ACUTE CORONARY

SYNDROME
PGI Calro Antonio H. Lanuza
Manila Doctors Hospital - Internal Medicine Department
OBJECTIVES

1. To present a case of acute coronary syndrome

2. To be able to formulate a differential diagnosis
3. To review the pathophysiology of ACS
4. To discuss the treatment and management of ACS
 Patient Profile Chief Complaint
Name P.D. Chest pain
Age 59
Sex M
Address Paco, Manila
Occupation Carpenter
History of Present Illness

2 hours
Interim
PTC

● While at work, suddenly had chest ● Patient noted increasing severity

pain, substernal in location, heavy, 5/10 of chest pain.
in severity, radiating in the shoulder,
● Persistence prompted consult at
associated with diaphoresis and
our institution.
shortness of breath.
● Patient rested and drank water but
offered no relief.
● No medications taken.
Baseline Functional Capacity

● Patient is able to do activities of daily living independently

● No paroxysmal nocturnal dyspnea, no orthopnea
● Patient can climb 2 flights of stairs with rest in between flights.
 Past Medical History

● Hypertensive (10 years)

○ Highest BP of 160/100 mmHg
○ Usual BP of 130/90 mmHg
○ Allegedly compliant to Losartan 50mg OD

● No history of previous myocardial infarction or stroke, diabetes

mellitus, allergies, asthma, tuberculosis, kidney, and liver disease.
● No history of previous surgeries or hospitalizations.
 Family History

● Maternal: Hypertension
● Paternal: Hypertension, diabetes mellitus, died of myocardial
infarction at 59 years old
● (-) PTB, COPD, allergies, bronchial Asthma, thyroid disease, or
malignancies.
 Personal and Social History

● Cigarette smoker: 5 pack years

● Occasional alcoholic beverage drinker
● Denies illicit drug use
● Stays at home most of the time maintaining the house
● Diet consist mainly of pork meat and vegetables
● No exposure to known COVID (+) patient
 Review of Systems

(-) body weakness, (+) easy fatigability, (-) weight changes,

Constitutional (-) decrease in appetite

Hematologic (-) easy bruising, (-) pallor, (-) bleeding

Skin (-) edema, (-) rashes, (-) pruritus

HEENT (-) blurring of vision, (-) headache, (-) otalgia, (-) nasal
discharge, (-) nasal obstruction, (-) epistaxis, (-) dysphagia
Respiratory (-) difficulty of breathing, (-) hemoptysis, (-) dyspnea, (-)
tachypnea
 Review of Systems

(-) vomiting, (-) dysphagia, (-) abnormal masses, (-) lesions,

Abdomen (-) diarrhea, (-) constipation, (-) hematochezia, (-) melena

Genitourinary (-) dysuria, (-) hematuria, (-) anal pain

Musculoskeletal (-) joint pains, (-) edema, (-) limitation of movement on all
extremities
 Physical Examination

Constitutional
Awake, conscious, coherent, not in cardiorespiratory distress, ambulatory

Vitals
BP: 130/90 mmHg (left arm); 130/90 mmHg (right arm) Temp: 36.7°C
RR: 18 cpm
O2 Sat: 95%
HR: 90 bpm

Anthropometrics
Height: 165 cm Weight: 70 kg BMI: 25.7
(overweight)
 Physical Examination

Skin, Hair, Nails

Brown, soft, smooth and warm to touch, good skin turgor, no lesions and
discolorations

HEENT
Normocephalic and symmetrical skull. No lesions or deformities noted. Symmetrical
facial features. No masses, lesions or deformities noted on the face. No blurring of
vision, no neck vein engorgement.

Chest & Lungs

Symmetric chest expansion, equal tactile fremitus, resonant on all lung fields,
bronchovesicular breath sounds on both lungs, no adventitious sounds heard, no
crackles, no rhonchi, no wheezing.
 Physical Examination

Cardiovascular
Adynamic precordium, normal rate, regular rhythm, no heaves or thrills, s1 louder at
apex, s2 louder at base, no murmurs heard, no pericardial friction rub, PMI located at
the 5th ICS LMCL. No jugular venous distention (JVP=8 cmH20 at 45°).

