Acute coronary syndrome

Definition
▪ Acute coronary syndrome (ACS): the suspicion or confirmed presence of acute
myocardial ischemia
Acute coronary syndrome may be further classified into the following categories:
▪ NSTE-ACS: acute coronary syndrome manifesting without ST elevations on ECG
▪ Unstable angina: absence of detectable myocardial injury biomarkers
▪ STE-ACS: acute coronary syndrome manifesting with ST elevations on ECG
Overview of acute coronary syndrome (ACS)
NSTE-ACS STE-ACS
Type Unstable angina (UA) (NSTEMI) (STEMI)
Description Acute myocardial Acute myocardial ischemia Acute myocardial ischemia that
ischemia that is not that is severe enough to is severe enough to cause ST-
severe enough to cause cause detectable quantities segment elevations on ECG
detectable quantities of of myocardial injury
myocardial injury biomarkers but without
biomarkers or ST- ST-segment elevations on
segment elevations on ECG
ECG
Clinical Symptoms are not reproducible/predictable.
presentation Angina at rest/with minimal exertion and is usually not relieved by rest or
nitroglycerin
New-onset angina
Severe, persistent, and/or worsening angina (crescendo angina)
Autonomic symptoms may be present: diaphoresis, syncope, palpitations, nausea,
and/or vomiting
Pathophysiology Partial occlusion of Classically due to partial Classically due to complete
coronary vessel → occlusion of a coronary occlusion of a coronary artery
decreased blood supply artery Affects the full thickness of the
→ ischemic symptoms Affects the inner layer of myocardium (transmural
(also at rest) the heart (subendocardial infarction)
infarction)
Cardiac Not elevated Elevated Usually elevated
troponin
ECG Finding No ST elevations No ST elevations ST elevations (in two
Normal (e.g., ST contiguous leads) or new left
depression, loss of R wave, bundle branch block with
or T-wave inversion) strong clinical suspicion of
myocardial ischemia
Treatment Invasive management depends on risk stratification Immediate revascularization
(e.g., TIMI score) Adjunctive medical therapy
Anticoagulants, antiplatelet therapy (e.g., aspirin, similar to NSTE-ACS
ADP receptor inhibitors)
Statins, Antihypertensive therapy (beta blockers,
ACEIs)
Pain management (opioids, nitrates)
 Typical VS Atypical Presentation:
MI presentation Typical Atypical: Most common
Character of Discomfort, heaviness, pressure, Sharp, stabbing, pleuritic, soreness, burning,
pain Tightness & fullness indigestion
Location of pain Retrosternal, pericardial Epigastric, rarely chest
Radiation of Jaw, Neck, Arms (usually?) Right arm
pain
Associated S/S Perfuse sweating, N/V, SOB, Anxiety, Fatigue, dyspnea and flu like symptoms,
Palpitations Fatigability, weakness back pain, palpitations, N/V
RF HTN, DM, smoking, FHx, HCH Female, advanced age, CHF, old stroke,
non-White racial group

Clinical features
Description
Classic Acute retrosternal chest pain
presentation Typical: dull, squeezing pressure and/or tightness
Commonly radiates to left chest, arm, shoulder, neck, jaw, and/or epigastrium
Precipitated by exertion or stress
Symptom relief after administration of nitrates is not a diagnostic criterion for cardiac ischemia.
The peak time of occurrence is usually in the morning.
Dyspnea (especially with exertion)
Pallor, Nausea, vomiting, Diaphoresis, anxiety
Dizziness, lightheadedness, syncope
Other findings Tachycardia, arrhythmias
Symptoms of CHF (e.g., orthopnea, pulmonary edema) or cardiogenic shock (e.g., hypotension,
tachycardia, cold extremities)
New heart murmur on auscultation (e.g., new S4)
Atypical presentations: more likely in elderly, diabetic individuals, and women
Stabbing, sharp chest pain
No or minimal chest pain: Autonomic symptoms (e.g., nausea, diaphoresis)
More common Epigastric pain
in inferior MI Bradycardia
Clinical triad in right ventricular infarction: hypotension, elevated jugular venous pressure, clear
lung fields

Diagnosis
Approach
▪ ECG: should be performed immediately once ACS is suspected or considered as
differential diagnosis. immediate revascularization therapy, preferably PCI
▪ Cardiac troponin levels: Measure as soon as possible and repeat after 1–6 hours
▪ Patients suspected of having STE-ACS should be evaluated immediately for
revascularization therapy.

