIONS AND
SHORTNESS OF BREATH, THIS IS THE 5TH EPISODE OF CHEST PAIN IN THE
PAST FIVE YRS( THIS IS HOWEVER MOST SEVERE)
ODQ-N/V+, SWEATING +, ORTHOPNEA-, PND-, PEDAL EDEMA-, EASY
FATIGUE-DIZZINES-SYNCOPE-, COUGH -, NECK/JAW/ ARM PAIN -
CT.
•SE=NIL
•PMSH=KNOWN HPT ,NO PAST SURGERIES
•DH-TAB BISOPROLOL 2.5 MG OD, TAB EMPA 10 MG OD . NO KNOWN DRUG /FOOD ALLERGIES
•FM- HPT+ , DM -
•SH- ALCOHOL- ,SMOKING -
•OE
•MIDDLE AGED WOMAN ON O2 SUPPORT VIA A NASAL PRONG , AT 4L/MIN , P-J-F-,ACYANOSED ,
HYDRATION SATISFACTORY , NO PEDAL EDEMA
•VITAL
•BP-109/67MMHG
•PULSE 100BPM RGV
•RR- 24 CPM
•T- 36.2
•CVS - S1 S2 M+ PANSYSTOLIC LOUDEST IN THE MITRAL AREA WITH RADIATIONS TO THE AXILLA
APEX 6 ICS AAL
•RESP-AE ADEQUATE BILAT , NO ADDED SOUND
•ABDO- SPLENOMEGALY ( ABOUT 10 CM B ELOW THE COASTAL MARGIN) S - 2K -
•CNS GCS 15/15 ALERT + CONCIOUS
•IMPRESSION
• ACS IN A KNOWN HPT
INITIAL MGT
ADMITED TO A/E
NURSED IN A CARDIAC POSTION
OXYGEN AT 4L/MIN VIA NP
IV MORPHINE 10MG ST + IV METOCLOPRAMIDE 10 ST
DISPERSIBLE ASPIRIN 300MG STAT
( NB- ONCE ACS IS SUSPECTED , EVERYBODY GETS MONA)
PLAN
ECG, BLOOD SAMPLES TAKEN FOR INVESTIGATIONS , CHEST
XRAY ,ECHOCRDIOGRAM
ECG
BLOOD WORKS
• CARDIAC PROFILE- • OTHER LABS
• TROPONIN I =40.85 HIGH ( UL - • RFT, LFT, HBA1C =NORMAL
20) • FBC,LIPID -NORMAL
• LDH-757 HIGH (UL-618)
• AST-26 N
• CK-46 N
• CK-MB-< 3 N
X RAY
NEW IMP –NSTEMI IN
HPT/HYPERTROPHIC HEART DISEASE
•INPATIENT MGT/ DISCHARGE MEDS
•TAB ASPIRIN 7MG OD X 30
•TAB CLOPIDOGREL 75 MG OD X 30
•TAB BISOPROLOL 2.5 MG OD X 30
•?TAB ATORVASTATIN 20MG NOCTE
•TAB EMPAGLIFLOZIN 10 MG OD X 30 ( HF)
•SC ENOXAPARIN 40 OD X 2
•TO BE REVIEWED AT THE CARDIOCLINIC IN A WEEKS TIME THE AN ECHO
REPORT
IDEAL=(CORONARY ANGIOGRAPHY IN WELL RESOURCED CENTRES IN
72HRS)