Acute Coronary

Syndromes

Dr Anwar ul Haq
TMO Cardiology Unit
PGMI HMC
Ischemic Heart Disease

– Chronic Stable Angina

– Acute Coronary Syndromes

ST-segment Elevation MI
NSTEMI
UA
Stable angina
– Chest/arm discomfort
– Reproducible with stress
– Relieved with rest or nitroglycerine
Unstable angina
– Occurs even at rest and lasts >10 min
– Severe and new onset
– Crescendo pattern
NSTEMI
– Features of UA with elevated biomarkers of myocardial necrosis
1. Plaque erosion with superimposed
nonocclusive thrombus
2. Dynamic obstruction
3. Progressive mechanical obstruction
4. Secondary to increased Myocardial oxygen
demand
UA/NSTEMI angiography data
– ~5% L main stenosis
– 15% TVD
– 30% DVD
– 40% SVD
– 10% no critical stenosis
The “Culprit lesion”
– Eccentric stenosis
– Scalopped/overhanging edges
– Narrow neck

Angioscopy may reveal white platelet-rich thrombi against

the red thrombi of acute STEMI
Clinical Hallmark
– Typical chest pain
– Dyspnoea
– Epigastric discomfort
– Diaphoresis
– Pale cool skin
– Sinus tachycardia
– 3rd and/or 4th heart sounds
– Basilar rhales
– Hypotension
Electrocardiogram

– ST depression
– Transient ST elevation
– T wave inversion
– New ST deviation
– New deep T wave inversions
Cardiac Biomarkers

– Those with elevated CK-MB and Troponin at increased

risk for death or recurrent MI
– Degree of Troponin elevation directly proportional to
mortality
– In those with unclear history small Troponin elevations
may not be diagnostic of ACS
 DIAGNOSTIC EVALUATION
6-7 million patients present with chest pain in US
20-25% have ACS
FIRST STEP
– Likelyhood
High : Typical history, established CAD, prior MI, CHF, new
ECG changes, elevated enzymes
Intermediate : Age >70, male, DM, peripheral arterial or
cerebrovascular disease, old ECG abnormalities
DIAGNOSTIC PATHWAYS
– Clinical history
– ECG
– Cardiac markers
– Stress testing

– GOALS
Recognize or exclude MI
Evaluate rest ischemia
Evaluate significant CAD
RISK STRATIFICATION & PROGNOSIS
GLOBAL risk
TIMI Trial
New biomarkers
– CRP
– B-type natriuretic peptide
– CD-40 ligand
TREATMENT
– Bed rest
– ECG monitoring
– Biomarkers of necrosis
– Morphine sulphate
– ACEi
– HMG-C0A reductase inhibitors

– ANTIISCHEMIC
Nitrates
B-blockers
Ca-channel blockers
– ANTITHROMBOTIC
Aspirin
Clopidogrel
UFH/LMWH
INVASIVE vs CONSERVATIVE STRATEGY

Class 1 Recommendations for use of an Early Invasive Strategy

– Recurrent angina at rest/low level activity despite Rx
– Elevated Tnt or TnI
– New ST depression
– Rec. angina/ischemia with CHF symptoms, rhales, MR
– Positive stress test
– EF < 0.4
– Decreased BP
– Sustained VT
– PCI < 6 mos, prior CABG
 LONG TERM MANAGEMENT
Risk factor modification :
– Smoking cessation
– Optimal weight
– Exercise
– Appropriate diet
– Optimal BP
– Hyperglycemia
– Lipid management
PRINZMETAL’S VARIANT ANGINA
1959 Prinzmetal et al.
– Transient ST elevation
– Cause of the spasm
Hypercontractility of vascular smooth muscles
Vasoconstrictor mitogens
Leukotrienes
Serotonin
Vasospastic disorder
– Migraine
– Raynaud”s phenomenon
– Aspirin induced asthma
 CLINICAL/ANGIOGRAPHIC
MENIFESTATIONS
Transient ST elevation with rest pain

Ergonovine
Acetylcholine
Hyperventilation

– Nitrates + Ca channel blokers

– Coronary revascularization in those with discrete proximal fixed
obstructive lesions
– Acute active phase
– ~90-95% survival 5 years
Thanks