Immediate management
▪ Perform a focused clinical evaluation and ABCDE survey and Establish IV access.
▪ Establish IV access and obtain blood samples for laboratory studies.
▪ Measure cardiac troponin as soon as possible upon clinical presentation.
▪ Initiate supplemental O2 for cyanosis, respiratory distress, or SpO2 < 90%.
▪ Give aspirin if there are no contraindications.
▪ Consider adjunct medical therapy for ACS, e.g., sublingual nitroglycerin DOSAGE for
chest pain relief.
▪ If present, manage tachyarrhythmias and treat acute heart failure, cardiogenic shock,
and/or complete heart block.
▪ Obtain an ECG immediately if ACS is considered a potential diagnosis.

Unstable Angina Pectoris

A. General Characteristics
1. Pathophysiology
A. With unstable angina, oxygen demand is unchanged. Supply is decreased secondary to
reduced resting coronary flow. This is in contrast to stable angina, which is due to
increased demand.
B. Unstable angina is significant because it indicates stenosis that has enlarged via
thrombosis, hemorrhage, or plaque rupture. It may lead to total occlusion of a coronary
vessel.
2. The following patients may be said to have unstable angina:
A. Patients with chronic angina with increasing frequency, duration, or intensity of chest
pain
B. Patients with new-onset angina that is severe and worsening
C. Patients with angina at rest
▪ Unstable angina has a higher risk of MI and death than stable angina, and patients with
this diagnosis should be hospitalized. Its management is encompassed in Acute Coronary
Syndrome.

Treatment
1. Hospital admission on a floor with continuous cardiac monitoring. Establish IV access
and give supplemental oxygen if patients are hypoxic. Provide pain control with nitrates
(below) and opioids if pain refractory to nitrate therapy alone.
2. Aggressive medical management is indicated—treat as in MI except for fibrinolysis
A. Aspirin (325-mg dose)
B. P2Y12 inhibitor (clopidogrel, ticagrelor, prasugrel). The most commonly used agent
is clopidogrel—shown to reduce the incidence of MI in patients with unstable angina
compared with aspirin alone.
C. β-Blockers—first-line therapy if there are no contraindications
D. Low–molecular-weight heparin (LMWH) is superior to unfractionated heparin
E. Nitrates are first-line therapy for chest pain
F. High-intensity statin (atorvastatin 40 or 80 mg) started within 4 days of ACS
NSTEMI/UA
▪ Patients with NSTE-ACS are classified based on the presence (NSTEMI) or absence
(UA) of significantly elevated cardiac troponin (cTn) levels.
▪ A key element of management is to assess the necessity for and timing of PCI
(fibrinolytics are not indicated in NSTE-ACS). Multiple risk scores (e.g., HEART, TIMI,
GRACE) can help to determine an adequate strategy but are no substitute for individual
clinical judgment.
▪ Dual antiplatelet therapy and anticoagulation is indicated initially and the preferred
regimens vary based on patient risk factors and timing of revascularization.
▪ Some low-risk NSTE-ACS patients can be managed conservatively.

