Acute Coronary Syndrome
Definition: a spectrum of clinical presentations:
Unstable angina: angina of recent onset (<2 months), worsening or angina at rest.
Non ST elevation myocardial infarction: incomplete occlusion of coronary vesselsleading to ischemia and mild necrosis of myocardium (Troponin-I raised only)
ST elevation myocardial infarction: complete occlusion of coronary vessels leading tonecrosis of the myocardium
Epidemiology: Leading cause of death in Ireland, 1,200,000 cases / year in the US, morecommon in males, age of onset 50-60.
Atherosclerosis of the coronary vessels
Non-modifiable: male, family history, age, ACE gene polymorphism
Modifiable: smoking, hypertension, hyperlipidemia, diabetes mellitus, obesity,sedentary lifestyle, high F-VII & fibrin, cocaine use, alcoholism, COX-2 inhibitors,hyperinsulinism, lipoprotein(A), OCP
Formation of atheroma in the coronary vessels:
Following insult to the vascular endothelium platelets aggragate and lipids,scavenger cells (macrophages) move to the injured site and start ingestingthe lipid until they become foam cells.
There is also migration of muscle cells to the endothelium and hyperplasia
A fibrous cap is formed by fibroblasts at the endothelium
The major trigger for coronary thrombosis is considered to be plaque rupture causedby the dissolution of the fibrous cap due to the release of metalloproteinases(collagenases) from activated inflammatory cells. This event is followed by plateletactivation and aggregation, activation of the coagulation pathway, andvasoconstriction. This process culminates in coronary intraluminal thrombosis andvariable degrees of vascular occlusion
History & Exam
Central crushing chest pain, that may radiate to the arm, neck or jaw, brought on byexercise, cold weather, following a big meal, or stress.
The pain is associated with nausea +/- vomiting, diaphoresis, pallor, syncope or pre-syncope, palpitations and dyspnoea.
Tachycardia, tachypnoea, hypo/hypertension, pallor, anxiety, signs of left orright heart failure, a 4
heart sound, pansystolic murmur.
Investigations: the diagnosis is clinical
haemoglobin (anaemia?), leucocytosis (infection?)
electrolyte disturbances establish a baseline for the patient andassess their renal function.
deranged in case of right heart failure.
bleeding disorder, this patient may undergo thrombolysis.
Diabetes mellitus, hypoglycaemia/hyperglycaemia
Fasting serum lipids