Gastrointestinal
Flat, no visible pulsation nor peristalsis, normoactive bowel sounds (10 per min),
soft, non-distended, no masses appreciated on palpation, nontender, nonpalpable
liver edge, liver span is 8 cm RMCL, Tympanitic abdomen on all quadrants
 Physical Examination

Musculoskeletal
No gross deformities on upper and lower extremities, no cyanosis, no edema, full equal
pulses in the upper and lower extremities, CRT<2sec

Neurologic
GCS 15, no neurologic deficit.
 Salient Features

History PE & ROS

59 y/o male BP 130/90 mmHg, HR 90 bpm, RR 18 cpm, O2 95%
Sudden onset of chest pain while working, substernal in location, Temp 36.7°C, BMI 25.7 (overweight)
heavy, 5/10 in severity, radiating in the shoulder, associated with (+) easy fatigability
diaphoresis and shortness of breath. (-) body weakness
(-) adventitious breath sounds
No relief upon rest
(-) orthopnea
Increasing severity of chest pain (-) neck vein engorgement
(-) palpitation
Hypertensive for 10 years
(-) murmurs
Maternal and paternal hypertension; father died of MI at 59 y/o
(-) pericardial friction rub
Cigarette smoker: 5 pack years
(-) abdominal pain
Diet consisting mainly of pork meat (-) edema
(-) exposure to known COVID patient
 Differential Diagnosis

Musculoskeletal Gastrointestinal Pulmonary Cardiac

Costochondritis Gastroesophageal Reflux Pulmonary embolism Unstable Angina

Disease Aortic Dissection
Pericarditis
 Differential Diagnosis

Musculoskeletal Gastrointestinal Pulmonary

Costochondritis Gastroesophageal Reflux Disease Pulmonary embolism

History of URTI, trauma,or
exercise. Pain typically is
persistent (days or longer),
worsened by touching the area.
Focal, unilateral tenderness near
the sternum.
Recurrent burning pain radiating Dyspnea followed by chest pain
from epigastrium to throat that is (classically pleuritic but often dull)
exacerbated by eating or lying and cough.
down and relieved by antacids
 Differential Diagnosis

Cardiac Cardiac Cardiac

Acute Aortic Dissection Pericarditis Unstable Angina

Characteristic symptom of Characterized by pleuritic pain Squeezing, tightness, or pressure

sudden onset unrelenting pain,
tearing in character, located at
the anterior chest often radiating
to the back between the shoulder
blades
exacerbated by breathing, sensation in the chest radiating to
coughing, or changes in position other parts of the body, at rest or
radiating to the shoulders and at exertion, lasting for more than
neck. 20 minutes.
Present Working Impression
Unstable Angina - High Risk t/c
Acute Coronary Syndrome;
Hypertensive Cardiovascular Disease
ECG

Normal rate
Sinus rhythm
Normal axis
Anterolateral wall ischemia
Essentially normal chest x-ray
 Laboratory Results
CBC Cardiac Marker Electrolytes

Hgb 130 0.515 Na 142

Trop I
ng/ml (15x)
K 4.1
Hct 39

WBC 6.2 UA Ca 2.2

Mg 1.03
Neu 67
SG 1.020

Lym 27
pH 6 PT 96%

Plt 270
Glucose Negative INR 1.02

Renal Function
Protein Negative Lipid Profile
Crea 69.7
WBC 1.2 Cholesterol 180
EGFR 98 ml/min
RBC 1 LDL 100

FBS 89 mg/dl Bac 1.3 HDL 41

 Risk Assessment
TIMI GRACE KILIP
Age ≥ 65 1 Age No signs of congestion I

≥ 3 risk factors for CAD 1 Heart rate S3 and basal rales II

Prior coronary stenosis of ≥50% 1 Systolic BP Acute pulmonary edema III

ST deviation on ECG 1 Creatinine Cardiogenic shock IV

≥2 anginal events in prior 24 hrs 1 Cardiac arrest at admission Class I (2-3% Risk of 30-day
mortality)
Elevated cardiac biomarkers 1 ST segment deviation

