Acute Coronary

Syndrome
Amira Azzam,Msc.
M.Mohsen.Msc
What we’ll cover in next 10 mins…

 Definitions

 Clinical features and differentiating ACS

 ECGs

 Management

 Complications
 What is Acute Coronary Syndrome?

Stable Angina Unstable Angina NSTEMI STEMI

 Definitions
 Unstable angina:
 An unprovoked or prolonged episode of chest pain raising
suspicion of acute myocardial infarction (AMI)
 Without definite ECG or laboratory evidence

 NSTEMI:
 Chest pain suggestive of AMI
 Non-specific ECG changes (ST depression/T inversion/normal)
 Laboratory tests showing release of troponins

 STEMI:
 Sustained chest pain suggestive of AMI
 Acute ST elevation or new LBBB

* ALS handbook 6th Edn

 Clinical features
 Tachycardia or
 Chest pain bradycardia
 Nausea

 Dyspnoea  Heart murmurs

 Palpitations
 Sweaty
 Vomiting
 Hypotension or
hypertension
 Pallor
 Syncope
 Asymptomatic/silent

 Indigestion
 Acute confusion  Fever
 Distinguishing features

 SA:  UA:  NSTEMI:  STEMI:

plaque platelet platelet complete
formation adhesion aggregation occlusion

 Precipitated by stress or  At rest or minimal exertion

exertion
 Lasts >20 minutes
 Lasts <20 minutes
 Often accompanied by other s/s
 Relieved by GTN or resting
 Poor GTN relief
 Risk Factors
Modifiable Non-Modifiable
 Smoking  Increasing age

 Obesity  Gender (male)

 Diet  Ethnicity

 Lack of exercise  Family History

 High serum cholesterol  ?Diabetes

 Hypertension

 ? Diabetes
 Differential Diagnosis
Cardiac Respiratory
• MI • Pulmonary embolism
• Angina • Pneumothorax
Pneumothorax
• Pericarditis • Pneumonia
• Aortic dissection

Chest pain
GI Musculoskeletal
• Oesophageal spasm • Costochondriasis
• GORD
GORD • Trauma
Trauma
• Pancreatitis
 Investigations
Bedside Obs, ECG, BM
Blood FBC, UE, LFT, lipids, cardiac enzymes, amylase, CRP
Imaging CXR
Special Echo, angiography

UA NSTEMI STEMI
Normal troponin Raised troponin Raised troponin
* ECG normal * ST depression * ST elevation
* Possible ST * Can be normal * Hyperacute T waves
depression * Possible T wave * New LBBB
inversion * T inversion (hours)
* Q waves (days)

** ST
ST elevation
elevation is
is >1mm
>1mm in
in limb
limb leads
leads and
and >2mm
>2mm in
in chest
chest leads
leads
Important ECG findings
 Where is the problem?

Inferior II, III, aVF Right coronary

Lateral I, aVL (+V5-6) Left circumflex (or LAD)
Anterior V1-2 septum, V3-4 apex, V5-6 ant/lat LAD
Posterior ST depression in V1-3 Left circumflex or right
coronary
 Common ACS management
 Morphine (5-10mg slow IV injection)

 Oxygen (titrate sats to need:94%-98%)

 Nitrates : spray (400mcg =1 spray) or tablet SL(1-5mg)

 Aspirin (300mg chewed)

 Plus an antiemetic i.e.

Metoclopramide 10mg IV

* BNF 64
 Unstable angina & NSTEMI
 LMWH i.e. Enoxaparin 1mg/kg BD or Fondaparinux 2.5mg
OD
 Clopidogrel 300mg / ticagrelor180mg loading dose

 Beta blocker : bisoprolol/metaprolol/carvidelol

 Nitrates – usually IV

 Consider coronary angiography within 72 hr

 Scoring systems
GRACE scoring
 Predicts 6/12 mortality in
NSTEMI patients
 Age
 HR and systolic BP
 Killip class (CCF, pulmonary
oedema, shock)
 Cardiac arrest on admission
 Elevated cardiac markers
 ST segment change
TIMI
 Risk of cardiac events in next
30 days
 Age >65
 Known coronary artery
disease
 Aspirin in last 7/7
 Severe angina (>2 in 24hr)
 ST deviation >1mm
 Elevated troponins
 > CAD risk factors
 STEMI
 TIME IS MUSCLE
 Percutaneous coronary intervention (Primary PCI)
 ‘Call to balloon time’ of 120 minutes
 Requires clopidogrel 600mg loading dose
 Rescue PCI after failed thrombolysis

 Thrombolysis
 Streptokinase / alteplase / tenecteplase…
 Contraindications
 Clopidogrel 600mg loading dose AND LMWH

 If failed thrombolytic so for rescue PCI with 24 hours

 If successful thrombolytic return to NSTEMI guidelines for timing of
invasive coronary angiography
 Longer-term management

 Continuous ECG monitoring as inpatient/ CCU

 Aspirin 75mg OD (lifelong)

 Clopidogrel 75mg/ticagrelor 90mg BID (1 year)

 Beta blocker (1 year - lifelong)

 ACE inhibitor

 Statin

 Modification of risk factors

 Complications
Early <72hr Late
 Death  Ventricular wall rupture

 Cardiogenic shock  Valvular regurgitation

 Heart failure  Ventricular aneurysms

 Ventricular arrhythmia  Cardiac tamponade

 Myocardial rupture  Dresslers syndrome

 Thromboembolism  Thromboembolism
 Summary

 Don’t forget to learn what you think you already know!

 ECG often

 Structured approach

 Know your acute management – MONA

 Senior review is always the right answer

Thank
you
 Any
question