 ACUTECORONARY

SYNDROME

DR GIMBO HYUHA
PRESENTATION TO ED/OPD

CHEST PAIN
Top 5 Life-threatening causes of Chestpain
 Acute Coronary Syndrome (ACS)
 Aortic Dissection
 Cardiac Tamponade
 Cardiogenic Pulmonary Edema (Acute
decompensated heart failure)
 Pulmonary embolism
…OTHERWISE KNOWN AS
CARDIAC TISSUE DEATH
Acute Myocardial Infarction…
 Acute Coronary Syndrome (ACS)
 Unstable angina (UA)
 Ischemia
 Normal Cardiac Enzymes
AND
No ST segment elevation

 Non-ST Elevation Myocardial Infarction

(NSTEMI)
 Evidence of tissues ischemia/infarct
 Raised Cardiac Enzymes
BUT
No ST segment elevation

 ST Elevation Myocardial Infarction (STEMI)

 Infarct to tissue death (necrosis)
 Raised Cardiac Enzymes
AND
Presence of ST segment elevation
Anatomy of the Coronary Arteries
Investigations
And…

The Electrocardiogram (ECG)

 First, the basics

Figure 31.1
Wallis L and Reynolds T. AFEM Handbook of Acute and Emergency Care. Oxford University Press, 2013
ECG
1. ECG is the single best test to identify pts with STEMI
upon ED presentation
- Septal wall  V1-V2
- Anterior wall  V3-V4
- Lateral wall  I, aVL, V5,V6
- Inferior wall  II, III, aVF
- Posterior wall: Reciprocal of V1-V3 (R/S>1 in V1 &
V2)
- Right ventricular MI:  V1, RV4, RV5, RV6
Cardiac enzymes
Lab Test Detectable Peak Normalize
CK-MB Activity 3-8hr 9-30 hr 1-3 days
Troponin I 2-6 hr 10-24 hr 7-10 days

DON’T FORGET OTHER BASELINES !!!! (RFT,Electrolites, FBP, PT,PTT)

MANAGEMENT
Management Strategies in ACS

 Early
& Maintenance Management Strategies –
IMPORTANT IN PLACES WITH NO
CARDIOLOGY UNIT BEFORE
TRANSFER!!!!!!!!

 Reperfusion strategy
 Early Management Strategies in ACS
 ABC
 Assessment of the hemodynamic state and correction
 Relief of ischemic pain (SL/IV Nitroglycerine + Morphine)
 Nitrates contraindindicated in RV infarct and PDE-5 inhibitor (sildenafil,
tadalafil)
 Antithrombotic therapy (Aspirin, Clopidogrel, Heparin)
 To prevent Re-thrombosis or acute stent thrombosis
 Beta-blocker therapy
 To prevent recurrent ischemia and life-threatening ventricular arrhythmias
 Statin therapy (Atorvastatin 40mg or 80mg initially)
 To prevent reperfusion injury
 ACEI or ARB
 To prevent remodeling of the left ventricle
Reperfusion strategy in ACS

 Initiation of reperfusion therapy with:

Percutaneous Coronary Intervention (PCI)
(Door to Balloon ≈ 90 min)
or
Thrombolysis (Door to Lytics ≈ 30 min)
 Streptokinase
 Staphlokinase
 Urokinase
 Alteplase
 Tenecteplase
TIME IS MUSCLE!!!
 BEYOND OUR CARE !!!!!!!
So then, how can we do it?
(Based on our setting)

ACS

Early Management strategy

STEMI UA/NSTEMI

Low risk:
Risk
Thrombolysis PCI TIMI<3 stratification
High risk: TIMI≥3
chestpain <12hrs (PCI capable center)

Conservative strategy Invasive strategy

(PCI capable center)
Coronary Angiography

within 3 to 24 hrs
RISK >>> BENEFIT

Conservative strategy
DISPOSITION
Disposition

 All patients with concern for ACS should be admitted

 Patients with STEMI or those given thrombolytics should
go to the ICU for close monitoring
Thank you
READ!!!!

1. STG
2. EMAT GUIDELINE ON MANAGEMENT OF ACS