Use of aspirin in prior 7 days 1 Abnormal cardiac enzyme

TOTAL = 3 (13.2&%risk) Killip class

TOTAL = 106 (5% probability of death

from admission to 6 months)
 Present Working Impression
Acute Coronary Syndrome Non ST-Segment Elevation
Myocardial Infarction, Anterolateral Wall Ischemia,
KILLIP I, TIMI 3, GRACE 106;
Hypertensive Cardiovascular Disease;
Dyslipidemia
 Admit to CCU
IVF: 40cc/hr D5NSS with Isoket drip 10mg

Diagnostics
CBC, UA, serial troponin I, lipid profile, FBS, electrolytes, creatinine, PT,
INR, serial 12-L ECG, CXR, 2D-Echo

Therapeutics
Load:
1. Aspirin 80 mg 4 tabs now then 1 tab OD
2. Clopidogrel 75 mg 4 tabs now then 1 tab OD
3. Atorvastatin 40 mg 1 tab now then ODHS
MANAGEMENT 4. Enoxaparin 0.6 Sq Q12 for 5 days
5. Carvedilol 6.25 mg 1 tab OD now then BID
Add-on:
1. Pantoprazole 40 mg 1 tab now then OD
2. Trimetazidine 35mg 1 tab BID
3. Lactulose 30cc ODHS

May shift to oral ISDN 5mg tab as needed for chest pain once Isoket drip
consumed.
DISCUSSION
 Acute Coronary Syndrome

● ACS results from an acute obstruction of a coronary artery.

Consequences depend on degree and location of obstruction.

Unstable Angina NSTEMI STEMI

Non-occlusive thrombus
Non-occlusive thrombus sufficient to Complete thrombus occlusion
cause tissue damage and mild
Non-specific ECG and
myocardial necrosis ST elevations on ECG or new LBBB
Normal cardiac enzymes
ST depression +/- T wave inversion Elevated cardiac enzymes
Occurs at rest or with minimal on ECG
exertion usually lasting >10 minutes
More severe symptoms
Elevated cardiac enzymes
 Acute Coronary Syndrome
Symptoms
Similar in each of these syndromes (except sudden death) and include chest discomfort
(tightness, pressure, heaviness) at rest or for a prolonged period (>10 mins) not relieved
by sublingual nitrates, or recurrent chest discomfort.

Radiation
Back, neck, jaw, arm(s), shoulder(s) or epigastrium.

Associations
Dyspnea, shortness of breath, diaphoresis, dizziness, nausea or vomiting.
Pathophysiology
 Unstable Angina

NSTEMI
History and PE
New-onset chest pain at the substernal region radiating to the neck, left shoulder
and/or left arm.
Associated with: Diaphoresis, sinus tachycardia, S3 orS4, crescendo angina,
hypotension, nausea/vomiting

Cardiac Markers
NSTEMI: Elevated
UA: Normal

ECG
 Initial Management

Bed rest with continuous ECG monitoring for ischemic and

arrhythmia detection in patients with ongoing rest pain.

Supplemental oxygen
 Management

Nitrates
For initial management of anginal pains, 0.4 mg sublingual NTG tablets or spray
taken 5 min apart can be administered until the pain is relieved, or a maximum of
1.2 mg has been taken within 15 minutes.
 Management

Beta Blockers
Beta-blocker by oral or IV route be administered if there is ongoing chest pain in
the absence of contraindications: Hemodynamic compromise including
hypotension, active bronchospasm, severe bradycardia or heart block greater than
1st degree unless with pacemaker, myocardial infarction precipitated by cocaine
use, and overt heart failure including pulmonary edema.
 Management

Calcium Channel Blockers

It is recommended to use oral long-acting calcium antagonists for recurrent
ischemia in the absence of contraindication and when beta-blockers and nitrates
are maximally used.
 Management

ACE-I / ARB

An ACE-I/ARB is recommended when hypertension persists despite treatment

with nitroglycerin and a beta-blocker in patients with LV systolic dysfunction or
congestive heart failure (CHF), high risk chronic CAD, in ACS patients with
diabetes, and in chronic kidney disease (CKD) unless contraindicated.
 Management

Morphine Sulfate

1 to 5 mg IV is recommended for patients whose symptoms are not relieved after

three serial sublingual NTG tablets, or whose symptoms recur despite adequate
anti-ischemic therapy.

