Acute Coronary Syndromes

Definitions

Result of plaque rupture!

Includes: Unstable angina, NSTEMI, STEMI

Unstable angina:

accelerating pattern of pain: ↑ frequency, ↑ duration, ↓ threshold of exertion, ↓ response to Tx

angina at rest

new-onset angina

angina post-MI or post-procedure (PCI, CABG)

MI diagnosis: Troponins (evidence of necrosis)+ 1 of the following:

Sx of ischemia (chest/upper extremity/mandibular/epigastric discomfort; dyspnea)

ECG changes (ST-T changes, new LBBB or pathological Q waves)

Imaging evidence (myocardial loss of viability, wall motion abnormality or intracoronary thrombus)

if biomarker changes are unattainable, cardiac symptoms + new ECG changes is enough

NSTEMI diagnosis: meets MI criteria without ST elevation or LBBB

STEMI diagnosis: meets MI criteria with ST elevation or new LBBB

pneumonia • ECHO . compilations (acute mitral regurgitation. ≥2 mm in precordial leads • ST depression/T inversion in UA/NSTEMI • Q waves . peak in approx. pulmonary edema (ischemia complication).monitor to prevent arrhythmias (ordered as part of electrolyte panel) • PT/PTT/INR .to decide on ACEI • CXR . and pericardial effusion) . extent of infarct. and persist for 1-2 weeks)! • ECG (generalization): ! • ST elevation (in 2 contiguous leads)=new LBBB in STEMI • ST elevation: ≥1 mm in limb leads.rule out anemia as 2° cause of MI • K. 24 hours. overall Fn of ventricles.questionable Dx.assessment of cardiomegaly.Investigations • Troponins (elevated in 2-3 hours.to assess bleeding state • Creatinine . Mg .loss of myocardium (if 1/2 of R wave) • CBC . aneurysm. LV rupture.

nitroglycerin (SL—>IV).deactivates clotting factors (mostly Xa) • β-blockers .ABCs. O2. does not prevent mortality • The rest of the meds on this page decrease mortality/improve survival (!):! • • ASA . oxygen. Nitroglycerine) • NSTEMI: BEMOAN (β-blocker. pain control (morphine IV. ASA. Morphine. Nitrates) http://nstemi.↓ contractility.Management (general approach) • Treat acute problem! • General . rest.org/nstemi-vs-stemi/ • STEMI: Thrombolysis (within 30 min) vs PCI (within 90 min) • Nitroglycerin .↓ platelet aggregation • Some patients may get Clopidogrel • Some may get IIb/IIIa inhibitors - • Heparin (Enoxaparin) . Enoxaparin.vasodilates (↑ O2 supply). ↓ HR (↓ O2 demand) Treat underlying coronary disease:! • ACEI • Statins • Education .

TIMI risk score for UA/NSTEMI TIMI = thrombolysis in myocardial infarction 1 point each: ! ! ! ! ! Hx Presentation Age ≥65 yr Recent (≤24 h) severe angina ≥3 risk factors for CAD ST-segment deviation ≥0.5 mm Known CAD (stenosis ≥50%) Increased cardiac markers Aspirin ! Risk Score = Total Points
 If TIMI risk score ≥3. consider early LMWH and angiography
 .

ventricular septum. half of these within first 3 months. remodelling —> ventricular arrhythmia • ischemia of conduction system—>bradyarrhythmias. or free wall rupture • Mitral regurgitation (due to wall stiffness/remodelling) • Acute heart failure (left or right heart) Inflammatory! • Acute pericarditis (day 1-6) • • • Subtype .STEMI complications and prognosis • Complications! • • • Arrhythmic (minutes-first few days): • acute ischemia.3-7 days): • Rupture of papillary muscle.Dressler syndrome (abnormal immune response to damaged myocardium) Left ventricular thrombus (most common is apex of the left ventricle after an anterior STEMI) Prognosis! • 5-15% of hospitalized patients die • After discharge: 6-8% within first year. block Mechanical (direct results of myocardial damage . LV impairment. 4% per year following first year .