Acute Coronary Syndrome (ACS)

&
Myocardial Infarction

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Wandikayi C. A. Matowe, RPEBC, PhD

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ACUTE CORONARY SYNDROME (ACS)
1. Clinical spectrum of acute coronary artery
disease including unstable angina, acute
myocardial infarction (MI), & sudden
coronary death
• Non-STEMI (non- ST elevation myocardial
infarction) with at least two of the following
criteria
– symptoms at rest; raised serum Troponin;
ECG changes
• STEMI (ST elevation myocardial infarction):
– symptoms with ST elevation on ECG
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Acute Coronary Syndrome

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ACS

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Acute Coronary Syndrome & MI

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 ACS: STEMI Progression

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 Abnormal ECG Tracings
• Primary T-wave inversions:
• Benign syndromes: e.g. persistent juvenile T-wave
pattern and the digitalis effect
• Morbid conditions: acute coronary ischemic events
and CNS catastrophe

Secondary T-wave changes

• Aberrant ventricular activation in the context of normal
action potential characteristics e.g. bundle branch
blocks, preexcitation states, and ventricular ectopic or
paced beats
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Hemodynamics in Myocardial Infarction

Adapted from Hochman42 and Hollenberg et al43. with permission of the publishers. Copyright © 2003, the American Heart Association, and copyright ©
1999, the American College of Physicians. (mod – wm sept 2018): 9
Myocardial Infarction (MI)

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 Management of Acute STEMI
• Important to diagnose on-going STEMI
Several goals:
• Relief of ischemic pain
• Assessment of the hemodynamic state
• Correction of abnormalities present
• Initiation of reperfusion therapy with primary
percutaneous coronary intervention or
fibrinolysis
• Initiation of antithrombotic therapy
Treatment:
• Preservation of circulation & tissue oxygenation
 antianginal + antiplatelet plus other drugs PRN
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Emergency Treatment of Angina in ACS
MONA
Morphine:
•  pain & anxiety and relieves
• Also produces venodilation,  can  venous
return &  preload (i.e.  oxygen demand)
Oxygen:
•  ST segment elevation & limits ischemic injury
(start with oxygen vs. morphine)
Nitroglycerin:
• Causes coronary dilation  greater perfusion
 preload & afterload
Aspirin:
• Give chewable ASA (160 - 325 mg orally ASAP)
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Management of Unstable Angina (ACS)
• Antiplatelet agents: (Aspirin, Clopidogrel,
Glycoprotein 2b/3a Inhibitors) (ASA 325 mg OD
initially)
• Anticoagulants (Heparin or Enoxaparin)
• Nitroglycerin (sublingually or by buccal spray;
i.v. if pain persists; topical or oral for
maintenance)
• Beta-blocker (heart rate to 50-60 bpm)
• ACE-inhibitor
• Statin / lipid-lowering agent if applicable
(prophylactic therapy) 13
Management of Unstable Angina/MI
High-risk patients:
• Catheter-based myocardial revascularization
(PCI)
• Thrombolytics are contraindicated in the
absence of ST segment elevation

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 General Measures
• Ventilation support (O2) to correct hypoxemia
and acidosis!
• NSTEMI* - non-ST segment elevated
myocardial infarction
• Optimize intravascular volume
• Sodium bicarbonate - only for severe metabolic
acidosis (arterial pH less than 7.10 to 7.15)
• Aspirin
• Intravenous heparin (UFH)
• Possible glycoprotein IIb/IIIa inhibitor with
NSTEMI*
• Insertion of pulmonary artery catheter
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Acute ‘Decompensated’ Heart Failure
(ADHF)
• Sudden worsening of signs and symptoms of
heart failure
Signs & symptoms:
• SOB (dyspnea), difficulty breathing peripheral
edema, fatigue

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 Possible Consequences of MI/ADHF
Signs & Symptoms
Shock
• Rapid, weak, or absent
• Hypovolemic Shock pulse, irregular heart rate
• Cool, clammy skin
• Cardiogenic Shock
rapid and shallow
• Distributive Shock breathing
• Chest pain & nausea
• Neurogenic
• Confusion, anxiety
• Septic shock light headedness
• Decreased BP & urine
• Anaphylaxis
output
• Dilated pupils or lackluster
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ACUTE HEART FAILURE MANAGEMENT

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Current Treatment of AHF

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Management of Acute Heart Failure
Positive inotropes
• Beta adrenergic agonists e.g. isoproterenol
• Dobutamine, Dopamine
• Phosphodiesterase-III Inhibitors:
– Milrinone, Inamrinone
Pressor Agents
• Agents to restore tissue perfusion
- Epineprine / Norepinephrine
- High dose dopamine
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 DOBUTAMINE
• Activates β-1 and β-2 adrenoceptors  positive
inotropic effect predominates
Mechanism of action:
• Low doses  β1 selective adrenergic agonist
•  contractility without substantially  either HR or
peripheral resistance
Indications:
• Short-term inotropic support in patients with
cardiac decompensation due to depressed
contractility
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 DOPAMINE
Effects are dose-dependent:
Low Doses  selectively activate D1 receptors in
several vascular beds (e.g. kidney)  vasodilation
  renal blood flow (e.g. in the treatment of
shock)
Intermediate Doses:  activate cardiac β1
receptors  improve myocardial contractility (
+ve inotropic effect)
High Doses: activate 1 receptors!!!
Produces less of an increase in heart rate
compared to isoproterenol
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 Dopamine
Indications:
• Chronic cardiac decompensation e.g. CHF 
corrects hemodynamic imbalances in shock (MI,
trauma, septicemia, open-heart surgery, renal
failure)
Side Effects:
• Cardiac arrhythmias, dyspnea
• Nausea, vomiting, Headache, tolerance with
continued infusion
Contraindications:
• Pheochromocytoma or uncorrected
tachyarrhythmias or ventricular fibrillation
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 NESIRITIDE
• Recombinant B-type natriuretic peptide  arterial
& venous vasodilator with modest diuretic and
natriuretic properties
Mechanism of Action:
• Activates guanylyl cyclase   cardiac output by
vasodilation without increasing heart rate or
oxygen consumption
Indications:
• Treatment of acutely decompensated CHF with
shortness of breath at rest or with minimal
activity
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 Milrinone, Inamrinone
• Phosphodiesterase III (PDE III) inhibitors
Used for short-term management of HF
•  force of contraction and cause vasodilation
• Only given IV and can produce potentially
serious adverse effects
• Used for a short time when HF refractory to
other drugs
• Clinically significant thrombocytopenia occurs
in ~10% of patients receiving inamrinone (rare
with milrinone)
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 Treatment of Shock
• Shock is a medical emergency
• Goal  find and treat the cause of shock
• Supportive therapy to maintain tissue perfusion
and oxygenation
•  drugs to  blood pressure and improve heart
function:
– Dobutamine
– Dopamine
– Epinephrine
– Norepinephrine
– Milrinone & amrinone
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ADHF: Management Principles

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