Management
Immediate revascularization
Emergency coronary angiography with PCI
▪ Indication: preferred method of revascularization in patients suspected of having STEMI
▪ Procedure: balloon dilatation with stent implantation
▪ First medical contact (FMC) to PCI time
▪ Ideally ≤ 90 minutes and should not exceed 120 minutes
Revascularization
a. Benefit highest when performed early (within 90 minutes of hospital arrival for patients
with STEMI or new LBBB)
b. Revascularization options include thrombolysis, PCI, or CABG
▪ Several studies have shown enhanced survival and lower rates of recurrent MI and
intracranial bleeding when PCI performed by skilled personnel is chosen over
thrombolysis. For patients with a delayed presentation, fibrinolysis alone may be a better
option.
▪ Urgent/emergent CABG is typically performed only in the setting of mechanical
complications of an acute MI, cardiogenic shock, life-threatening ventricular arrhythmias,
or after failure of PCI. It is almost never performed in the acute setting on a stable
patient.
c. P2Y12 inhibitors—evidence suggests that the benefit of clopidogrel or ticagrelor is
additive to the effects of aspirin.
▪ Clopidogrel or ticagrelor therapy should be initiated in all patients who undergo PCI and
receive a stent.
▪ Dual antiplatelet treatment with aspirin and a P2Y12 inhibitor (clopidogrel or ticagrelor)
should continue for at least 30 days in patients who receive a bare metal stent, and at
least 12 months in patients who receive a drug-eluting stent

Fibrinolytic therapy in STEMI

▪ Indications (in STEMI and STEMI equivalents, if all of the following apply):
▪ PCI cannot be performed ≤ 120 minutes after FMC.
▪ Symptom onset ≤ 12 hours OR 12–24 hours with clinical signs of ongoing ischemia (PCI
is even more preferable in this context)
▪ No contraindications to fibrinolysis present
▪ Timing: within < 30 minutes of patient arrival at the hospital
 Contraindications
▪ If > 24 hours
▪ Regimens (one of the following): Tenecteplase, Alteplase, Reteplase, Streptokinase
Common contraindications for fibrinolysis in STEMI and STEMI-equivalent
Absolute contraindications Relative contraindications
Active bleeding (not including menses) Major surgery within past 21 days
Bleeding diathesis/known coagulopathy Current SBP > 180 mm Hg or DBP >
Any prior intracranial bleeding 110 mm Hg
Intracranial or intraspinal surgery within the past 2 months Ischemic stroke > 3 months ago
Serious head trauma within the past 3 months Solid malignancies
Ischemic stroke within the past 3 months Internal bleeding (e.g., GI bleed) in the
Severe hypertension unresponsive to emergency therapy past 2–4 weeks

Dual antiplatelet therapy (DAPT) and anticoagulation in STEMI: Timing: Therapy should be initiated
without delaying revascularization.
Class Regimen if undergoing PCI Regimen if undergoing fibrinolysis
Dual Antiplatelet Aspirin AND one of the following ADP Aspirin AND ADP receptor
therapy receptor inhibitors inhibitor: clopidogrel
Prasugrel, Ticagrelor, Clopidogrel
Anticoagulation Unfractionated heparin OR Bivalirudin One of the following:
Unfractionated heparin,
Enoxaparin. Fondaparinux
Glycoprotein IIb/IIIa Consider one of the following at time of Not routinely recommended
inhibitor (GPI) primary PCI. Abciximab, Eptifibatide,
Acute medical treatment in ACS includes “MONA”: Morphine, Oxygen, Nitroglycerin, and
Aspirin. But remember: Morphine, oxygen, and nitroglycerine are not necessarily indicated
for every patient
Adjunct medical therapy in ACS
Class Drug Indication CI and consideration
Nitrates Nitroglycerin Nitroglycerin Systolic blood pressure < 90 mm Hg
Sublingual, Sublingual Use of PDE 5 inhibitor (e.g., sildenafil) in
Intravenous Intravenous the previous 24 hours (48 hours for
tadalafil)
Suspected RV infarction
Beta Metoprolol , Oral: any patient without Signs of heart failure (e.g., pulmonary
blockers Bisoprolol contraindications edema)
IV: continuing hypertension, (Risk of) cardiogenic shock
refractory ischemic pain Hypotension
Bradycardia
ACE Lisinopril Consider within 24 hours in Hypersensitivity, Active liver disease
inhibitors/ Captopril stable patients with: STEMI, Muscle disorder, Pregnancy,
ARB Ramipril LVEF ≤ 40%, Heart failure, breastfeeding
Hypertension, Diabetes mellitus Bilateral renal artery stenosis or a
solitary kidney
High- High- All STEMI/NSTEMI patients, Hypersensitivity, Active liver disease
intensity intensity regardless of baseline Muscle disorder, Pregnancy,
statin statin cholesterol breastfeeding
Old exams
1. patient with STEMI, and ecg showed ventricular tachycardia, BP: 90/60, HR:60. What’s
the next step in management
A. DC Cardioversion
B. IV Lidocine
C. Amiodarone