Meperidine hydrochloride can be substituted in patients who are allergic to

morphine.
 Management

Antiplatelet

Aspirin at initial dose of 160-325 mg non-enteric formulation, followed by 80-160

mg daily should be administered as soon as possible after presentation and
continued indefinitely

P2Y12 inhibitors (ticagrelor, prasugrel or clopidogrel)

It is recommended to start a P2Y12 inhibitor in addition to aspirin for a period of 12
months unless there are contraindications such as excessive risk of bleeding.

Discontinue ticagrelor and clopidogrel at least 5 days prior to elective CABG, and 7
days for prasugrel, unless CABG or the need for a P2Y12 inhibitor outweighs the risk
of bleeding.
 Management

Anticoagulants

It is recommended to start unfractionated heparin (UFH), enoxaparin or fondaparinux

in addition to antiplatelet therapy.

UFH should be given for 48 hours. Enoxaparin or fondaparinux should be given for 5
to 8 days, or during the entire duration of hospital stay if admitted less
than 5 days.

Discontinue Enoxaparin 12 to 24 and Fondaparinux 24 hours before CABG procedure.

 Management

Fibrinolytic Therapy

It is not recommended to use IV fibrinolytic therapy in patients with UA or in patients

without acute ST-segment elevation, a true posterior MI, or a presumed new left BBB.
 Management

Early conservative Vs. Invasive strategies

It is recommended that an early invasive strategy (as early as possible up to 72 hours)

followed by revascularization (PCI or CABG) be used in patients with any of the following
high-risk indicators:
● Recurrent angina/ischemia at rest or with low-level activities despite intensive anti-ischemic therapy
● Elevated cardiac biomarkers (TnT or TnI) or new or presumably new ST-segment depression
● Signs or symptoms of heart failure (HF) or new or worsening mitral regurgitation
● High-risk findings from noninvasive testing
● Hemodynamic instability
● Sustained ventricular tachycardia
● PCI within 6 months
● Prior CABG
● High-risk score (e.g. TIMI, GRACE)
● Reduced LV systolic function (LVEF less than 40%)
 PCI
Percutaneous Coronary Coronary Artery Bypass
Intervention Graft

Recommended for patients Recommended for patients CABG

with 1-2 vessel CAD w/wo
significant proximal LAD
CAD but with a large area
of viable myocardium and
high risk criteria on non
invasive testing.
with significant left main
disease and the preferred
revascularization strategy
for patients with multi-
vessel coronary disease,
with depressed systolic
function (LVEF)
 Hospital Discharge
A. Lifestyle modification that includes smoking cessation, achievement or maintenance of optimal
weight, daily exercise, and diet.
B. Daily exercise of 30 minutes or 5 days per week.
C. Consider referral of patients who are smokers to smoking cessation program or clinic and/or an
outpatient cardiac rehabilitation program.
D. Intensive lipid-lowering therapy is strongly recommended by combining dietary interventions with
pharmacotherapy using statins, or combination with other lipid-lowering agents to reduce
LDLc < 100 mg/dL.
E. A fibrate or niacin if high-density lipoprotein (HDL) cholesterol is less than 40 mg per dL, occurring
as an isolated finding or in combination with other lipid abnormalities
F. Hypertension control to a blood pressure of less than 140/90 mm Hg or less than 130/80 mm Hg if
patient has diabetes or chronic kidney disease.
G. Tight control of hyperglycemia in diabetes. Goal is HbA1c of less than 7%
STEMI
History and PE
New-onset chest pain at the substernal region radiating to the neck, left shoulder
and/or left arm. Occurs at rest, more severe, and lasts longer
Associated with: Pallor, diaphoresis, tachycardia, vomiting, raised JVP, or anxiety

Cardiac Markers
STEMI: Elevated

ECG
 Initial ER Management

Detailed history taking, physical examination and a 12 lead ECG

be taken within 10 minutes of arrival at the ER.

The patient should be placed on a cardiac monitor immediately,

with emergency resuscitation equipment including a
defibrillator, nearby.
 Initial ER Management

Routine Measures

✓ Aspirin 160 to 320 mg tablet (non-enteric coated, chewed).

✓ Clopidogrel 300 to 600 mg whether or not fibrinolysis will be given.
✓ Clopidogrel 600 mg or prasugrel 60 mg or ticagrelor 180 mg when a patient will
undergo PCI.
✓ Nitrates, either via sublingual or intravenous(IV) routes. Nitrates are
contraindicated in patients with hypotension or those who took a
phosphodiesterase 5 (PDE5) inhibitor within 24 hrs (48 hrs for tadalafil).
✓ Morphine 2 to 4 mg IV for relief of chest pain
✓ Supplemental oxygen during the first 6 hours to patients with arterial oxygen
saturation of less than 90%.
In-Hospital Management
 In-Hospital Management

Fibrinolysis

● It is strongly recommended to undergo immediate thrombolysis (unless

contraindicated), with a door-to-needle time of less than 60 minutes as a goal.
● Perform an ECG to patients treated with fibrinolysis, 60 to 90 minutes after
administration to determine the presence of failed reperfusion.
● In the case of failed reperfusion, offer immediate coronary angiography, with
follow-on PCI if indicated. Do not repeat fibrinolytic therapy.
 In-Hospital Management

Nitrates

● Oral nitrate use is recommended in the acute and stable phase for the control of
anginal symptoms.
● Nitrates given intravenously may be recommended during the acute phase in
patients with hypertension or heart failure. its use is contraindicated among
patients with hypotension, right ventricular infarction, or the use of PDE 5 inhibitors
in the previous 48 hours.
 In-Hospital Management

Antiplatelet

● Aspirin should be continued indefinitely and clopidogrel (75 mg daily) should be

continued for at least 14 days and up to 1 year in patients with STEMI who receive
fibrinolytic therapy.
 In-Hospital Management

Beta-Blockers

● Oral beta blockers should be started within the first 24 hours in the absence of any
contraindication, regardless of the intervention used.
● Ideal target heart rate is set at 55 to 60 beats per minute.
 In-Hospital Management

Statins

● High-dose statins are recommended in all patients during the first 24 hours of
admission for STEMI, irrespective of the patient’s cholesterol concentration in the
absence of contraindications (allergy, active liver disease).
● Atorvastatin or rosuvastatin are recommended during the early phase of therapy
up to at least four weeks.
● Give high-dose rosuvastatin (20 to 40 mg) or atorvastatin (40 to 80 mg) therapy
before emergency PCI to reduce periprocedural inflammatory response, to reduce
myocardial dysfunction, and to prevent contrast-induced nephropathy.
 In-Hospital Management

ACEi / ARBS

● It is recommended that an acei be given to patients within 24 hours, unless

contraindicated (hypotension, significant renal failure and known allergy).
● it is recommended that an ARB be given to patients who are intolerant of ACEIs.
 In-Hospital Management

Percutaneous Coronary Intervention

● Recommended in patients with STEMI and ischemic symptoms of less than 12

hours’ duration or if contraindicated with fibrinolysis.
● Primary PCI is the recommended method of reperfusion when it can be performed
in a timely fashion by experienced operators within 90 minutes.
● Aspirin 160 to 320 mg is recommended before primary PCI. After PCI, aspirin
should be continued indefinitely.
● P2yY12 inhibitor therapy is recommended as a loading dose and maintained for
year to patients with stemi who receive a stent.
 In-Hospital Management

Coronary Artery Bypass Grafting

● CABG is recommended in failed PCI with persistent pain or hemodynamic

instability in patients with coronary anatomy suitable for surgery or those that are
not candidates for PCI or fibrinolytic therapy.
● PCI and fibrinolysis can restore blood flow in an acutely occluded coronary artery
in a much shorter time than CABG
 In-Hospital Management

Cardiac Rehabilitation

● Rest - Physical rest or bed rest is necessary in patients with HF. Passive mobilization
exercises are carried out to prevent untoward effects resulting from prolonged bed
rest and to decrease the risk of venous thrombosis.
● Exercise - In order to prevent muscle deconditioning, a stable patient should be
advised on how to carry out daily physical activities that do not induce symptoms.
● Exercise training encouraged in stable patients.
 In-Hospital Management

Hospital Discharge

● If the patient has undergone reperfusion therapy with no significant arrhythmias,

recurrent ischemia or congestive HF, patient can be safely discharged in less than 5
days.
● Exercise testing is recommended either before discharge (submaximal), early after
discharge (within 2 to 3 weeks) or late after discharge (within 3 to 6 weeks) for
prognostic, activity prescription, evaluation of medical therapy.
REFERENCES