2. Patient with dyspnea or something, on examination there is a mid systolic murmur,

increases with valsalva and doesn’t radiate to the carotids:
A. Aortic stenosis
B. Hypertrophic obstructive cardiomyopathy

3. Patient diagnosed with NSTEMI, decided to be low risk and is planned to do cardiac
catheterization tomorrow morning, he is on aspirin, ticagrelor, and nitroglycerin, what
should be added as he waits for the procedure:
 A. Clopidogrel
B. Warfarin
C. Alteplase
D. An ACEi

4. pt with ischemic heart disease on ( ace i , beta blocker , high statin , asprin , lazix ) what
to add ?
A. Clopidogrel
B. loop diuretic
C. calcium channel blocker

5. a 72 years old male patient was brought to the ER with a chest pain for 2 hours
duration. He was given morphine in the ambulance and now he does not have pain. He
was given aspirin. The ECG showed STEMI and atrial fibrillation. What is the best
management?
A. Emergency cardiac catheterization and PCI
B. Anti-thrombolytic
C. Echocardiogram to check the cardiac function.

6. Case about male patient with moderate retrosternal pain not radiating and not changed
by movement or breathing. Associated with nausea without vomiting. ECG showed ST
segment depression and T wave inversion in inferior leads. He was given IV NGT,
aspirin, oxygen. He usually takes sublingual nitroglycerin and on beta blocker for his
stable angina. What is the best next step in management?
A. Stent
B. CABG
C. Clopidogrel
D. Thrombolytic with alteplase

7. A 65 years old male admitted with acute coronary syndrome (NSTEMI), he is diabetic
and hypertensive on metformin and metoprolol. Coronary angiography showed 3 vessel
disease and ...... . What is the appropriate treatment for him?
A. Coronary artery bypass surgery
B. Multi vessel stenting
C. Multi vessel percutaneous angioplasty starting with the tightest one
D. Medical therapy with beta blockers, nitrates and ACE inhibitors

8. 70 years old retired patient with past medical history presented to ER 4 hours after
onset of severe substernal crushing chest pain radiated to left arm and neck. ECG
showed significant ST segment elevation in lead I aVL, V5, V6, the patient has no clear
cut of anticoagulation contraindications. What is the best management?
A. Intravenous tissue plasminogen activator alone
B. Intravenous tissue plasminogen activator with aspirin
C. Intravenous tissue plasminogen activator with heparin
D. Intravenous tissue plasminogen activator with aspirin and heparin
 E. Thrombolytic therapy is contraindicated according to the patient’s age

9. which of the following describes atherosclerosis in chronic stable angina?

A. Thick fibrous cap
B. Rupture of the plaque
C. Thrombosis?
D. Platelet aggregation

10. Acute ST-elevation myocardial infarction:

A. Result from plaque rupture in 90% luminal obstructive lesion
B. Usually represent plaque rupture of moderate atheroma
C. Heparin is indicated in non-fibrin specific thrombolytics
D. Heparin is not indicated in fibrin specific thrombolytics
E. Active menstrual is a contraindication to thrombolytic therapy